A community-based self-testing programme achieved 76% uptake
of HIV testing in urban Malawi, with very high accuracy of test reading and
linkage to care, researchers from Malawi, Liverpool School of Tropical Medicine
and London School of Hygiene and Tropical Medicine reported on Thursday at the
21st Conference on Retroviruses and Opportunistic Infections (CROI) in Boston.
Self-testing for HIV using the OraQuick oral fluid test is
already available in the United States and is likely to be approved for use in
Europe in 2014, and is already available on a formal or informal basis in many
low- and middle-income countries, but there is still limited evidence on its
The Malawian study is the first large evaluation of the
acceptability and utility of self-testing in a resource-limited setting. It was
conducted in Blantyre as part of a more comprehensive research study that
examined the use of self-testing followed by initiation of antiretroviral
therapy at home, in order to improve linkage to care and speed up treatment initiation.
study was presented at CROI in 2013, and showed that the package of
interventions tripled the uptake of HIV treatment in Blantyre, Malawi.
The study was conducted in 16 neighbourhoods or clusters. The
16 neighbourhoods contained an adult population of 16,660 adults aged 16 and
over. In each neighbourhood, two households were trained to distribute the HIV
self-test and availability was advertised through proactive distribution.
A total of 13,966 test kits were distributed, of which 89% were returned,
used. Uptake was calculated at 76% of the population. Although uptake was
higher among women, especially during the first month of the self-testing
programme, 67% of all men in the study neighbourhoods used a self-test kit.
People who were not part of a couple were more than twice as
likely to use a self-test kit in the first month of the programme (adjusted
odds ratio 2.22, 95%
CI 1.54-3.16), and young people were significantly more likely to use a
self-test kit throughout the one-year follow-up period. These findings suggest
that young people and those who are seeking to form new relationships find
self-testing particularly acceptable and desirable, an encouraging finding for
the establishment of new norms around HIV testing behaviour in a country with
very high HIV prevalence.
study also found that self-test kits enabled testing in a large population who
had never tested before; 44% of men and 43% of women were testing for the first
time and three-quarters of testers had not tested for HIV in the previous year.
Nine per cent of people who used a self-test kit were
prepared to reveal, in confidence, that they had tested positive. Of these, 78%
had already been linked to HIV care and 25% had started antiretroviral therapy.
In this study, a random sample comprising 10% of those who
had used a self-test kit were asked to test again for HIV for quality
assurance. The quality assurance sample found 99.3% agreement between self-test
results and results of testing by a healthcare worker. The quality assurance
sample found sensitivity of 93.8% and specificity of 100%.
The coercive use of self-testing by male partners has been
frequently expressed as a concern in all settings. The Malawian study found
that coercion from partners was significantly more likely to be reported by men than by
women (147 men, 3.7% and 119 women, 2.2%, p<0.001). However, 94% of people
who reported that they had been coerced into testing also said that they would
recommend a self-test to friends or family, raising questions of how coercion
was defined in this study and how pressure to test is experienced and
negotiated within relationships.
The study also attempted to evaluate adverse reactions to
testing, such as gender-based violence or suicides, through the use of 112 key
informants distributed across the self-testing clusters. No cases of gender-based
violence or suicide were reported and there was a high level of acceptability
of self-testing as a method of learning one’s HIV status among the study
population. Approximately 45% said that they would prefer a private self-test
for their next HIV test, while approximately 20% would like to self-test with a
counsellor in attendance. The remaining 35% preferred the idea of voluntary counselling
and testing at a health centre or at home, with someone else administering the
In a March 2014 update to its Consolidated guidelines on the use of antiretroviral drugs for treating
and preventing HIV infection, released at the conference, the World Health
Organization (WHO) encouraged national policy makers to consider updating testing
regulations to allow self-testing. The guidelines also recommend that countries
should look at how to create channels for reporting and redress in the event of
misuse of self-test kits. They also recommend that self-test kits should be
carefully regulated to ensure that people have access to accurate test kits,
and that provision should be made to ensure that people who test positive get a