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

What is HIV self-testing?

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.

While there is no HIV self-test currently available in Canada, the INSTI HIV self-test, a finger-prick blood test for HIV self-testing, is under review for approval in Canada. This test has already been approved for use as a point-of-care test in Canada.

What did the literature review examine?

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:

• performance of oral-fluid tests versus blood tests
• acceptability of self-tests and people’s willingness to pay for them
• ability of self-tests to reach individuals not accessing conventional HIV testing
• pre-test counselling, post-test counselling and linkage to care

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

What are the potential benefits of HIV self-testing?

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.

What are the potential challenges and opportunities associated with HIV self-testing?

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:

• Individuals are able to conduct both oral-fluid and blood HIV self-tests as successfully as healthcare workers.
• Blood self-tests are better able to correctly identify an HIV-positive test result than oral-fluid self-tests, that is, they have greater sensitivity (fewer false-negative results).
• Blood self-tests are better able to correctly identify an HIV-negative test result than oral-fluid self-tests, that is, they have greater specificity (fewer false-positive results).
• Although blood self-tests have better sensitivity and specificity than oral-fluid self-tests, blood self-tests are more likely to be invalid because of user or manufacturer error, potentially due to the greater likelihood that an insufficient sample will be collected with blood versus oral-fluid tests. It is important to ensure that HIV self-testing kits include instructions for how to properly collect samples.
• Blood self-tests are able to identify HIV infection earlier than oral-fluid tests, that is, they have a shorter window period.

The review also found that people who self-test prefer oral-fluid collection over blood collection. Given that the first HIV self-test to be approved in Canada will be 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 to be used 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.

What are the implications of the review for service providers?

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:

• Self-testing is an effective testing option to offer alongside conventional testing. Self-tests are effective at reaching people not currently reached by conventional testing, including first-time testers and individuals who otherwise would not have tested for HIV or are undertested. Self-testing can also be an efficient testing alternative for individuals who test frequently and are already familiar with pre-test counselling messages.
• Blood tests were found to be more accurate than oral-fluid tests at identifying HIV infection; however, individuals preferred oral-fluid collection over blood collection. Testing programs can address concerns about blood collection in their education related to HIV self-testing.
• Facilitating public access to self-test kits can remove cost-related barriers potentially associated with HIV self-tests.
• There are many potential methods for pre- and post-test counselling of people who self-test. Service providers incorporating self-tests into their programming can support people who are self-testing with pre- and post-test counselling resources. Various pre- and post-test counselling delivery methods are available, and therefore counselling approaches can be tailored to the preferences of specific populations. mHealth could play a role in post-test prevention education counselling for people whose HIV self-test result is non-reactive.
• Linkage to care is not optimal among people who use self-tests unless an evidence-based approach (e.g., follow up by trained personnel, telephone hotlines) is used. Options for linkage need to be available for people who self-test. Testing programs incorporating self-tests into their services can have a role to play in following up with people who self-test to facilitate linkage to care.

When considering this review, it is important to remember the following:

• The review provides a broad overview of the challenges of HIV self-testing, and these factors may not affect all populations in the same way. Further audience-specific considerations will need to be taken into account by service providers looking to implement self-testing in their communities.
• The review describes examples of HIV self-testing interventions, but it doesn’t assess the strength of the reported outcomes or whether certain self-testing interventions are better than others. Further research can help address which interventions are most effective at realizing the benefits and overcoming the challenges of HIV self-testing.

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

1. Public Health Agency of Canada. Summary: Estimates of HIV Incidence, Prevalence and Canada’s Progress on Meeting the 90-90-90 HIV Targets, 2016. Ottawa: Public Health Agency of Canada; 2018. Available from: https://www.canada.ca/en/public-health/services/publications/diseases-conditions/summary-estimates-hiv-incidence-prevalence-canadas-progress-90-90-90.html
2. Steehler K, Siegler AJ. Bringing HIV self-testing to scale in the United States: A review of challenges, potential solutions, and future opportunities. Journal of Clinical Microbiology. 2019; 57(11):e00257-19.
3. World Health Organization. Guidelines on HIV Self-testing and Partner Notification:Supplement to Consolidated Guidelines on HIV Testing Services. Geneva: World Health Organization; 2016. Available from: https://www.who.int/hiv/pub/self-testing/hiv-self-testing-guidelines/en/