Original post by Annet Adong, Research Analyst in the Sectoral Department at the Economic Policy Research Center (EPRC) in Uganda
On December 1st, 2015, World AIDs day was celebrated under the international theme of ‘Getting to zero'- that is, zero new HIV infections, zero discrimination, and zero AIDS-related deaths. As we think through the feasibility of actually ‘getting to zero’, an aspect that remains crucial is the move to HIV testing approaches that mainstream testing so it’s the new normal, rather than the exception. This includes approaches that can be offered in a wide range of settings and via technologies that are more effective in identifying recent infections than previous techniques.
Although Uganda has significantly curbed the HIV/AIDs scourge within its population over the years, a significant proportion of people remain unaware of their status at any given point in time. Repeat testing and couples counseling rates are both low. According to the Demographic Health Survey of 2011, 71% of women and 52% of men had never even been tested for HIV. When asked to consider whether they had been tested in the past 12 months before the survey, only 42% of women and 30.4% of men had been. The test rates are even lower in Kampala, with only 43% of the total population (both men and women) reported to have received an HIV test in the last 12 months.
In addition to other social and structural barriers to HIV testing, stigma remains a crucial barrier in Uganda and many other African countries. For example, if someone goes to a clinic and knows the the clinician leading the testing, it’s likely the person will politely greet and ask the clinician how they are doing- and then promptly walk out without getting tested. As a means of protecting anonymity, self-testing provides an opportunity for people to test comfortably and easily in the privacy of their homes. Self-testing helps those living with undiagnosed HIV become aware of their condition so that they can reduce the risk of transmitting the virus to others and benefit from appropriate treatment, care, and support associated with detecting the disease early. The gap in testing, coupled with benefits of early HIV treatment, could be key drivers to promote self-testing within the population.
There are two different approaches to self-testing. The first involves the patient using an oral rapid test kit. The person self-testing uses the kit to take a sample from their mouth before placing it in a small, medicine-filled bottle that then reveals the test results. The process is relatively simple and can be performed by anyone irrespective of their level of education. Another home sampling option found in developed countries involves the individual taking a mouth swab or finger prick and mailing it to a laboratory. The results are then made available online, by text message, or by phone. However, this approach requires a functioning mailing address, which proves difficult in countries such as Uganda where homes in rural areas may not have access to mail service.
A study in Malawi found high uptake rates for HIV self-testing (over 50%), yet the concept of self-testing remains relatively new in Uganda and in several other African countries. Aside from Kenya, other African countries are yet to incorporate self-testing into their national HIV testing policies. Barriers to home testing uptake can be attributed to a number of variables, such as misuse, self-harm, and the limited availability of HIV self-help kits. In addition, self-testing is only the first step towards knowing one’s HIV status. There is also need for a second confirmatory test at a health facility, coupled with appropriate counselling. Creating awareness around the importance of self-testing, increasing access to HIV treatment, and addressing infrastructural challenges (such as limited health units) are some of the steps Sub Saharan countries can begin to take to 'get to zero'.