December 1st is World AIDS Day. Although much progress has been made in tackling HIV, in 2015, there were over 36 million people living with HIV, and over 2 million people become newly infected with HIV each year.
But the ambition to end HIV is strong. Two years ago, the UNAIDS announced its 90-90-90 Initiative. By 2020, 90 per cent of all people living with HIV will know their HIV status. By 2020, 90 per cent of all people with diagnosed HIV infection will receive sustained antiretroviral therapy (ART), and 90 per cent of all people receiving ART will have viral suppression. A recent analysis of HIV care cascades from 69 countries showed that no country analysed met the 90-90-90 targets. Diagnosis was the greatest break point globally, but the most frequent key break point for individual countries was providing ART to those diagnosed with HIV.
A diagnosis of HIV today is not a death sentence. There are good diagnostic tools, and effective antiretroviral treatments. Despite these tools, about 40 per cent of individuals living with HIV do not know that they are infected. This has to change. Stigma, long waiting time in clinics, perceived discrimination and marginalization prevent people from coming forward to test in health facilities. In this context, HIV self-testing offers an innovative solution.
Saliva-based HIV self test. Photo by Nitika Pant Pai
What is HIV self-testing? According to WHO, HIV self-testing is a process in which a person collects his or her own specimen (oral fluid or blood) and then performs an HIV test and interprets the result, often in a private setting, either alone or with someone he or she trusts. Results are usually ready within 20 minutes or less, and there are several home tests available on the market (e.g. OraQuick In-home HIV test by OraSure). It is important to note that individuals with positive results on the self-test need to seek confirmatory tests at health centers. A home test alone is not sufficient to confirm HIV.
Research shows that HIV self-testing is feasible, accurate, acceptable to people, and successful in increasing the uptake of testing. Self-testing more than doubles uptake of HIV testing among men who have sex with men and male partners of pregnant or post-partum women. It increases uptake of couples HIV testing among male partners of pregnant or post-partum women. Self-testing does not increase HIV risk behaviours or the number of bacterial sexually transmitted infections. There is no evidence of increase in reported social harm, adverse events or behaviours.
This week, the World Health Organization released its guidelines and recommendations in support of self-testing. I had the privilege to contribute to this guideline. WHO now recommends that HIV self-testing should be offered as an additional approach to HIV testing services. With this WHO policy, I hope that health ministries in countries deeply impacted by the epidemic will work to accommodate self-testing within their health systems, and make sure HIV home tests are easily accessible.
However, testing alone is not sufficient to end the HIV epidemic. Linkage to adequate anti-retroviral treatment is an important next step. Many countries impacted by HIV struggle with rapid initiation of ART and retention of patients in care. Innovative technologies and strategies can help overcome such gaps in service delivery.
For example, we have developed an integrated innovative strategy called HIVSmart!, an award winning app-based HIV self-testing strategy with proven proof of concept evidence. This innovation is supported by Grand Challenges Canada (an agency funded by the Canadian government), Department of Science & Technology, South Africa, South African Medical Research Council, and the Research Institute of the McGill University Health Centre.
With innovation, strong partnerships, and continued funding, we can end the AIDS epidemic for good!
The HIVSmart! mobile app works with saliva-based HIV self-tests and is available in many languages. The smartphone and app strategy engages, interprets and links self-testers to counselling and clinical care. The app is used in conjunction with an approved HIV self-test kit, offering a de-stigmatized, private and confidential testing option for individuals who suspect they are infected with HIV. It is currently being evaluated in South Africa, with an international team of scientists from McGill University and the University of Cape Town.
Without diagnosis, medicine is blind. To end the HIV epidemic, we need people with HIV to be diagnosed. This requires a patient-oriented testing strategy, one that is convenient, private, patient-centric, adaptable, and amenable to integration within existing programs of care. Such a strategy will have far greater success than trying to fit patients into the current testing programs that have failed to engage and diagnose people with HIV. As Dr Margaret Chan, the Director General of WHO put it, "HIV self-testing should open the door for many more people to know their HIV status and find out how to get treatment and access prevention services."
I am excited about the new WHO policy on HIV self-testing, and would like to see the policy implemented on the ground, especially in countries devastated by the AIDS epidemic. I am thrilled that Canada is showing great leadership in the fight against HIV, TB and Malaria, and I am very enthusiastic about the potential of using mobile phones, apps, and innovative strategies to exploit the true potential of HIV self-testing. With innovation, strong partnerships, and continued funding, we can end the AIDS epidemic for good!
Dr Nitika Pant Pai is an Associate Professor of Medicine at McGill University, Montreal, and a researcher at the Research Institute of McGill University Health Centre. She has won many awards for her innovative HIV research, including the Accelerating Science Award Program (ASAP) Award, Maude Abbott Award, and Grand Challenges Canada Stars in Global Health Award (@Nikkipantpai).
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