HIV self-testing: the key to unlock the first 90 in West and Central Africa

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HIV self-testing: the key to unlock the first 90 in West

and Central Africa

Didier Koumavi Ekouevi, Alexandra Bitty-Anderson, F. A.

Gbeasor-Komlanvi, Ahuatchi Patrick Coffie, Serge Paul Eholie

To cite this version:

Didier Koumavi Ekouevi, Alexandra Bitty-Anderson, F. A. Gbeasor-Komlanvi, Ahuatchi Patrick

Coffie, Serge Paul Eholie.

HIV self-testing:

the key to unlock the first 90 in West and

Central Africa.

International Journal of Infectious Diseases, Elsevier, 2020, 95, pp.162-166.

Perspective

HIV

self-testing:

The

key

to

unlock

the

first

90

in

West

and

Central

Africa

Didier

K.

Ekouevi

*,

Alexandra

M.

Bitty-Anderson

,

Fifonsi

A.

Gbeasor-Komlanvi

,

Ahuatchi

P.

Cof

_fie

,

Serge

Paul

Eholie

a

UniversitédeLomé,FacultédesSciencesdelaSanté,Lomé,Togo

b

CentreAfricaindeRechercheenEpidémiologieetenSantéPublique,Lomé,Togo

c

ISPED,UniversitédeBordeaux&CentreINSERMU1219–BordeauxPopulationHealth,Bordeaux,France

d_{ProgrammePACCI,siteANRS,Abidjan,Coted’Ivoire} e

UnitépédagogiquedeDermatologieetInfectiologie,UnitédeFormationetdeRechercheenSciencesMédicales,UniversitéFélixHouphouët-Boigny,Abidjan, Coted’Ivoire

f

CentredeRecherchesurlesMaladiesInfectieusesetlesPathologiesInfectieuses,UniversitéFélixHouphouët-Boigny,Abidjan,Coted’Ivoire

ARTICLE INFO Articlehistory:

Received13November2019

Receivedinrevisedform7February2020 Accepted11February2020

Keywords: HIVSelf-testing Challenges Implementation WestandCentralAfrica

ABSTRACT

TheWestandCentralAfricanregion(WCAR)stillregisterssomeofthehighestratesofnewHIVinfections worldwide(16%)despitealowprevalenceofHIV(1.9%).Inthisregion,only48%ofpeoplelivingwithHIV areawareoftheirHIVstatus.Tofillthisgap,HIVSelftesting(HIVST)couldpotentiallybeanadditional approachtoovercomethebarrierstodiagnoseHIVinfectedpatients,thereforebeingoneofthekeysto unlockthefirst90asrecommendedbytheWorldHealthOrganization(WHO)since2016.However,many challengesremainfortheadoptionofHIVSTinroutineclinicalpracticeinlowprevalencesettingsand needtobecontextualizedtoWCARsettings.Wereportinthispapersomeofthechallengesanddiscuss opportunitiesforasuccessfulimplementationofHIVSTintheWCAR.

©2020TheAuthors.PublishedbyElsevierLtdonbehalfofInternationalSocietyforInfectiousDiseases. ThisisanopenaccessarticleundertheCCBY-NC-NDlicense( http://creativecommons.org/licenses/by-nc-nd/4.0/).

Introduction

In 2014, the Joint United Nations Program on HIV/AIDS (UNAIDS) introduced a strategy aimed at eliminating the HIV epidemicby2030,byachievingthefollowinggoals:diagnose90% ofallHIV-positivepersons,provideantiretroviraltherapy(ART)to 90%ofthosediagnosedandachieveviralsuppressionfor90%of thosethreated,by2020(Levietal.,2016).Sincethen,therehas beenaglobalsurgefromnationalentitieswiththegoalofreaching thosegoalsby2020.

Sub-Saharan Africa(SSA)is theregionoftheworldwiththe highestburdenoftheHIVepidemic.TheWestandCentralAfrican region(WCAR),whichcomprises25countries,ishometo7%ofthe worldpopulationandto17%(6.1million)ofallpeoplelivingwith HIV(PLHIV)worldwide(JointUnitedNationsProgrammeonHIV/ AIDS(UNAIDS),2020).TheaverageprevalenceofHIVinWCARis relativelylowcomparedtothatofEasternandSouthernAfricawith 1.9%vs.6.8%in2017(AVERT,2020a;AVERT,2020b),butWCARstill

registers some of the highest rates of new HIV infections worldwide(16%)(AVERT,2020;JointUnitedNationsProgramme on HIV/AIDS (UNAIDS), 2020) and 21% of AIDS-related deaths (AVERT,2018).TheWCARcontinuestolagbehindtherestofSSA withonly8%and24%declinesinnewinfectionsandAIDSrelated deaths,respectively,since2010,whilenewinfectionsdeclinedby 29%intheEasternandSouthernAfricaregionoverthesameperiod (UNAIDS,2019).Inregardtothecascadeofcare,only48%ofPLHIV areawareoftheirHIVstatus,40%ofPLHIVareonantiretroviral therapy(ART)and29%arevirallysuppressed(AVERT,2018).The latest report of UNAIDS underlines these disparities in WCAR wherelessthan60%oftheHIVpopulationistested.Thereportalso pointedoutthedifficultiesinthis regionspecificallyinkeyand vulnerablepopulations,whicharestillstigmatizedand discrimi-natedinthisregionmorethaninothersettingsinSSA(UNAIDS, 2019).

Basedonthesegaps,HIVSelftesting(HIVST)couldpotentially beanadditionalapproach toovercomethebarrierstodiagnose HIV-infectedpatients,thereforebeingoneofthekeystounlockthe first90asrecommendedbytheWorldHealthOrganization(WHO) since2016(WorldHealthOrganization,2020).

Self-testingisdefinedasaprocessinwhichapersonwhowants toknowhisor herHIV status usesa kittocollecta specimen,

*Correspondingauthorat:UniversitédeLomé(Togo),FacultédesSciencesdela Santé,DépartementdeSantéPublique,Togo.

E-mailaddress:didier.ekouevi@gmail.com(D.K. Ekouevi).

https://doi.org/10.1016/j.ijid.2020.02.016

1201-9712/©2020TheAuthors.PublishedbyElsevierLtdonbehalfofInternationalSocietyforInfectiousDiseases.ThisisanopenaccessarticleundertheCCBY-NC-ND license(http://creativecommons.org/licenses/by-nc-nd/4.0/).

ContentslistsavailableatScienceDirect

International

Journal

of

Infectious

Diseases

performsatestandinterpretsthetestresultsforhimselforherself (WorldHealthOrganization,2020).Multi-countryevidencefrom EasternandSouthernAfricaconfirmshighfeasibility,acceptability and accuracy of HIVST across many delivery models and populations,includingadolescents,menandfemalesexworkers, with reassuringly minimal harm (World Health Organization, 2020;Figueroaetal.,2015;Chokoetal.,2018;Chokoetal.,2015; Lippmanetal.,2018;vanDyk,2013).TwopilotstudiesonHIVST werefundedbyUNITAIDinsub-SaharanAfrica(SSA).Theongoing STARInitiativeisafive-yearprojectdividedintotwophases.The first phase (2015–2017) in Malawi, Zambia, and Zimbabwe generated information abouthow to distributeHIVST products effectively,ethically,andefficiently,andansweredquestionsabout thefeasibilityandacceptabilityofHIVSTinthegeneralpopulation (Ingoldetal.,2019;Hatzoldetal.,2019).Thesecondphaseofthis projectisongoingwithaddedcountriesofSouthAfrica,Swaziland andLesotho,andwilldistribute4.8millionHIVSTkitsby2020.The second project, ATLAS, launched in 2018 aiming to assess the feasibility and acceptability of HIVST among people with the highestriskofcontractingHIVinthreecountriesinWestAfrica: Côted’Ivoire,Mali,andSenegal(UNITAID,2019).Arecentstudy conductedin theDemocraticRepublic ofCongohasshown the same findings and an excellent practicability comparable to EasternandSouthernAfrica(Tonen-Wolyecetal.,2019a).Todate, 18 WCAR countries have adopted HIVST in their national HIV testingpolicyguidelines,ninesetuppilotstudies,andonlyone (Nigeria)hasimplementeditwitha rolloutplan(WHO,2020). Many challenges remain for the adoption of HIVST in routine clinical practice in low prevalence settings and need to be contextualized toWCARsettings.The objectiveof this paperis to examine these challenges and discuss opportunities for a successfulimplementation.

Firstchallenge:identifythebestthetargetpopulation

Public health strategies should target and prioritize three populations:men,adolescentsandwell-knownkeypopulations. HIV testing is a public health priority especially among key populationssuchasfemalesexworkers(FSWs),clientsoffemale sexworkers,sexpartnersofotherkeypopulationsandmenwho havesexwithmen.InWCAR,64%ofnewHIVinfectionsoccurredin these populations (UNAIDS, 2019). However, thepopulation of WCAR is predominantly young, with more than 64% of the populationundertheageof24(UnitedNationsPopulationFund, 2018).Thispopulation, with62,000adolescents newlyinfected withHIVin2016,hasthehighestrateofHIVincidence(UNAIDS, 2020).Ingeneral,adolescentsrarelyhaveapointofentryintothe healthcaresystemandstructuresofHIVtestingandcounseling (HTC)specificallydedicatedtothemarepracticallynon-existent, whichmakesthemparticularlyvulnerable.HIVSTwouldofferthe opportunity for adolescents to access HIV testing and would contributetoincreasingtheratesofHIVtestinginthispopulation. Foradolescents,therearemultipleapproachesthatcouldbeused to promote access to HIVST:the door-to-door HIVSTapproach whichconstitutesaninnovativewaytodistributeself-testkits; m-Healthincludingsocialmediaplatformsinlocallanguagestoraise awarenessandtopresentthevideo-basedinstructionsforuseof the HIVST; and facilitating the delegation of tasks allowing community health workers to facilitate access to HIVST by adolescents in a community-based approach (Tonen-Wolyec etal.,2019c).

InWCAR,althoughwomenaredisproportionallyaffectedbythe HIV epidemic with higher prevalence and incidence of HIV comparedtomen,menarestill importantinbreakingthecycle ofheterosexualHIVtransmission(KharsanyandKarim,2016;Sileo etal.,2018).TherearenodedicatedservicesformenforHIVtesting

similartothose forwomen,whoaresystematicallyofferedHIV testing during antenatal consultation. Moreover, men are less likelytoaccessHIVcareservices,includingHIVtestingservices due toculturalandgendernorms,andotherstructuralbarriers (facility operating hours, lackof confidentiality) (Camlin et al., 2016).Forthispopulation,HIVSTwouldpalliatetothosebarriers andcontributetomenhavingaccesstohealthcare.

Forkeypopulations,HIVSTshouldbeastrategyadditionalto otheravailableapproachessincetheprevalenceandincidenceof HIV in thesepopulations is still elevated (Joint UnitedNations ProgrammeonHIV/AIDS(UNAIDS),2010).Table1summarizesthe barriers to expanding HIV testing in WCAR according to the population.

Secondchallenge:acceptabilityofHIVST

Overall,interventionsontheimplementationofHIVSTinSSA have proven to be successful with higher rates of HIV testing uptakewithHIVSTcomparedtothestandardofcare(Bateganya etal.,2010).Differentstrategiescouldbeputinplacetoimplement HIVST in SSA: community-based or health facilities based (supervised) HIVST. In both strategies, themain reason for the preferenceforself-testsisthefactthattestingisinitiatedbythe clientratherthanthehealthcareprovider,comparedtoclassicHIV testingandcounselling, whichareinitiatedbytheproviderand remove the patient’s autonomy and potentially in the African context,confidentiality(vanDyk,2013).Community-basedHIVST consists in providing HIV self-tests toresidents of community clusters, with pre- and post-counseling offered by community workers. Thisstrategy has beenshown to besuccessful in the uptakeandincreaseofthenumberofpeoplegettingtestedand beinglinkedtoHIV care,especiallydue tocommunityworkers (Chokoetal.,2015;Mulubwaetal.,2019).HIVSTathealthfacilities referstotheself-administrationofanHIVself-testinsidethesite oftenunderthesupervisionofthehealthcareprovider(vanDyk, 2013).In both cases,HIVSThasthe advantagesof beinghighly acceptableand ofincreasingHIVtestinguptake among popula-tionsthataredifficulttoreachwithroutineHTC(malepartners, youngwomen,adolescents,students,femalesexworkers(Hatzold et al., 2019;Tonen-Wolyec et al., 2019a; Mulubwaet al., 2019; Harichund andMoshabela,2018;Pintyeetal.,2019).HIVSThas severalbenefits.Severalstudiesreportedincreasedconfidentiality andprivacy,decreasedburdenonthehealthcaresystem,decreased coercivetestingbyhealthcareworkers,anddecreasedstigmaand discriminationassociatedwithHIVST(HarichundandMoshabela, 2018).Autonomytomakeone’sownchoiceofHIVtestingmethod wasalsocitedasadvantageousbyvanDyketal.(vanDyk,2013). Makushaetal.,reportedthatHIVSThasthepotentialtoaddress genderdisparatebarrierstotesting,oftenencounteredbymalesat HIV testing centers, such as non-male friendly testing spaces, inconvenientoperating hoursand healthcare providerattitudes thatmaynotbesensitivetomen’sneeds(Makushaetal.,2015). Also,studyoutcomesfromcurrentliteratureontheadvantagesof HIVSTreiteratetheargumentthatHIVSTshouldbeofferedasa complementaryHIVdiagnosisorscreeningmethodtoovercome current barriers associated with conventional HIV testing approaches(voluntarycounsellingandtesting,provider-initiated counsellingandtesting,etc.)(HarichundandMoshabela,2018). Thirdchallenge:strategiesforthedistributionofHIVST

Two complementaryapproacheshavebeensuggestedbythe WHOandtheLiverpoolSchoolofTropicalMedicinein2013forthe implementationofself-testing.Inthefirstapproach,“supervised testing”,ahealthcareworkerfromthecommunityorthehealth center is involved at several steps in the provision, in the

administrationandinterpretation of theself-test.In the “unsu-pervised approach” to self-testing, HIV self-tests would be distributedbyhealthcareworkersinhealthcarecentersorwould beprovidedfromaregularpharmacy(Johnsonetal.,2014).Access toself-testscouldbefacilitatedbyvendingmachines,asisthecase forcondomdistribution.Thelevel ofeducationofpeopleusing HIVSTwouldthenbethemainfactorofchoiceforthesupervisedor unsupervisedHIVST.Hence,forthosewithhighlevelsofeducation, theprobability of errors in reading theresults of the test and interpreting is low. On the contrary, among those with low educational levels, the “supervised testing” would be the recommendedapproachtolimittheriskoferrors.IntheAfrican context,studieshavedemonstratedthatthepreferredchoiceof HIVSTbetweentheoralfluidself-testandthefinger-prickself-test, was thefirst method, due tothe ease of useand painlessness (Indravudhetal.,2018;Sibandaet al.,2019).HIVpre-and post-counseling are an essential aspect of HIV testing, for the psychological support of people willing to test for HIV (van Rooyenetal.,2015).Dependingontheapproachtoself-testing,on the level of education and on socio-economic factors, the counselingmodalitiesvary.The ATLASprojectis anexampleof animplementationprojectthatcouldhelptobetterdescribethe typeofHIV self-testingkitand counselling(e.g.,phone,regular clinicalvisit)thatcouldbedeliveredtoWestandCentralAfrican communities.

Fourthchallenge:linkagetoHIVpreventionandcareservices/facilities Thischallengeisparticularlyimportanttoachievethesecond andthird90targets.Thereisalsotheissueofpost-testcounseling andlinkagetocare,whichinthecontextofSSAandWCARremains animportantissue.Thegoalofincreasingthenumberofpeople whogettestedforHIVistobeabletogetpeopleundertreatment and to ultimately have PLHIV with undetectable viral load. Ensuring linkage to care should then be a condition for self-testing to be effective, in addition to post-test counseling for

behavioralchangeinthecaseofanegativeHIVtest(Bainetal., 2016).Linkage tocareis limited in WCAR,witha weakhealth systemandalackofpoliciesonHIVST.Toincreasethelinkageto careafterusingHIVST,somestrategiesaretestedsuchastheuseof smartphone applications and mHealth interventions (Adeagbo etal.,2019;Balánetal.,2020).Innovativeapproachesareneededto referHIV-infectedpatientsinthecontextoflowprevalenceofHIV. Fifthchallenge:funding/sustainability/susbsidy

Costisoneofthemajorconcernsforpoliciesthatwouldliketo implement HIVST. However, the largest gap between resource availabilityandthe2020resourcesneedstargethasbeenobserved inWCAR.Atthesametime,internationalfundingsupporttended toslowdownintherecentyears.Funding,cost,andquantification/ forecasting of HIVST are other critical aspects to take into consideration.Informationisscarceand insufficient toestimate theneedsofHIVSTatthenationallevelinascalingupprocess.A studyinMalawiexploredcost-effectivenessofHIVSTcomparedto facility-based HTC,and foundthat HIVSTcost was significantly lowerthanfacility-basedHTCfortheclient;however,itwasmore costly than facility-based HTC when needing to identify HIV-positiveindividuals andadministertreatments,hence aheavier burden for health care providers (Maheswaranet al., 2016).In anotherstudyoncostsofHIVST,respondentsindicatedthatthe governmentshouldberesponsiblefortheprocurementoftests, andshouldbepayingatleastsomepartofthecostoftestkits; respondents alsodrew a parallel betweenthe distributionand availabilityofself-testsand thatofcondoms(van Rooyenetal., 2015).Since2017,financialsupportprovidedbydonorstobring theunitcostoftheOraQuickself-testkitdowntoUS$2inselected sub-Saharan African, removed a critical cost barrier to HIVST expansion (Indravudh etal., 2018;OraSureTechnologies, 2013). Funding for self-tests could in fact be subsidized by local government,withinthe frameworkof controllingtheHIV/AIDS epidemic. Hopefully, the Global Fund (GF) and PEPFAR would expandaccessandsupportforHIVSTinSSA(Resource Mobiliza-tion,2020;PEPFAR,2018).Therecentpledgesof14billionUSDfor thereplenishmentofGFofferanexpectationtoreinforceprograms in global health for HIV testing through novel differentiated services and facilities models adapted to low-prevalence HIV settingssuchas WCARcountries(ResourceMobilization,2020). Thisdonorfunding,historicallyreducedinWCAR,willprobably help countriesin this region to unlockthe first 90 and reach UNAIDS95-95-95toendingAIDSin2030(TheLancetHIV,2017). The sustainability of HIV testing depends not only on the acceptability and feasibility of HIVST but also on the financial supportwhichcanhaveacriticaleffectonHIVST accessibility.First, aneedsassessmentiscrucialtoidentifythetargetpopulation.The privatesectorimplicationwillbeessential,aswellasaprivateand publicpartnership.Also,a cost-effectivenessofvariousdelivery modelsisneededtoidentifythebestpopulationtoprioritizein ordertoachievethefirst90.

Sixthchallenge:researchgaps

InWCAR,researchonHIVself-testingislimited(Table2).Only tworesearchstudiesareplannedinNigeria.Thefirst(NCT03874663) istostudytheacceptabilityandperformanceofHIVSTinayouth populationaged14–24years,andthesecondone(NCT04070287), withtheenrolmentofyouthaged14–24,isaprospectiveone-year assessment of five youth participatory interventions. Further research is needed to ensure the feasibility of HIVST, and the adaptation ofthe bestapproachfor a successful scaleup in an integrated and comprehensive package of HIV diagnosis in the contextofWCAR.TheprojectATLAS,whichisnotaresearchproject,

Table1

HIVself-testingbarriers. Barriers

MSM ˗Stigmatizationanddiscrimination ˗LimitedaccesstoHIVservicesfortesting ˗Inadequateservices

FSW ˗Stigmatizationanddiscrimination ˗Limitedaccesstocare

˗Negativeattitudeofhealthcareworkers ˗Limitedaccessibilitytohealthcareservices DU ˗Stigmatizationanddiscrimination

˗Personalisolation ˗Criminalisation

˗LackofservicesfortestingandtreatingHIV Adolescents ˗Noentrypointsintothehealthcaresystem ˗LackofhealthcarestructuresforHIVtesting ˗LowlevelofknowledgeonHIV

˗Lowriskperception

Men ˗FearandworryofknowingHIVstatus ˗Accessibilityofhealthservices Women ˗Drugsandreagentsstockout

˗Longwaitinglinesatclinics ˗Lateantenatalvisits

Couples ˗Lackofprovisionfortestingofcouples ˗Lackofsocialsupport

launchedin2018fallswithinthisapproach,bytargetingpopulations thathaveneverbeentestedbeforeandkeypopulations.Theproject providedthesepopulationswithatotalof500,000HIVoralself-tests inthreefrancophonecountriesofWestAfrica,Mali,SenegalandCôte d_’Ivoire. The study will document the impact of HIVST as a complementary screening strategy, will assess the necessary requirementsforthescale-upofHIVSTstrategybylocal govern-mentsandwillidentifythedistributionmodelsthataremost cost-effective (UNITAID, 2019).Finally, thelack of studies and inter-ventionsonHIVSTinWCARrepresentachallengetotheeffective implementation ofHIVST in WCAR.Very fewstudies and inter-ventionshaveexploredthedifferentaspectsoftheimplementation ofHIVSTinthecontextoftheWCAR.Additionalresearchgroups shouldfocusonidentifyingthechallengesandopportunitiesforthe successfulimplementationofHIVSTin thecultural,politicaland socialcontextoftheWCAR.Weareurgently callingformore research in this region to informstakeholders of HIV self-testing oppor-tunities.Thiscouldbeanadditionalstrategytoincreasethe_first90in thisregion.

Conclusion

HIVSTrepresentsanopportunityandakeytounlockthefirst90 inWCARandcatchuptotherestofthecontinentandtheworld. WiththeurgentneedtoimplementsuchanopportunityinWCAR, a frameworkthat wouldtakeinto accountprioritypopulations suchaskeypopulationsandalsoadolescentsandmenisneeded. Thisstrategyshouldrelyoncommunityhealthworkersandshould beintegratedintonationalstrategicpolicies.Additionalresearchis neededtoaddresssomechallengesthatwould remain,suchas linkagetocareandcost-effectivenessofthisstrategy.

Conflictofinterest

Theauthorshavenoconflictsinteresttodeclare. Fundingsource

Thisopinionpaperwasnotfunded. Ethicsapprovalandconsenttoparticipate

This study was opinionpaper and ethical approvalwas not requested.

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Table2

SummaryonmainresultsonHIVself-testinginWestandCentralAfrica.

ReferenceNumber Country Population HIVSTkits Mainresults

Tonen-Wolyecetal.(2019a) DRC–Bunia N=1,012University Students

BloodbasedHIVST ˗81.4%acceptabilityofHIVST

˗Betteracceptabilityamongstudents>24-year-old ˗AcceptabilityassociatedwithpriorknowledgeofHIV

self-testing

˗Posttestcounselingsupportedby86.9%ofolderstudents (>24yearsold)andby80.7%ofyoungerstudents(<24 yearsold)

Tonen-Wolyecetal.(2019b) DRC-Kisangani N=628 Adolescents(15to 19yearsold)

BloodbasedHIVST (ExactoTestHIVkit)

˗95.1%acceptabilityofHIVtesting ˗96.1%correctlyusedtheself-test

Lyonsetal.(2019) Senegal N=1,149 Through convenience sample

Oraltest

(OraQuickHIVself-testkit)

˗94.3%reportedusingHIVST

˗74.5%reportedbeingcomfortableusingHIVST ˗86.1%foundtheinstructionseasytofollow

Grésenguetetal.(2017) CentralAfrican Republic–Bangui

N=300adult volunteers

Bloodbasedtest (ExactoTestHIVkit)

˗96.9%ofHIVself-testwerecorrectlyinterpreted ˗91.6%correctlyperformedtheHIVself-testand23%asked

fororalassistance

Izizagetal.(2018) DRC-Kikwit university

N=290

UniversityStudents Media

Notmentioned ˗AcceptabilityofHIVST:81.4%

˗WillingnesstoconfirmaHIVpositiveself-testresultata localhealthcarefacility:66.1%

Tunetal.(2018) Nigeria N=257MSM Medianage25 yearsold

Oraltest

(OraQuickHIVantibodytest)

˗97.7%reportedhavingusedtheHIVself-testkits ˗Post-testcounselingwassoughtforall14whotested

positive

Tonen-Wolyecetal.(2018) DRC–Kisangani andBunia

N=322

Generalpopulation andhealthcare workers Meanage=30 yearsold

Bloodbasedtest (ExactoTestHIVkit)

˗79.6%ofparticipantscorrectlyunderstoodthe instruc-tionsforuseofthetest

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