The first step to guiding people living with HIV towards treatment is empowering them to know their HIV status. Yet in many places where MSF works, there is a reluctance to get tested at a clinic, and link to treatment. The fear and stigma still associated with HIV, lack of confidentiality, long distances to clinics, staff un-friendliness and limited clinic opening hours are just a few reasons.
HIV self-testing (HIVST) – where a person collects their own sample (oral fluid or blood) and then performs the HIV test (with or without supervision), interpreting the result often in private – is a discrete, empowering and innovative way to increase HIV testing among people who are harder to reach with ‘classical’ testing and counselling strategies. HIVST is a valuable addition to the choices that can be offered alongside other testing approaches (see WHO’s Guidelines for Self-testing and Partner Notification)
While it should be remembered that HIVST is a screening tool, which must be followed by a confirmatory test, early evidence suggests that it offers benefits in accessing hard-to-reach groups such as men, adolescents, and sex workers who are at highest risk of HIV infection.
MSF and HIVST
In the coming years, MSF will substantially expand the use of HIVST through coordinated, intersectional initiatives in multiple countries, deliberately targeting a variety of high and low prevalence settings with various delivery strategies. New approaches will be explored to help reach the 40% of people not yet diagnosed with HIV, and those most vulnerable or exposed to HIV yet most unlikely to test, including drug users, sex workers, and young women, and men in general.
MSF teams are working on answering a variety of research questions about the acceptability and feasibility of self-testing in different contexts. A major consideration is how people who test positive get the essential confirmatory HIV test, and how they are linked to treatment. Another key question is how HIVST can be used to maintain links with people who test HIV negative to increase the likelihood of retesting, particularly among high-risk groups as part of prevention strategies that could also include condoms, PreP and circumcision.
So far, MSF has completed small feasibility or pilot studies on self-testing in Swaziland, and South Africa (Eshowe and Khayelitsha) and is now implementing self-testing projects in Khayelitsha, DRC (Kinshasa) and Guinea (Conakry) with more to come. Self-tests are available alongside condoms in many MSF offices in South Africa for staff to use.
Resources for HIVST
Although the SELF-test suggests it is individually directed, it is crucial that people using an HIVST really understand when and how to make use of it. Health promotion strategies should be integrated into all HIVST initiatives to encourage uptake, correct use and linkage to care. Useful tools include demonstration videos, leaflets, posters and hotlines which are being variously used in MSF HIVST projects.
An intersectional HIV-ST Coordinator (based in Amsterdam and managed by MSF’s Aids Working Group) has now been recruited to coordinate around MSF strategies for the implementation of HIVST in different settings among various populations.
In addition, all HIVST-related health promotion material from MSF projects is being collected by SAMU, and is available via OneDrive here.
A great example is this instructional video from MSF’s HIV team in Conakry, Guinea to explain HIVST to pregnant mothers:
SAMU is also providing support on HIVST operational research and implementation aspects, including health promotion to increase knowledge about HIVST and also establishment of comprehensive systems for maintaining accuracy in HIV-ST activities.
It should be remembered that MSF is just one small player alongside many other actors implementing and researching HIVST. Considerable external resources are therefore available to support teams implementing HIVST – with hivst.org offering the most comprehensive resources, including tools to improve linkage to care.