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World’s largest study of HIV self-testing gets off the ground
Roger Pebody, 2016-07-22 06:00:00

Early data from STAR, the largest study yet of HIV self-testing, suggests that there is a strong demand for self-testing in rural Zimbabwe, the 21st International AIDS Conference (AIDS 2016) heard this week. Other studies examined whether self-testing kits can help the male partners of pregnant women to test and whether such use might sometimes be coercive.

The World Health Organization (WHO) defines HIV self-testing as “a process in which an individual who wants to know his or her HIV status collects a specimen, performs a test and interprets the result by him or herself, often in private”. By giving people the opportunity to test discreetly and conveniently, HIV self-testing may increase the uptake of HIV testing among people not reached by other HIV testing services, including people who have never taken a test.

The STAR project is is aiming to explore a range of distribution methods in order to understand their effectiveness in reaching end-users and facilitating linkage to care. The four year project aims to ‘catalyse’ the market for HIV self-testing and generate evidence on the feasibility, acceptability, scalability, costs and cost-effectiveness of different approaches.

As well as influencing WHO guidance and national policies, the project aims to help companies and policy makers understand the size of the market for HIV self-testing - this could encourage manufacturers to invest more in this area.

In the first phase of the study (2015-2017) over 730,000 HIV self-tests are being distributed across Malawi, Zambia and Zimbabwe. The second phase of the project (2017-2019) will be extended to South Africa and will provide a further two million tests through the most successful distribution models in order to demonstrate the population-level health impact of HIV self-testing.

Distribution models being examined include:

  • Open access, through retail pharmacies.
  • Semi-restricted distribution by community health workers, sex worker peer educators and voluntary medical male circumcision mobilisers.
  • More restrictive distribution by clinicians in various settings: public sector health facilities, male circumcision clinics, HIV testing sites and private healthcare providers.

The conference heard data from a pilot project using paid community volunteers in one rural area of Zimbabwe. A process of community consultation identified 79 volunteers  who were trusted by their peers to go door-to-door to explain and distribute self-test kits.

Demand for the devices outstripped supply, with 8,095 kits distributed in a month. The volunteers were successful in reaching both men and women, with an estimated 61% of adult men and 52% of adult women receiving test kits.

Health workers in the region sometimes express the view that self-testing will best be done under the supervision of a health worker, so as to ensure that counselling is provided and the result is accurately read. This was an option in the project but the overwhelming majority of people (85%) preferred to take the test in private.

Focus group discussions were held in the community a few weeks later. Most respondents appreciated both the offer of self-testing and the knowledgeable and helpful community volunteers. Nonetheless some people said it could be hard to turn down the offer of the tests “because you respect the volunteer and they have put a lot of effort coming to your house”.

During focus groups it became apparent that some people with previously diagnosed HIV used a self-test in order to ‘verify’ their HIV status.

In a second Zimbabwean study, outreach workers brought a mobile testing unit to both rural and peri-urban communities. Given the choice between being tested by a health worker and using a self-test kit, 70% chose self-testing.