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Self-testing is a strategy that could expand HIV testing in Canada, where an estimated 14% of people with HIV are unaware of their HIV status.1 In other countries, HIV self-testing has been used either in the home environment through individual purchase or within HIV testing programs. It has been used to complement conventional forms of HIV testing. This article summarizes a literature review that examines the challenges and opportunities associated with HIV self-testing as well as evidence on potential solutions that may help us to better implement HIV self-testing in Canada.2
HIV self-testing involves an individual taking their own sample for HIV testing and then performing the test and interpreting the results themselves.3 Some HIV self-tests use oral fluid while others use blood collected through a finger prick. A positive HIV self-test result requires a second test performed by a trained HIV tester to confirm the diagnosis.
The INSTI HIV self-test, a finger-prick blood test for HIV self-testing, has been licensed for use in Canada. This test is also approved for use as a point-of-care test in Canada.
A literature review was conducted to examine the potential challenges and opportunities associated with the use of HIV self-testing and what the evidence suggests as solutions to the potential challenges. The review was conducted to inform the scale up of HIV self-testing in the United States, but it discusses factors and issues that can also apply in Canada.
The review focused on four core areas:
For more information on any of the information summarized below, please refer to the original review article Bringing HIV Self-Testing to Scale in the United States: a Review of Challenges, Potential Solutions, and Future Opportunities.2
The review of the literature identified many benefits of HIV self-testing. These include ease of use, convenience, ability to maintain privacy, ability to circumvent the stigma that may prevent people from accessing conventional testing approaches and ability to integrate self-testing into programs.
Because HIV self-testing can overcome some of the barriers to conventional testing, it has the potential to reach individuals who rarely test through conventional testing approaches, and it has the potential to increase testing frequency among individuals who are undertested.
Performance of oral-fluid self-tests versus blood self-tests
One of the potential concerns around HIV self-testing is the performance or accuracy of HIV self-tests. The literature review found that HIV self-tests are very accurate:
The review also found that people who self-test prefer oral-fluid collection over blood collection. Given that the first HIV self-test licensed for use in Canada is a blood test, it will be important to consider users’ willingness to use a test requiring finger-prick blood collection in self-testing education and promotion. The review found that one way to potentially address this concern could be to offer additional testing for sexually transmitted infections alongside HIV testing, as the possibility of conducting multiple tests at the same time made the finger prick more acceptable to some users.
The HIV self-test licensed for use in Canada is the INSTI self-test, a third-generation HIV test. According to the review, third-generation blood self-tests have a window period of about 22 days. The sensitivity of this test was found to range from 96.2% to 99.8% and the specificity was found to range from 98.2% to 99.8%. This means this test has a high degree of accuracy.
Acceptability of self-tests and individuals’ willingness to pay for them
Another potential concern with HIV self-testing is the acceptability of this form of testing for at-risk populations, and the willingness of individuals to pay for self-tests. The review found that HIV self-tests were acceptable to a range of different at-risk populations including men who have sex with men, sex workers, people who use drugs and trans women.
Individuals in high-income settings were found to be more willing to pay for a single HIV self-test than people in middle- or low-income settings, although the review noted that willingness was difficult to compare across studies because of the use of different price measurements. One way to address cost-related barriers would be to use public funding to provide free self-tests or subsidize the cost of self-tests. The review found that distribution of test kits by the public health system removes cost barriers and helps to reach lower socioeconomic groups.
Ability of self-tests to reach individuals not accessing conventional HIV testing
A potential opportunity associated with HIV self-testing is the ability of HIV self-testing to reach populations that are not currently being reached through conventional HIV testing. The review found that HIV self-testing can help reach people who are testing for the first time, who would otherwise not have tested for HIV and who are undertested (not testing as frequently as guidelines recommend). This speaks to the ability of HIV self-testing to complement conventional testing approaches and provide a new way to reach undiagnosed individuals and link them to care and treatment.
Specifically, peer-based or secondary distribution of self-test kits, where individuals share test kits with people in their networks, was found to be successful in reaching first-time testers. Other mechanisms to distribute HIV self-tests can include online, public health and clinic-based distribution, but more research is needed to determine the best distribution method(s).
The review noted the potential for interventions that are delivered via mobile phones (i.e., mHealth or mobile health) to improve HIV self-testing rates, as they automate testing reminders (e.g., text messages) and increase communications with clients without placing a burden on the health care system.
Pre-test counselling, post-test counselling and linkage to care
A final concern about HIV self-testing is the ability to incorporate pre- and post-test counselling and linkage to confirmatory testing and care. According to the literature review, several methods have been used to incorporate pre-test counselling with self-testing, including test kit inserts, telephone hotlines, phone text messages, websites, apps, online video counselling and pre-recorded online videos. The review was unable to compare specific methods of pre-test counselling or to recommend a particular one, as more research is needed to assess their effectiveness.
The review did note that the availability of different delivery methods for pre-test counselling provided an opportunity for service providers to offer different methods of pre-test counselling to suit the counselling preferences of different populations. The option of conducting HIV self-testing without pre-test counselling could be useful for people who have already experienced pre-test counselling on multiple occasions: it could make the testing process more efficient by avoiding the repetition of messaging that individuals have previously experienced and might also increase testing frequency.
The review found that several methods exist for post-test counselling including test kit inserts, telephone hotlines and online delivery using tools such as videos.
Linkage to care was found to be suboptimal for people with a reactive result on an HIV self-test, unless an evidence-based post-test counselling method is used. The review identified active methods of post-test linkage to care including one-on-one follow-up by a trained service provider using approaches such as phone text message or phone call. The review also identified passive methods of linkage to care such as brochures and flyers, telephone hotlines, phone messaging services, online programs and tools, vouchers and coupons, and appointment or referral cards. Both active and passive methods are included in the World Health Organization’s self-testing guidelines and described as potentially effective, although the evidence is limited.3
The review noted the potential of mHealth to assist with linkage to prevention services after a non-reactive (i.e., negative) HIV self-test. Further research into the use of mHealth for prevention education is needed.
The evidence from this review highlights challenges and potential solutions and opportunities for HIV self-testing that can affect its implementation. Service providers looking to develop programs to support HIV self-testing should consider the following:
When considering this review, it is important to remember the following:
Related resources
Reaching the first 90: how HIV self-testing can help us end the HIV epidemic (CATIE Blog)
HIV Testing – I know my HIV status (CATIE)
Task-shifting in HIV testing services (CATIE)
Peer distribution of HIV self-test kits (CATIE)
References
Erica Lee is CATIE’s manager, website content and evaluation the information and evaluation specialist at CATIE. Since earning her Master of Information Studies, Erica has worked in the health library field, supporting the information needs of frontline service providers and service users. Before joining CATIE, Erica worked as the Librarian at the AIDS Committee of Toronto (ACT).