UNAIDS’ “Fast Track” plan to end the AIDS epidemic includes a trio of targets known as “90 90 90”. Achieving the first 90 (testing) can only happen with a dramatic growth in the number of people testing their HIV status. Only about 54 percent of the approximately 37 million people with HIV around the world know their status. One way to reach this goal might be “self-testing” kits. Studies reported at the AIDS 2016 conference brought insight into how self-testing kits could work.

UNAIDS’ “Fast Track” plan to end the AIDS epidemic includes a trio of targets known as “90 90 90”—ninety percent of all people living with HIV will know their status, ninety percent of them will get effective treatment, and ninety percent of them will see the virus suppressed in their bodies… all by 2020. Achieving the first 90 (testing) can only happen with a dramatic growth in the number of people testing their HIV status. According to US Department of Health and Human services, only about 54 percent of the approximately 37 million people with HIV around the world know their status. One way to reach this goal might be “self-testing” kits, which can be used at home and yield results within twenty minutes using technology as simple as a swab and a test tube.

Studies reported at AIDS 2016 conference in Durban brought insight into how self-testing kits could work. We’ve summarized some of these abstracts and their key findings below.

Community-based distribution of HIV self-test kits: results from a pilot of door-to-door distribution of HIV self-test kits in one rural Zimbabwean community
Euphemia Lindelwe Sibanda reported on the findings of a study conducted by the Centre for Sexual Health and HIV/AIDS Research, Zimbabwe. Researchers distributed more than 8,000 HIV self-testing kits over a one-month period, door-to-door, in a rural district in Zimbabwe. People could choose to take their test with a trained community volunteer present or on their own. Participants were asked to return their used test kits to a locked drop box. Results were obtained from the used tests.

The 8,000 people who received kits represent well over half the adult population (both men and women) in the district. 85 percent declined assistance from a community volunteer and chose to take their test alone or with their partner. Sixty-eight percent of the kits were returned to the locked drop box. Researchers were able to establish HIV positive results for more than 1100 individuals (21 percent of the returned kits), and 824 of them sought follow-up services which represents 10 percent of the 8,000 who received a kit, and 15 percent of the returned kits. The study’s authors said demand for the kits exceeded supply. The authors also reported that especially high numbers of men and young people tested themselves at home.

Acceptability, feasibility and preference for HIV self-testing in Zimbabwe
Another study based in Zimbabwe also demonstrated the acceptability and desirability of self-testing. Sue Napierala Mavedzenge from RTI International presented a study of 1,000 participants, recruited from rural and urban outskirts. Of these, 70 percent opted to test themselves and 30 percent chose testing administered by a provider. At a two week follow up, 663 (95 percent) had used the home test kit, 32 individuals (5 percent) had not. Forty-seven (8 percent) had tested positive and 25 of them had sought follow up care.

Provision of oral HIV self-test Kits triples uptake of HIV testing among male partners of antenatal care clients: results of a randomized trial in Kenya
A study from Kenya suggests that self-testing could be an important tool for reaching men, who as a rule are less likely to seek testing. The Kenya study was presented by Anthony Gichangi of Jhpiego Kenya. This randomized trial followed 1,410 women who were counseled about HIV testing during ante-natal care visits. Some were provided standard care. Others were given literature about partner testing and the risk of HIV transmission from mother to child. A third group took home both literature and self-testing kits. Testing rates for the latter group (literature and a home testing kit) far surpassed the other two: 83 percent of the men in group three took the test. Only 28 percent of men from the first group, who received standard care, obtained a test. Thirty-eight percent of men responded to the literature alone. A majority of men and women who tested, including all three options, reported they took the HIV tests together.

Together these studies suggest that scaling up the availability of home test kits could spur accelerated HIV testing in countries hard hit by the epidemic. Visit here for a look at current initiatives, funded by UNITAID and implemented by Population Services International, advancing this work.

All this sounds like good news. And maybe it will be, especially if the field pays proper attention to the potential risks.

Understanding coercion in the context of semi-supervised HIV self-testing in urban Blantyre, Malawi
Wezzie Lora explored one such risk in a study conducted by the Malawi Liverpool Wellcome Trust.

In this study, fifteen heterosexual couples were interviewed on two occasions after having been provided with self-testing kits. A total of thirty men and women participated. Researchers asked if the participants experienced coercion by their partners to take the test. Some women reported feeling empowered by the option to bring a self-test home. More men than women said they felt coerced to take the test. Some of the participants rationalized coercion as sometimes acceptable or ethical, where there was history of infidelity, for example. Others characterized coercion as an “infringement of human rights,” according to the study’s authors. The study framed coercion as a culturally-informed concept and concluded that in certain contexts, under particular conditions, men and women expressed tolerance for coercion.

This raises a range of important questions about minimizing the risk of coercion in culturally appropriate ways. Details about what led women to feel empowered and how that affected their choices is important to understand. Certainly, the issue is complex—the privacy associated with testing at home may be appealing and empowering, and it may also invite coercion. What’s more, the privacy surrounding this technology might make it difficult for the field to ascertain if the net effect increases or reduces safety.

Self-testing offers the potential to quickly expand the global population who knows their status. Such a tool belongs alongside an equal imperative in the fight against HIV: an absolute commitment to protect human rights. More exploration is necessary and these studies, while leaving questions, also support that ongoing work.

Related:

Uptake, Accuracy, Safety and Linkage into Care over Two Years of Promoting Annual Self-Testing for HIV in Blantyre, Malawi: A Community-Based Prospective Study in PLoS Medicine

Home Tests – Centers for Disease Control and Prevention