By Dr. Karin Hatzold, Director HIV Self-Testing Africa (STAR) Initiative, and Shawn Malone, Project Director, Testing and Treatment for Men
December 1st marks the 30th anniversary of World AIDS Day. Because of the seismic progress made against AIDS in recent years, there is a clear path to the end of the global epidemic. But success is far from guaranteed, as the latest UNAIDS report shows, and one of the remaining challenges is ensuring consumers know their HIV status.
Globally, around 25% of people living with HIV (PLHIV) are unaware of their status. Despite a large and growing number of HIV tests performed each year, men, young people and other key populations are still being missed.
In line with this year’s theme, Know Your Status, UNAIDS’ report highlights both the gaps in testing and case studies from around the world on promising interventions to overcome this challenge.
Through novel and innovative approaches, PSI is playing a leading role in putting more power and control in the hands of those who have been excluded from years of investment in HIV testing.
BRINGING SELF-TESTING TO SCALE
HIV self-testing (HIVST) – which allows individuals to the test themselves in complete privacy – is making it possible to reach those who may not test otherwise, bringing us closer to achieving the UN 90-90-90 HIV testing, treatment and retention targets for 2020.
In 2015, the Unitaid Self-Testing Africa (STAR) Initiative began the largest evaluation of self-testing, led by PSI and a consortium of partners. Implemented initially in Malawi, Zambia and Zimbabwe, the STAR Initiative has now expanded to three additional countries, Eswatini, Lesotho and South Africa, with the aims of generating large-scale experience and evidence, creating an enabling environment and catalyzing a global market.
By November 2018, STAR distributed more than 2.3 million HIV self-test kits in the six project countries and is expected to reach 5 million tests distributed by the year 2020. As a result, HIV testing coverage has increased, with HIVST reaching many more men, young people and first-time testers. In 2014, just before the STAR Initiative began, only an estimated 45% of people with HIV in sub-Saharan Africa knew their status. Now, it is estimated that 81% of PLHIV in the region know their status.
The STAR Initiative is investigating ways to maximize linkages to care after a positive self-test. In a randomized controlled trial in Zimbabwe, STAR demonstrated a significant rise in treatment initiation in communities with self-testing versus communities without. HIVST can enhance index testing and partner notification, increasing the likelihood of sexual partner(s) taking up HIV testing, and there is evidence that a high proportion of partners test positive.
The STAR Initiative provides a strong foundation for other countries in Africa and globally to introduce self-testing and allow for rapid scale-up based on the rich evidence already gathered. Building on this work, both national programs and donors like PEPFAR and the Global Fund have begun to scale up HIVST. To achieve the target that 90% of PLHIV know their status–and realize the full potential of HIVST – continued effort will be needed at a global scale.
With funding support from the Bill & Melinda Gates Foundation, PSI, research partner Ipsos and design partner Matchboxology aim to address the gap in HIV testing and linkage among men by making HIV services more responsive to men’s needs and circumstances. The two-year project is speaking directly with more than 2,000 high-risk young men in South Africa about the factors that influence their decisions and behaviors around HIV testing and linkage, and in turn, using these insights to tailor our outreach.
In the qualitative research phase, the project has identified a range of barriers and challenges to uptake of HIV services among young men. They often live in an extremely challenging environment including stress, violence, trauma and uncertainty. Many struggle with dissonance between their aspirations and their reality, and an inability to meet societal expectations. They engage in high-risk sexual behavior that they rationalize or misunderstand and hold onto inaccurate but assuring indicators of risk. Masculine norms impede health-seeking, and the health system often leaves them feeling disrespected, hunted and coerced. Because they perceive many costs to testing and linkage, and few compelling benefits, many prefer not to know their status or to delay treatment until they become symptomatic.
Initial results of this research suggest that we will continue to lag behind in reaching men with HIV testing, prevention and treatment unless we view this group through an empathetic lens that seeks to understand the complex influences and experiences that shape their attitudes, decisions and behaviors. Only then can we work to strengthen their motivation and capability to access HIV services.
You can view the full report here.