What do you do if you are worried about your HIV status, but you cannot access a testing service? For people living in rural or semi-urban areas in Africa, this can often be the case.
Sex workers, and men who have sex with men are particularly likely to find it difficult, due to stigma and discrimination. Some people face long distances to reach a health facility.
Now a new self-testing pilot project might be about to change all this. At the 18th International Conference on AIDS and Sexually Transmitted Infections in Africa (ICASA), the Self-Testing Africa (STAR) project announced the launch of the largest HIV self-testing project ever seen in Africa.
Malawi, Zambia and Zimbabwe are taking part, and in the first year alone, nearly 750,000 self-testing kits will be distributed. Over four years, an estimated 2.7 million kits will be made available to the people that need it.
This is a four year pilot project with 2.9 million self-test kits being distributed. In the first phase, over two years, which is the research phase, 750 000 kits will be distributed in the three participating countries.
Rumbidzai Matewe, programme manager for the Zimbabwe Network of People Living with HIV and AIDS (ZNNP+), said: "Self-testing could provide a lasting solution to affected key populations and marginalised communities who do go for testing due to high stigma in our communities." She added that home-based testing would also provide privacy and confidentiality for people who did not test because of long distances to facilities and long queues.
Amos Makwaya, representative of the Ministry of Health in Malawi, said that self-testing is another step in providing more options for HIV-testing in communities while addressing key barriers of accessing services. "These barriers include lack of human resources, limited access, and HIV-related stigma.
We are confident that self-testing could play an important role in increasing HIV-testing uptake by shifting the control into the hands of Malawians [... ] This must be done in a manner that ensures accurate use, prevents social harms and still ensures linkage into care."
The four-year $23 million pilot project is being supported by UNITAID and is being implemented by Population Services International (PSI) in partnership with the London School of Hygiene and Tropical Medicine, the Liverpool School of Tropical Medicine and the University College London.
PSI heads the STAR consortium in close collaboration with the World Health Organization (WHO). PSI leads on HIV self-testing kit distribution in each country, and in-country research activities will be led by local research institutions like the Malawi Liverpool Wellcome Trust Clinical Research Programme, Zambia AIDS Related Tuberculosis Project and the Centre for Sexual Health and HIV/AIDS Research Zimbabwe.
Dr Karin Hatzold, project director of UNITAID/PSI, said: "It is estimated that less than 50 percent of adults living with HIV know their status, this is particularly true for high burden countries [... ] The kits will allow individuals to test themselves using an oral swab, at a time and location convenient to them and provide results within minutes."
UN 90-90-90 goal
At the launch of STAR, government health officials, affected populations and other stakeholders were in agreement that the project had great potential to contribute to the global effort to achieve UNAIDS' 90-90-90 treatment targets set for 2020.
The targets call on the global community to ensure that 90 percent of people living with HIV know their status, 90 percent of people with diagnosed HIV infection receive sustained antiretroviral therapy (ART) and 90 percent of individuals on ART achieve viral suppression.
Dr Hatzold said: "There is an urgent need to reach people currently not accessing HIV testing who include men, young people, key populations and other vulnerable populations."
Rumbidzai Matewe, programme manager for the Zimbabwe Network of People Living with HIV and AIDS (ZNNP+), said: "There is need to expand and democratise HIV testing initiatives if the UNAIDS treatment targets are to be met and home-based testing would be a game changer and a big part of the answer."
Considerations for HIV self-testing
WHO is providing guidance on the way forward for the STAR project and Dr Cheryl Johnson, WHO representative, noted some important considerations of the approach. "A key aspect of HIV self-testing is that like many self-tests it does not provide a diagnosis. All reactive test results need further testing by a health provider according to a national validated set of rules," she said. WHO has plans to produce international guidelines on self-testing.
Zimbabwe's minister of health and child care Dr David Parirenyatwa said at the launch of the STAR project: "In Zimbabwe we have tried voluntary counseling and testing and the provider initiated counseling and testing which did not give the desired results.
However, our concern on self testing is on the counseling aspect since the individual will be doing a self test, so the pilot project needs to investigate some of these issues and how they can be overcome."
As health experts like David Parirenyatwa and Cheryl Johnson have said, there is more that needs to be done in terms of counselling and introducing proper guidelines for self-testing before affected populations celebrate this new approach.
As of now, hundreds of key populations, mostly affected by stigma, will wait in anticipation to see whether self-testing will be a solution to protecting their privacy and health.