Is DIY HIV test­ing for you?

One in two South Africans liv­ing with HIV aren’t yet on treat­ment. Are self­tests the so­lu­tion?

Mail & Guardian - - Health - Adrian Puren

To­day, South Africa boasts the world’s largest HIV treat­ment pro­gramme and al­most one in ev­ery two peo­ple liv­ing with the virus has ac­cess to an­tiretro­vi­rals (ARVs), es­ti­mates the Joint United Na­tions Pro­gramme on HIV/Aids (UNAids). Still, this means that al­most 50% of HIV-pos­i­tive South Africans con­tinue to miss out on life-sav­ing med­i­ca­tion.

South Africa was al­ready lead­ing the world in ARV treat­ment when, in Septem­ber 2016, the health depart­ment de­cided to ex­pand, adopt­ing an ap­proach called “test and treat”. As part of this strat­egy, any per­son who tests pos­i­tive for HIV can start ARV ther­apy for free soon af­ter the di­ag­no­sis.

Pre­vi­ously, peo­ple would have had to wait un­til their CD4 counts — a mea­sure of the im­mune sys­tem’s strength — fell be­low a cer­tain count be­fore they could ac­cess free treat­ment.

“Test and treat” could elim­i­nate South Africa’s HIV epi­demic within 40 years, ac­cord­ing to a 2012 mod­el­ling study pub­lished in the jour­nal Plos One. But to do this and reach other lofty in­ter­na­tional goals, we’ll have to con­tinue to test about 10-mil­lion peo­ple each year or even more.

If we’re to in­crease HIV screen­ing dras­ti­cally to test and treat more peo­ple, then HIV test­ing may very well have to come out of the clinic and into the home.

Self-test­ing —whether with a fin­ger prick or an oral swab — may just be a way to do this, which is why it was in­cluded in the coun­try’s latest guide­lines and backed by the World Health Or­gan­i­sa­tion (WHO).

Self-test­ing can, for ex­am­ple, of­fer peo­ple au­ton­omy and pri­vacy while also en­abling them to ac­cess treat­ment sooner, ac­cord­ing to a 2016 re­search re­view pub­lished in the Jour­nal of the In­ter­na­tional Aids So­ci­ety.

It may also re­duce be­hav­iour that car­ries a high HIV-in­fec­tion risk and in­crease the per­cent­age of peo­ple who dis­close their HIV sta­tus to others for sup­port, ar­gues UNAids.

We know that some peo­ple — such as men who have sex with men, sex work­ers and in­ject­ing drug users — are at an in­creased risk for HIV in­fec­tion. We also know that they’re likely to face stigma and dis­crim­i­na­tion at our clin­ics, so HIV self-test­ing could be a pow­er­ful tool to in­crease test­ing and treat­ment among these vul­ner­a­ble groups. It may also en­tice ado­les­cents, cou­ples and even fre­quent retesters.

But what should this kind of test­ing look like?

The South African gov­ern­ment is con­sid­er­ing a num­ber of ap­proaches to self-test­ing. Test kits could be pro­vided by health pro­fes­sion­als or com­mu­nity health work­ers, or ob­tained at dis­tri­bu­tion points such as phar­ma­cies, su­per­mar­kets and vend­ing ma­chines. Test­ing could be done in pri­vate or with su­per­vi­sion. Costs will likely play a ma­jor role in de­cid­ing which op­tions to im­ple­ment.

Re­gard­less of how peo­ple get their hands on them, one thing is cer­tain: self-tests will have to be sim­pler and eas­ier to use than “pro­fes­sional” rapid tests. The DIY di­ag­nos­tics should have easy-to-fol­low in­struc­tions. Past stud­ies have found er­ror rates any­where from 0.37% to 5.4%, largely be­cause peo­ple ei­ther could not read test re­sults cor­rectly or did not fol­low in­struc­tions.

And if test­ing is go­ing to act as a gate­way to treat­ment, self-testers are go­ing to have to be able to ac­cess sup­port when they need it from, for ex­am­ple, hot­lines, ed­u­ca­tional ma­te­rial and re­fer­rals for treat­ment.

Tests should also be qual­ity as­sured. When the South African Phar­macy Coun­cil moved to al­low the sale of self-tests in 2015, it stated that DIY test­ing kits should be WHOap­proved or “pre­qual­i­fied”.

In July, the WHO pre­qual­i­fied its first self-test, OraSure Tech­nolo­gies Inc’s OraQuick test. WHO pre­qual­i­fi­ca­tion of medicines, vac­cines and di­ag­nos­tics plays an im­por­tant role in help­ing to ex­pand their use by al­low­ing coun­tries that might not have na­tional reg­u­la­tory bod­ies to rest as­sured that prod­ucts are safe.

The OraQuick test can de­liver a per­son’s HIV re­sults in as lit­tle as 20 min­utes. Some HIV self-tests, which have been vet­ted by in­ter­na­tional reg­u­la­tors, can al­ready be pur­chased at South African phar­ma­cies. But these have not yet been ap­proved by the WHO.

In the fu­ture, the South African Health Prod­ucts Reg­u­la­tory Author­ity — cur­rently be­ing de­vel­oped by the gov­ern­ment — will likely be tasked with ap­prov­ing new gen­er­a­tions of self-tests and mon­i­tor­ing their per­for­mance and safety af­ter they go on to the South African mar­ket.

This type of mon­i­tor­ing will be im­por­tant. For years, we’ve feared that do-it-your­self HIV test­ing would lead to harm, such as sui­cides af­ter pos­i­tive re­sults or hu­man rights vi­o­la­tions in the form of forced HIV test­ing.

To date, no study has yet sup­ported this as­ser­tion. Nev­er­the­less, pro­grammes to in­crease self-test­ing should be able to track these kinds of events if they oc­cur, and en­sure that coun­selling ser­vices are avail­able.

So, what else should you know about the DIY HIV test? HIV self­tests may still fail to di­ag­nose a pro­por­tion of in­di­vid­u­als, in par­tic­u­lar those in the ex­tremely early stages of HIV in­fec­tion.

If you test HIV neg­a­tive with a self-test, it’s im­por­tant to retest af­ter the win­dow pe­riod of about three months if you have had un­pro­tected sex or been ex­posed to blood that could have been in­fected with the virus. If you test pos­i­tive, it is im­por­tant that you con­firm the result and that you are linked to treat­ment if you are con­firmed to be pos­i­tive at a public health clinic or by a GP.

We may still have ques­tions about what HIV test­ing should look like but, with its pos­si­ble ben­e­fits, we can’t af­ford not to try to find the an­swers.

Home de­liv­ery: In Novem­ber, hu­man­i­tar­ian or­gan­i­sa­tion Doc­tors With­out Bor­ders (MSF) said it was con­sid­er­ing hav­ing com­mu­nity-based ad­her­ence clubs help dis­trib­ute DIY tests. Photo: Sa­man­tha Rein­ders

It’s pri­vate: DIY tests can be a pow­er­ful tool to in­crease test­ing and treat­ment among men and vul­ner­a­ble groups. Photo: Made­lene Cronjé

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