Testing the Limits

HIV Self-Test Programs Yield Promising Results

Over the past 15 years, the global health community has made incredible progress towards ending the Human Immunodeficiency Virus (HIV) epidemic. The rates at which those who are HIV-positive know their status, have access to Antiretroviral Therapy (ART), and are able to reach viral suppression — the main goal of ART — have increased dramatically, largely thanks to initiatives from governments and Non-Governmental Organizations (NGOs). However, at our current rate of progress, the world is still not on track to reach the 90/90/90 goals set out by the United Nations in 2014. These goals were, by 2020, to have 90 percent of HIV-positive people aware of their HIV status, to have 90 percent of those people on ART, and to have 90 percent of those people virally suppressed. If the international community is going to reach these benchmarks, something needs to fill in the gaps left by conventional HIV-treatment programs.

One candidate for this is HIV self-testing. On October 24, Kristen M. Little, Senior Research Adviser at Population Services International (PSI), presented on the current state of HIV self-testing around the globe. Sponsored by the economics department, the talk focused on the efficacy of various forms of self-testing kits currently on the market in Sub-Saharan Africa. Similar to pregnancy tests, these kits require a small sample from the user (most commonly saliva or blood) and can return a positive or negative HIV result within just a few minutes.

Ideally, the kits serve as a way for those who worry about their exposure to HIV to discover their HIV status when it would be problematic for them to visit a clinic. Many factors might lead to this situation, the most common of which is social stigma. In small communities, it can be very worrying for someone to visit a clinic to have an HIV test conducted, since there is a large chance that they might be recognized by another member of their community, or that the person conducting the test might themselves be a community member. This is especially difficult for certain “key populations,” including gay men, drug users, and other socially marginalized people who face high rates of exposure to HIV.

While self-testing kits can be very effective for these groups, there are still large barriers to their efficacy. The first, and most important, is cost. While the average price that a Kenyan is willing to pay is around one or two U.S. dollars, the actual price is closer to nine dollars. This issue can be mitigated by increased support for HIV self-testing kits from governments and donors. However, these potential supporters are often made hesitant by the lack of studies and evidence surrounding self-testing, especially when it comes to rates of treatment after an end-user tests themselves as HIV-positive. Bridging these difficult evidence gaps is one of the main priorities for HIV researchers currently.

Another issue is usability. These kits require precise usage in order to be effective, and they are often not very intuitive for the user. Traditional written instruction manuals often face mistranslations and fail to bridge cross-cultural divides. For example, one early version of a self-testing kit attempted to use symbols to instruct the end-user how to properly use the kit. Images seemingly obvious to an American, such as a dinner plate with a red slash through it instructing the user not to consume the test, were seen in an entirely different context. Many of the test users in Sub-Saharan Africa did not use the same eating utensils customary in the United States. And they also did not identify the red slash-through as a sign of negation. In successive iterations of the kit, many manufacturers have turned instead to video instruction, which leads to less confusion for users not culturally aligned with the manufacturers.

The successes and setbacks of implementing HIV self-testing across the world demonstrate larger lessons about public health innovation. In opposition to the truism “if you build it, they will come,” the main takeaway Dr. Little wanted those in attendance to understand was that public health innovations do not diffuse on their own. They must be actively pushed, marketed, and explained not only to the manufacturers and customers involved in their production, but also to world governments and agencies responsible for their distribution and adoption.