At the 12th International IAS Conference on HIV Science, WHO calls for countries to expand use of HIV self-testing (HIVST), to offer HIVST for initiation, continuation and re-starting pre-exposure prophylaxis (PrEP) and to promote testing through sexual and social networks to increase testing coverage and strengthen uptake of HIV prevention and treatment services for the general population in high-burden settings and in populations and regions with the greatest gaps in testing coverage. These recommendations are issued at a moment of unique opportunity, when self-care and self-testing are increasingly being recognized as ways to increase access, efficiency, effectiveness and acceptability of health care across many different disease areas, including HIV.
New recommendation
HIV self-testing may be offered as an additional option for testing at facilities (conditional recommendation, low-certainty evidence).
Although HIV testing is offered routinely in some clinical settings such as antenatal services, there are many missed opportunities for testing among people who present themselves at health facilities, including men who are often not offered testing even in high-burden settings. As of 2022, an estimated 5.5 million people with HIV still did not know their HIV status.
Offering HIV self-testing at facilities can increase testing uptake and improve the efficiency of service delivery, especially in settings where there are shortages of health workers and where HIV testing is not readily available otherwise.
Evidence from a systematic review showed that facility-based HIV self-testing may result in HIV testing uptake comparable to or higher than that with standard facility-based testing. Another finding of the review was that being able to access HIVST at facilities reduces barriers to testing and increases the proportion of people who are tested who are found to be HIV-positive. In Zimbabwe, offering HIVST in family planning clinics where HIV testing had not been routinely offered increased testing coverage from 0.5% to 64% within 3 months of implementation (1).
New recommendation
HIV self-testing may be used to deliver pre-exposure prophylaxis, including for initiation, re-initiation and continuation (conditional recommendation, low-certainty evidence).
Access to PrEP, which has been shown to be highly effective at reducing HIV infections, has yet to be scaled up. WHO now promotes the global scale-up of simplified PrEP delivery, with a focus on reducing the need for frequent facility visits, including through streamlining HIV testing requirements. Offering HIVST as an alternative strategy can be an innovative way to increase access to and effective use of PrEP in many programmes. HIVST can also be used to reassure people without HIV that their prevention practices are effective.
There is a range of PrEP options in which HIVST use could be considered, including oral PrEP (daily or on-demand) and the dapivirine vaginal ring. HIVST can also be considered as part of post-exposure prophylaxis (PEP) implementation. Further research on the role of HIVST in implementing long-acting injectable prevention options, such as cabotegravir, is needed.
New recommendation
Social network testing approaches may be offered as an additional approach to HIV testing as part of a comprehensive package of care and prevention (conditional recommendation, low-certainty evidence).
The guidelines also recommend that countries expand the offer of social network testing approaches (SNA) as a way to increase access to and uptake of HIV testing. Social network-based HIV testing is an approach for engaging sexual and drug-injecting partners and social contacts of people with HIV and of those who are HIV-negative and at ongoing risk, in voluntary testing services. This approach includes providing contacts with information about testing services or providing contacts with self-tests.
WHO has previously recommended this approach for people in key population groups, but now expands this recommendation for anyone in high-burden settings.
Findings from a systematic review showed that SNA may increase uptake of HIV testing - through HIV self-testing or standard facility-based testing - among sexual partners and social contacts of test promoters. Social network approaches may also increase the number of first-time testers, indicating the value of these approaches for closing the gaps in testing coverage and increasing the number of infections diagnosed.
"Offering people a range of HIV testing approaches is an effective way for programmes to reach HIV testing, prevention and treatment goals and to achieve and maintain low HIV incidence," said Dr Meg Doherty, Director, WHO Global HIV, Hepatitis, and STI Programmes. "Countries are encouraged to expand the use of HIV self-testing and scale up social network testing approaches to bridge gaps in coverage caused by access, stigma, awareness or affordability."
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The updated recommendations will be presented and discussed at following sessions of the 12th IAS Conference on HIV Science:
- Sunday, 23 July 2023, 15:00-16:30: What's new in WHO guidelines: innovations, treatment, integration and monitoring
- Monday, 24 July 2023, 17:15-18:15: Plenary session Social network approaches to HIV testing, Virginia Macdonald, WHO
- Wednesday, 26 July 2023, 10:30-11:30: Late breaker session Should social network testing be offered as an additional HIV testing approach? A GRADE systematic review and meta-analysis
- Poster EPCO458: Should HIV self-testing be offered as an additional testing option in health facilities?: A systematic review and meta-analysis
References
1. Integration of HIV testing and linkage in family planning and contraception services: implementation brief. Geneva: World Health Organization; 2021
