Abstract
IntroductionHIV self-testing (HIVST) has the potential to increase uptake of HIV testing among untested populations in sub-Saharan Africa and is on the brink of scale-up. However, it is unclear to what extent HIVST would be supported by stakeholders, what policy frameworks are in place and how variations between contexts might influence country-preparedness for scale-up. This qualitative study assessed the perceptions of HIVST among stakeholders in three sub-Saharan countries.MethodsFifty-four key informant interviews were conducted in Kenya (n=16), Malawi (n=26) and South Africa (n=12) with government policy makers, academics, activists, donors, procurement specialists, laboratory practitioners and health providers. A thematic analysis was conducted in each country and a common coding framework allowed for inter-country analysis to identify common and divergent themes across contexts.ResultsRespondents welcomed the idea of an accurate, easy-to-use, rapid HIV self-test which could increase testing across all populations. High-risk groups, such as men, Men who have sex with men (MSM), couples and young people in particular, could be targeted through a range of health facility and community-based distribution points. HIVST is already endorsed in Kenya, and political support for scale-up exists in South Africa and Malawi. However, several caveats remain. Further research, policy and ensuing guidelines should consider how to regulate, market and distribute HIVST, ensure quality assurance of tests and human rights, and critically, link testing to appropriate support and treatment services. Low literacy levels in some target groups would also need context-specific consideration before scale up. World Health Organization (WHO) policy and regulatory frameworks are needed to guide the process in those areas which are new or specific to self-testing.ConclusionsStakeholders in three HIV endemic sub-Saharan countries felt that HIVST will be an important complement to existing community and facility-based testing approaches if accompanied by the same essential components of any HIV testing service, including access to accurate information and linkages to care. While there is an increasingly positive global policy environment regarding HIVST, several implementation and social challenges limit scale-up. There is a need for further research to provide contextual and operational evidence that addresses concerns and contributes to normative WHO guidance.
Highlights
HIV self-testing (HIVST) has the potential to increase uptake of HIV testing among untested populations in subSaharan Africa and is on the brink of scale-up
We conducted key informant interviews (KII) with stakeholders who were purposively sampled in order to achieve a range of different perspectives of those working in HIV programming, including those with decision-making authority regarding HIV testing strategy and policy; HIV test procurement, and researchers
The views on constraints or opportunities of HIVST described here were initiated by respondents unless otherwise stated
Summary
HIV self-testing (HIVST) has the potential to increase uptake of HIV testing among untested populations in subSaharan Africa and is on the brink of scale-up. The global policy framework on HIVST has moved rapidly since the First International Symposium on HIV Self-testing (HIVST) in 2013 debated the legal, ethical gender and human rights aspects and set out a research agenda [1] This was followed by a review of research and policy priorities [2] and the release of a technical update on HIVST [3] that provided an outline to the steps countries need to take before embarking on HIVST scale-up. National HTC strategies usually endorse a basket of approaches to reach target populations and combine provider-initiated testing in health facilities with traditional stand-alone voluntary counselling and testing sites and a range of community outreach approaches. Critical gaps remain with up to 50% of people untested; key populations, men and adolescents underserved [13,14] and traditional HTC approaches failing to achieve rates of linkage to care and treatment services adequate to ensure public health gains without additional strategies and resources [15Á19]
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