WHO policy on HIV self-testing

By Madhukar Pai Moderator | 06 Feb, 2017

In December 2016, WHO published their Guidelines on HIV self-testing and partner notification.

Please see:

http://www.who.int/hiv/pub/vct/hiv-self-testing-guidelines/en/

WHO recommends HIV self-testing and states that: HIV self-testing (HIVST) is an empowering and innovative way to reach more people with HIV and help achieve the first of the United Nation’s 90–90–90 targets – for 90% of all people with HIV to know their status by 2020. Expanded use of HIVST can contribute to these global targets by reaching first-time testers, people with undiagnosed HIV or those at ongoing risk who are in need of frequent retesting.

Will be great to hear from this community on how HIV self-testing can be taken to scale in high HIV prevalence countries.

Best

Madhu

Replies

 

Richard Galli Replied at 8:08 AM, 6 Feb 2017

HIV self testing is gaining widespread support in low and middle income countries especially in sub-Saharan Africa. It is seen as a way of reaching key populations, through private and public sector initiatives, without further encumbering the often over-burdened traditional HIV testing programs that are in place in many countries. Despite challenges associated with proper linkage to care for self testers who test positive, there are many demonstrations of successful outcomes in HIV self testing pilots currently under way. The STAR project in high burden countries Malawi, Zambia Zimbabwe and is a good example http://hivstar.lshtm.ac.uk/.

UNITAID has published an excellent overview of HIV self testing, available at http://www.aidsdatahub.org/sites/default/files/publication/UNITAID_HIV_rapid_... and recently launched a call for proposals to expedite HIV self testing in LMIC: https://www2.fundsforngos.org/latest-funds-for-ngos/unitaid-call-for-proposal...

There will be much more on the self testing front in the coming months.
Regards,
Rick

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Prof Sarman Singh Replied at 8:41 AM, 6 Feb 2017

Regarding the HIV self testing I would be more cautious to generalise the
some success stories. I would focus countries where stigma and
discrmination against HIV positives is still high. I have counselled
thousands of patients most in late 11990s and early 2010 when HIV incidence
was very high in India. My worry is that if a person tests positive, what
are options before him or her. It is very likely that due to stigma the
person may hide the HIV positive status and may continue to have protected
or unprotected sex with spouse oo with other sex partners. If there is any
behavioural change in his/her sexual practices, the spouse may raise
question and to avoid such question he may go out of marriage and continue
spreading HIV. Another extreme is that he /she may commit suicide without
telling to anybody. However, the underlying fact is tat such situations
are more likely in populations with low literacy rates where they can
niether read books, or use internets. Having said that such programmes may
be much succesful in counties with literacy and high access rate to
internet.

Prof. Sarman Singh

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Sujatha Chandrasekaran Replied at 11:55 AM, 7 Feb 2017

I agree with Dr.Sarman singh. My experience in HIV testing and counselling
in India also indicates the same- patients may not be mature for
self-testing. With high-prevalence of health-illiteracy and social-stigma,
self-testing may not be appropriate.

Sujatha Chandrasekaran.

Mark Pettigrove Replied at 1:04 PM, 7 Feb 2017

I agree with Galli. We should embrace HIVST. Like some of you I was skeptical at first, but the potential for increased coverage can't be denied. My concern is of a more technical nature. To be sensitive/ specific these tests must be performed, stored, transported, etc properly and correctly. Whole blood testing is more suited to POC or the lab setting, but we have seen that diabetics and others are capable of successfully using whole blood tests. Innovation in sample capture (smaller volume, eliminate use of transfer pipet, oral tests) is needed. Costs for HIVST kits (lancet, test, etc) and oral tests are still quite high.
Technical and social aspects of HIVST need to be addressed, but we shouldn't prevent progress by citing "what if?"
Self testing is empowering to the individual. Maybe we as health professionals are showing a bit of hubris by saying this is not possible for the layperson.

Peter MacPherson Replied at 3:24 PM, 7 Feb 2017

As I have been involved in a few of the HIV self-testing studies, I thought I would share some thoughts.

Firstly, I would not underestimate the transformative potential of empowering people to take control of the manner in which they test for HIV. Medicalised approaches have not nearly achieved the very high rates of testing coverage required, and certain groups (e.g. men, key populations) have been inequitably served. Response to the introduction of HIV self testing e.g. in Blantyre has been extremely encouraging.

Secondly, it is my impression that accuracy is sufficiently high for most target populations. Robust systems for linkage to confirmatory testing and subsequent care and prevention are clearly going to be essential, but as ever in public health, we shouldn't let the best be the enemy of the good. Would that there were a similarly accurate, reliable and easy tuberculosis self-diagnostic test.

Finally, I think the pressing major areas of concern are around the development of the appropriate mix of HIV self testing delivery models to benefit currently underserved populations; this will likely need to be led at country, and even regional and district level - "know your epidemic, and your response". And around ensuring good standards of quality assurance and monitoring & evaluation; both will be challenging because of the nature of HIV self-testing, and will require innovate approaches: we probably have much to learn from post-marketing surveillance systems.

Madhukar Pai Moderator Replied at 7:54 PM, 7 Feb 2017

The WHO policy on HIV self-testing provides a very good summary of the research that has been done to address many of the concerns raised about self-testing:

Key evidence has found that HIVST, when compared to standard HIV testing:

• More than doubles uptake of HIV testing among men who have sex with men and male partners of pregnant or post-partum women.
• Increases uptake of couples HIV testing among male partners of pregnant or post-partum women.
• Nearly doubles frequency of HIV testing among men who have sex with men
• Can result in identifying an equivalent or greater proportion of HIV-positive people.
• Does not increase HIV risk behaviours (such as condomless anal intercourse) or the number of bacterial sexually transmitted infections (STIs).
• Does not decrease uptake or frequency of testing for STIs.
• Does not increase reported social harm, adverse events or behaviours.
• Can perform as well as an HIV RDT used and interpreted by a trained health worker.
• Can achieve acceptable sensitivity (80–100%) and specificity (95.1–100%), especially using products that meet quality, safety and performance standards.

But, clearly, HIVST is not meant for all people or all settings. WHO policy states: Any person who is uncertain about how to correctly perform
the self-test, or interpret the self-test result, should be encouraged to access facility- or community-based HIV testing.

Vijay Nema Replied at 11:46 PM, 7 Feb 2017

It seems we are inhibitory to new thoughts when we say self testing may not
be appropriate in HIV. This is something like condom usage. There were days
when people did not want to talk about condoms in public but now its a
normal thing to discuss and use. A little literacy about why and how to use
through a nationwide campaign may help. Moreover, when there is a need to
reach "hard to reach populations", we must bring in the convenience of self
testing so as to promote diagnosis in such groups and bringing them under
the umbrella of treatment and care.

Sujatha Chandrasekaran Replied at 11:52 PM, 7 Feb 2017

I have this question as well.

What if the self-test result is positive and the person chooses to keep the
results to himself. Who notifies it to the public health? I am not sure if
self-testing, however robust the test system/method maybe,should be left to
the patient.

Cheryl Johnson Replied at 3:18 AM, 8 Feb 2017

Very interesting discussion!

Just to clarify, if a person as a reactive (positive) result this person needs further testing to provide a diagnosis. As with all HIV testing, a validated national algorithm with at least 2 reactive tests in a high prevalence setting and three reactive tests in a low prevalence setting is needed to provide an HIV-positive diagnosis. So reporting of an HIV-positive diagnosis would still be captured in the existing reporting system.

There are several additional ways that are being used by programmes and research studies to collect information on the number and proportion of people with a reactive self-test result.

So far, there has been use of community-based platforms, hotlines, vouchers and rebate schemes, e-readers and mobile applications where individuals can share their results as well as receive information and support to link to care. Other systems include manufacturers working with the national programme to try to use the data they collect through post-market surveillance and link with the national health system data.

There is a list of different monitoring and reporting tools that are being used in the WHO guidelines if useful for more details: http://www.who.int/hiv/pub/vct/hiv-self-testing-guidelines/en/

Bikash Sah Replied at 8:55 AM, 15 Feb 2017

HIVST (Self Testing) is also not practicle in our country too where people who are aware of being HIV positive don't dare to visit Hospital because of high prevalence of illiteracy and social stigma and discriminations. Opt out system is followed in the antenatal cases where they ordinarily get tested unless they decline and it is found almost all antenatal cases get their HIV test done and in the positive cases, they receive proper counseling to receive further treatment. If this opt out system is used in every cases i.e. if generalized for the patients visiting hospital and also for individuals getting marriage, going other country, at high risks etc. then its possible to achieve United Nation 90-90-90 targets in developing countries like our Nepal.