Karin Hatzold
Director of HIV, Tuberculosis and Viral Hepatitis at Population Services International (PSI) and Director of the Unitaid-funded STAR (Self-Testing AfRica) Initiative
Pioneering work over the last eight years to bring HIV self-testing to Africa has been instrumental in shaping global policy and advancing diagnostics for various infections.
Eight years ago, only 53% of those living with HIV globally were aware of their status. By 2022, the World Health Organization (WHO) reported that had risen to 86%, with 76% receiving antiretroviral treatment (ART) and 71% achieving viral suppression.
Access to HIV self-testing
The convenience and discretion of self-test kits have proven attractive to those who may not otherwise test due to stigma or logistical challenges accessing healthcare facilities.
Dr Karin Hatzold is Director of HIV, Tuberculosis and Viral Hepatitis at Population Services International (PSI) and Director of the Unitaid-funded STAR (Self-Testing AfRica) initiative — the largest evaluation of self-testing. She explains: “Before, there were groups of people who weren’t accessing testing (for HIV), such as men and adolescents as well as key populations, sex workers, men having sex with men. It was about removing barriers for them.”
Uptake in testing and treatment
Zimbabwe was one of six countries in sub-Saharan Africa where STAR, led by PSI with a consortium of international and local partners, was piloted initially alongside Malawi, Zambia, South Africa, Lesotho and Eswatini. Results from the study in Zimbabwe speak for themselves.
Between 2017 and 2019, 360,000 HIV self-tests (HIVST) were distributed, and testing uptake increased from 35% to 75%. Results showed that 25% of those who accessed HIVST had never used an HIV test before — evidence that the strategy was indeed reaching new audiences.
Before the study, concerns existed regarding whether individuals conducting self-tests and receiving positive results would follow up with clinic tests and begin appropriate treatment. Concerns were unfounded as evidence revealed a promising 30% rise in ART usage, mirrored across other pilot countries.
Between 2017 and 2019, 360,000 HIV self-tests (HIVST) were distributed, and testing uptake increased from 35% to 75%.
Self-testing is the new norm
Before the Covid-19 pandemic, self-testing wasn’t part of any national psyche, so it has taken massive effort to build awareness and trust in the process. “We used various distribution models adapted to context and population to be reached in different countries,” explains Dr Hatzold.
“In South Africa, for example, community workers were distributing kits at bus stations and in taxi ranks and hotspots where we knew we could reach people who would benefit from HIV self-testing, especially men who do not have time … for testing.”
Social media posts and advertising campaigns reinforced the ground-level activity, increasing awareness and driving participation. “We have achieved what we wanted, and this has even taken over from conventional testing. It has become the norm,” confirms Dr Hatzold.
Diagnostics drive policy change
When STAR launched in 2015, there were no affordable, quality-assured HIV self-tests approved for use in low and middle-income countries (LMICs). With no quantitative evidence on market demand or the effectiveness of self-testing, manufacturers weren’t willing to take the risk.
STAR helped fill that data gap and encourage further investment in diagnostic tools. By 2016, WHO rolled out global guidelines for HIVST and, as of June 2022, WHO had prequalified six HIV self-test kits. These include both oral fluid and blood-based products, ensuring their quality, safety and effectiveness for use. Now, 102 countries have HIVST policies, and 38 are actively implementing HIVST.
Empowering self-testing for public health
HIVST is now recognised as a key tool in reaching the UN’s 95-95-95 targets, whereby 95% of people with HIV know their status, 95% of diagnosed cases are receiving sustained ART and 95% are on therapy and achieving viral suppression by 2030.
“The project has been catalytic, informing a scaling up of activity,” says Dr Hatzold, who, through STAR, is applying lessons learned from HIV to advance self-testing for Covid-19, Hepatitis C and B plus sexually transmitted infections — with potential to develop a single test for multiple infections.
Self-testing initiatives will undoubtedly underpin a move toward more integrated and decentralised systems. “If we want to achieve universal healthcare, we must put tools in the hands of the people, and that starts with diagnostics,” concludes Dr Hatzold.