A Rising STAR

March 2019 – The largest global HIV self-testing initiative, known as the Self-Testing Africa (STAR) Initiative, has produced strong evidence that the approach is an effective and accessible way for young people and men to find out their status. Now, a special issue of the Journal of the International AIDS Society (JIAS) presents crucial new insights on the introduction of HIV self-testing on a large scale, drawing on lessons from the Unitaid-funded project.

Realizing the potential for HIV self-testing in Africa: Lessons learned from implementation and scale-up of the (STAR) project’, coordinated by WHO and STAR, brings together 11 studies. The compilation presents evidence on how to distribute HIV self-testing products in an efficient, effective, and ethical manner.

The studies, which mainly focus on a community-based distribution approach, comprise findings relevant to program design; distribution of self-testing kits and linkage of users to prevention or care. Other aspects covered by the issue concern the cost-effectiveness of HIV self-testing, quality-assurance, regulations, and ethical considerations.

Specifically, the JIAS publication offers insights into the following issues:

  • Uptake of testing among men and adolescents in Malawi, Zambia and Zimbabwe. The study shows that HIV self-testing reached a high proportion of men, young people and first-time testers when delivered at scale using male- and youth-sensitive approaches. It shows that self-testing as essential to reaching UNAIDS fast-track targets for 2020 (Hatzold et al).
  • Linkages to prevention or care services after HIV self-testing. The research concludes that, where possible, collecting data on users’ self-testing and linkage experiences can provide valuable insights for programming and the design of interventions (Neuman et al).
  • Economic costs of door-to-door community-based distribution of HIV self-test kits. The study provides the first empirical evidence of these costs drawing on data from Malawi, Zambia and Zimbabwe (Mangenah et al).
  • Epidemiological impact and cost-effectiveness of community based-HIV self-testing (CB-HIVST). Researchers demonstrate the epidemiological impact of CB-HIVST, while highlighting the importance of finely targeting interventions. They suggest taking into account the prevalence of undiagnosed HIV, the sub-population, and the overall costs of delivering this testing modality. Linkage to voluntary medical male circumcision significantly enhances the cost-effectiveness of HIV self-testing (Cambiano et al).
  • Social harms of the distribution of HIV self-test kits. The study demonstrates the low frequency of serious social harms after the distribution of 175,000 kits in Malawi. The most frequently reported harm were the relationship difficulties encountered by serodiscordant couples (one HIV-positive and the other HIV-negative). The study provides a classification and severity framework to help anticipate, prevent and manage harms (Kumwenda et al).
  • Distribution of HIV self-test kits. The research concludes that assessing the preferences of users can help improve distribution, and maximize the number of testers who are linked to prevention or care services. (Sibanda et al).
  • Instructions for use of HIV self-tests. As manufacturers’ instructions are translated into other languages, and it is important to assess whether they are easy for users to understand. The study, which draws on evidence from Malawi and Zambia, shows that can be rapidly evaluated using cognitive interview techniques (Simwinga et al).
  • Regulatory environment. The study examines HIV self-testing regulations in Malawi, Zambia and Zimbabwe. It also explores ways of supporting a more coherent regulatory environment for the introduction of new in vitro diagnostic devices, including HIV self-testing (Dacombe et al).
  • Quality- assurance for HIV self-testing programmes. Researchers evaluate delayed re-reading of used OraQuick® HIV-1/2 rapid antibody tests. They also look at quality-assurance implications for HIV self-testing programmes (Watson et al).

Why HIV Self-Testing?

Access to HIV testing services has steadily increased in the last three decades –progress that has been largely driven by rapid tests and greater availability of HIV testing in health centers and at the community level.

However, an estimated 25 percent of people living in HIV globally do not know they have the virus. In eastern and southern Africa alone, an estimated 2,7 million people living with HIV are not aware of their status.

HIV self-testing is a discreet and convenient way for people to find out their status, particularly where those living with HIV face high levels of stigma. To advance global HIV goals, the Unitaid-funded STAR Initiative launched in 2015 to support the evaluation and introduction of self-testing on a massive scale.

Rising Star

The evidence generated by this catalytic investment has directly informed WHO guidelines on HIV self-testing, released in December 2016, and led to the prequalification of two HIV self-testing products.

As a result, 59 countries now have policies on HIV self-testing and 28 are actively implementing it, with an additional 53 reporting that a policy is under development. By the end of 2018, several quality-assured products had been registered, including two kits prequalified by WHO.

Enabling policies, pre-qualification and regulations have speeded donor procurement of kits, which has hit a forecasted estimate of 16 million units by 2020.

With its wealth of evidence, this JIAS special issue can be harnessed by global health practitioners, policy-makers and civil society organizations take HIV self-testing further, faster.

Banner image: (c) Unitaid/Eric Gauss

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