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HIV self-testing has several advantages, but some barriers to HIV testing likely to remain
Roger Pebody, 2016-06-07 07:50:00
A service offering kits for HIV self-testing in South Africa
has the potential to improve uptake of HIV testing by individuals who fear
breaches of confidentiality or who do not trust healthcare workers, according
to a qualitative study published in PLoS
ONE. But other, long-standing barriers to accessing HIV testing are likely
to remain pertinent – individuals who do not feel ‘ready’ to know their status,
who worry about HIV-related stigma or who fear dying of AIDS will probably
still be reluctant to test.
While self-testing is not prohibited in South Africa and the
OraQuick In-Home HIV Test is available, influential stakeholders have warned
against self-testing. Concerns include the lack of counselling, the challenge
of ensuring linkage to care, the potential for coercive use of self-testing devices, and their accuracy. The 2015 national guidelines state that “HIV self-testing is
currently not recommended and supported in South Africa”.
Researchers from Médecins Sans Frontières (MSF) wanted to better
understand whether HIV self-testing could help more people to know their HIV
status. Although HIV testing is offered to all patients at MSF health facilities
in the Khayelitsha informal settlement near Cape Town, only 30% accept.
In-depth interviews and focus group discussions were
conducted with nine individuals (mostly men) who had declined HIV testing as
well as seven female healthcare workers (nurses, counsellors, community
caregivers). In addition, two individuals who had accepted testing were
interviewed alongside their sexual partners. The OraQuick device was
demonstrated during interviews and focus groups.
MSF have used the findings to inform a
pilot intervention offering self-testing in Khayelitsha.
In line with previous research, respondents shared the
perception that the OraQuick device is easy to use, provides an alternative for
people concerned about intimacy and confidentiality, and gives individuals control
of when and where to test.
A 20-year old man said:
“It’s better because
you can take this and go home. Nobody sees your results. Only you know. I
prefer that it’s confidential. I know that I do have HIV but nobody saw me,
it’s me alone. Now it’s my duty to go there and take the ARVs.”
Men and young people were thought to be particularly likely
to benefit from a provision of HIV testing away from health facilities – spaces
associated with women’s health-seeking behaviour.
“They [men] don’t even
wanna go to the private clinic, mobile clinic... If you give this test, they
take it and do it to themselves, it is gonna be much easy for them.”
However the research identified many barriers to HIV testing
which the provision of self-testing kits would be unlikely to overcome. Many
individuals who might suspect that they have HIV were described as being ‘not
ready’ for testing.
“There are people who
are still treating people who are diagnosed [with AIDS] as outcasts from the
community. That’s why you find out that some people are still afraid to know their
status, and some of them are not aware that if you are HIV-positive you still
are as healthy as everyone if you are taking the ART. . . once there is
somebody who is diagnosed with HIV, the only think that clicks in somebody’s
mind is that ‘I am going to die’.”
Social pressures on men to conform to a public image of
masculinity were described. Men are expected to provide for their families, to
be able to bear life’s adversities and only attend clinics when sick.
Respondents tended to distinguish between the acceptability
of the device and actual uptake of self-testing. If an individual was not
convinced of the importance of knowing his or her status, self-testing would still not be used.
Respondents also raised concerns about some possible
disadvantages of self-testing. In line with the everyday dominance of men over
women in the community, men may coerce their female partners into testing.
Discordant results within a couple might result in arguments or violence –
especially if they had not received any counselling. People getting reactive results
might be unlikely to seek confirmatory tests or link themselves to medical
care. People getting negative results might be sexually disinhibited:
“You want to celebrate!
… You feel released and throw the condom away!”
The healthcare workers who took part in the study were
especially likely to have concerns about potential harms. Some suggested that
kits should only be provided to individuals who could demonstrate that they
fully understood the procedures involved and who would be ready to attend
post-test counselling. However the researchers comment that too much contact
with health workers or follow-up could remove one of the perceived benefits of
The study has informed a pilot intervention at Médecins Sans
Frontières' facility in Khayelitsha. Individuals who decline HIV testing in the clinic
will be offered a self-testing kit to take away. Rather than simply make the
kits available, their use will be introduced by counsellors.
As suggested by respondents, counsellors will explain HIV
transmission pathways, the concept of antibody-based testing, the window
period, the need to continue using condoms, and how to link to care. Printed
materials explaining how to use the kit will be provided in the local Xhosa
language. Follow-up will involve enquiring about test results via mobile phone
technologies, asking about harms and measuring linkage to care.