Scaling Up HIV Self-Testing to Achieve UHC

By Karin Hatzold, Associate Director & Project Director, HIV, PSI

The impact of COVID-19 on HIV services is of particular concern in sub-Saharan Africa  

COVID-19 has overwhelmed health systems in many countries and lockdowns have disrupted access to health care services — further jeopardizing public health goals including achieving universal health coverage (UHC). Supply chains for health care commodities, diagnostics and drugs and critical resources have been diverted from HIV programs to fight the new pandemic. 

The COVID-19 pandemic has disproportionately impacted the people most affected by existing diseases: the poor, the marginalized, those without access to health care. People living with HIV experience more severe outcomes and have higher comorbidities from COVID-19 than people not living with HIV. Yet, in mid-2021, most people living with HIV did not have access to COVID-19 vaccines.

In Africa, the impact of the COVID-19 pandemic on HIV services is of particular concern and has stalled progress towards UHC. 

HIV remains one of the leading causes of mortality with more than 460,000 HIV related deaths across sub-Saharan Africa in 2021 despite improvement in HIV prevention, testing and treatment. Some countries experienced nearly 50% declines in HIV testing and 35-40% declines in antiviral therapy (ART) in 2020 during COVID-19 lockdowns compared to pre-pandemic 2019 levels.

The appearance of new COVID-19 variants, such as Omicron, and the horrific increases in cases in the fourth wave observed in many countries suggest that the pandemic is likely to continue over the next few years. Countries need to be prepared to prevent the negative impact on HIV services, especially HIV testing, ART, and continuation of HIV prevention service delivery. 

Maintaining testing services during Covid-19 through HIV self-testing

HIV self-testing (HIVST) is an effective  self-care tool, allowing individuals to seek out an HIV test based on their own assessment of risk and need. 

Offering a discreet and convenient way to test, HIVST has rapidly become a standard approach to HIV diagnosis, particularly in many high burden settings. In order to reach people from priority population groups globally—during and beyond the pandemic—HIVST provided a foundation from which the potential of other self-testing and self-care approaches can now be more readily realized.

Implementation of HIVST can be easily adapted to the COVID-19 context. The Unitaid-funded STAR Project has shown that HIVST can replace facility-based HIV testing to decongest health care facilities. HIVST distribution at community level can be adapted to increase access, including at market access points, COVID-19 screening and vaccination sites, mail-order systems, and pharmacies.  In high HIV burden settings, distribution of HIVST kits from pregnant women to their male partners or home-based testing together with the partner using HIVST kits has been highly effective to reach men who have never been tested for HIV, including undiagnosed men living with HIV. 

HIVST can also be considered for initiation, continuation and monitoring of pre-exposure prophylaxis (PrEP). 

Routine HIV testing is a core component of patient management in PrEP programs and recommended quarterly for all individuals taking PrEP. However, frequent HIV testing can be burdensome to some PrEP patients, particularly for those who face logistical barriers to accessing healthcare, which are further exacerbated during Covid-19 restrictions.

Following the WHO and PEPFAR recommendations for HIVST use during Covid-19, Brazil, Vietnam and South Africa started implementing HIVST/PrEP services. Telemedicine and HIV self-testing were adopted by Brazilian Public Health services to minimize disruptions in PrEP access and delivery during the COVID-19 pandemic showing high level of acceptability among PrEP/HIVST users and providers of PrEP telemedicine. HIVST/PrEP home delivery demonstrated increased access to men who have sex with men, transgender and non-binary individuals facing stigma, adherence concerns, and medical distrust. Similarly, in Vietnam HIV self-test kits were couriered, posted, or otherwise delivered to those seeking testing services and people who tested negative with the self-test could receive PrEP in the same way that they had received the HIVST kit, through online ordering and home delivery.

New WHO guidance on the use of HIVST to be considered for people taking post-exposure prophylaxis and PREP could increase access continuation, retention and adherence to PrEP, providing opportunities for users to manage their own health care needs. Simplifying PrEP and adapting services to the real world, including HIVST/PrEP online and virtual interventions, will provide more options and flexibility for taking PrEP based on clients needs and preferences, greater convenience and reduced opportunity costs and is leading to greater user engagement, empowerment and ownership, which should be considered as countries work to expand UHC. 

HIV self-testing needs to be further scaled up 

While the number of countries with HIVST policies and implementation in the public and private sector has increased exponentially since 2016 when WHO normative guidance has been launched. But there is still a substantial gap in the number of registered WHO prequalified HIVST kits as well as scaled distribution at the country-level. 

Considering the effect of COVID-19 on individuals, communities and health systems, countries should urgently overcome policy and regulatory barriers to HIVST implementation and enable widespread access to HIVST as part of countries’ approach to achieving UHC. Making HIV self-testing available as a part of the health system during and after the COVID-19 is an essential measure to ensure that those at risk of HIV, including those that have never tested for HIV before, have continued access to COVID-19 safe HIV testing, antiretroviral therapy and PrEP — and is part of an overall health system.

Join STAR Initiative at ICASA 2021 this week to learn more about how HIV self-testing (HIVST) is playing a critical tool to maintain essential testing services during COVID-19 disruptions.