Promising uptake of HIV self-testing in Africa
HIV self-testing is found to be more popular than standard testing, particularly among men, but accessing treatment after a positive result is an issue.
An evidence review of 11 HIV self-testing trials in East and Southern Africa has found promising uptake among many groups, particularly men.
Researchers analysed findings from trials conducted between 2011 and 2019 in Malawi, Kenya, Zambia and Uganda involving around 59,000 people in total. Participants included pregnant women and their partners, truck drivers, rural communities, sex workers and hospital outpatients.
Trials compared HIV self-testing with testing conducted by healthcare workers in facilities or community-based locations such as workplaces.
Results from seven trials found uptake of HIV self-testing was significantly higher than standard testing.
Two Kenyan trials asked pregnant women to either give self-testing kits or vouchers for facility-based testing to their male partners. In these trials, the option to self-test significantly increased the number of men testing.
But six trials investigating links to HIV care found people with a positive self-test result were less likely to go to clinics for treatment than people who were tested by healthcare workers.
Harmful incidents related to self-testing did occur but were rare. Six trials measured this and ten incidents were reported in total and were mainly of verbal or physical abuse from a partner. Introducing the idea of self-testing to people in a cautious way, particularly to those at heightened risk of partner violence, is advisable.
A trial in Malawi involving 16,660 people compared two different types of self-testing. People who were given the option to self-test at home, and could also have confirmatory testing and begin treatment at home if they tested positive, were more likely to begin treatment and have a CD4 count test than people who had to visit a health facility for further care following a positive self-test. But people who started HIV treatment at home were less likely to still be on it after six months than those who began treatment in facilities.
The Malawi trial also found a higher rate of people who accepted testing tested positive in the home-based care group compared to those who were offered self-testing alongside facility-based care if needed. This is known as the ‘positivity yield’. It is important to consider as it can be used to estimate how many tests need to be conducted to detect one person living with HIV, which has cost and resource implications. Despite its importance, most trials in the review did not report on this measure.
The Malawi findings suggest that offering optional home-based HIV care for self-testers could improve treatment access but ensuring people then stay on treatment is essential.
Using apps or text messages to encourage self-testers with a positive result to visit a clinic for diagnosis and treatment could also help to increase the number of self-testers who access HIV care.
The study’s authors call on future self-testing trials in sub-Saharan Africa to consider different approaches to self-testing in relation to testing uptake, positivity yield and links to care. The potential of self-testing to reach first-time testers and marginalised groups, such as men who have sex with men and people who use drugs, should also be explored.