Self-testing for HIV using oral tests
could radically increase HIV testing rates in tuberculosis
programmes, TB researchers argued this weekend at the 41st Union
World Conference on Lung Health in Berlin.
Similarly, community sputum
collection points where individuals can go to provide a sputum sample
for TB detection, without having to wait to see a nurse or doctor,
have proved very popular in Zambia.
Rates of diagnosis for both TB and
HIV remain very low, and even when a person is diagnosed with one
infection, screening for the other infection may not take place.
Furthermore, even if people have
symptoms that might indicate active TB, their likelihood of having
those symptoms fully investigated is low. A community survey in
Zambia in 2006 among 9000 people who identified themselves as
suffering from persistent cough found that only half had attended a
health facility as a result, said Dr Helen Ayles of the London School
of Hygiene and Tropical Medicine.
Just less than half who attended a
health facility were asked to produce sputum in order to test for TB,
and just 5% of all those questioned eventually started TB treatment,
despite a local TB prevalence of 960 cases per 100,000 and a local
HIV prevalence of 26%.
Given these barriers, TB specialists
working in countries with a high burden of both TB and HIV have been
asking how rates of diagnosis and access to care can be improved, as
a first step towards reducing the burden of TB in these settings.
In Zambia, the ZAMSTAR
study, led by Dr Helen Ayles, is currently comparing approaches
to TB case-finding and TB/HIV service delivery. As part of its
enhanced community case-finding strategy, the study is running
community sputum collection points, as well as open access sputum
collection points at health facilities. These require no appointment
and no nurse time and will provide a result to patients within 48
A big advantage of these schemes,
said Dr Ayles, is that they avoid concentrating patients with
potentially infectious TB in crowded waiting rooms for long periods.
People with suspected TB are very happy with the speed of the
process, and keen to be tested when the barrier of extended waiting
time is removed. Nearly 40% of the sputum samples being processed in
the laboratories used by ZAMSTAR now come from community collection
points, showing how much the innovative method is extending the reach
of TB case-finding efforts.
Community sputum collection is also
having other unforeseen benefits.
“Almost as soon as we set it up the
community sputum collectors decided that the sputum collection points
were going to be condom distribution points too,” said Dr Ayles.
From condom distribution it should be
only a short step to offering HIV testing, but at the moment
programmes predominantly offer conventional voluntary counselling and
testing, or door-to-door testing. Significant resistance remains to voluntary counselling and testing, for a host of reasons, including the difficulty of attending the facility, fears about confidentiality and the quality of the counselling.
In Malawi, for example, research led
by Dr Liz Corbett of the London School of Hygiene and Tropical
Medicine has found that when compared with door-to-door VCT conducted
by health care workers, the possibility of self-testing was much more
Self-testing using an oral saliva
test has already been piloted in Malawi, and proved highly
acceptable, said Dr Corbett. Ninety-one per cent of a sample of 260
randomly selected Malawians offered the opportunity to carry out the
oral test themselves took the test, and 99.2% got the result right
“Withholding a fabulous diagnostic
from the population because of concerns about their ability to handle
it seems lunacy to me,” said Dr Corbett.
“The commonest feedback we had was 'Why don't we know about these tests and why isn't the government in
Malawi distributing these tests to everyone each year?'”
Some people are more cautious about
the use of self-testing. Jeremiah Chakaya, head of Kenya's National
TB Control Programme pointed to the
recent case of a Kenyan policeman who went on a rampage and shot
ten people after learning that he was HIV-positive.
“HIV and sexually transmitted
infections will remain stigmatised for a long time to come. There are
absolutely no issues with the accuracy of the test but we shouldn't
promote self-testing without dealing with stigma.
“Disclosure is a big problem, as we
can see from the preference for self-testing in Malawi. Will people
go to their doctor and say 'I did a self-test yesterday and I am
HIV-positive', or will they go into themselves and get depressed and
get angry?” he asked.
There's also concern about forcible
testing; some people raised concerns at the conference about the
potential use of the tests to forcibly test partners or family
“If you can't even negotiate condom
use, how are you going to deal with it when your husband brings an
HIV test kit home?” asked one delegate from South Africa during a
debate on self-testing.
“One of the big things about
self-testing is that couples really like it,” said Dr Liz Corbett.
“Women are being tested through the PMTCT programme and men are
using their status as a surrogate for their own status. Women told us 'If we take the test kits home our men will test with us.'”
Concerns also exist about the effect
of self-testing on sexual behaviour in those who test negative. There
is some evidence from studies of voluntary counselling and testing
that a negative test is not associated with a subsequent reduction in