Is HIV self-test among the missing links to reach the #endAIDS goal?

Shobha Shukla / Bobby Ramakant *

Almost half the countries worldwide have not yet included HIV self-test in their AIDS response. Only one-fourth of all nations globally do HIV self-test routinely. This is despite the strong evidence which exists not only for HIV self-test, but also how self-tests for COVID-19, diabetes, or pregnancy, have yielded major public health and development gains.

Then why wait to expand HIV care cascade by including HIV self-test, asks Dr Ishwar Gilada, who was the first medical doctor to begin HIV medical management when first case got diagnosed in the country in 1986.

Why HIV testing is an entry point?

It is worrisome that globally, 15% of people living with HIV did not knew their status in 2021. In India one in four people living with HIV did not know their HIV status in 2021. The COVID-19 pandemic had further negatively impacted the pace of HIV testing.

"Unless we ensure that all people living with HIV know their status, how will every person with HIV receive full cascade of HIV care services and stay virally suppressed (maintain undetectable viral load)? HIV testing is the key entry point to HIV care cascade. Ensuring that every person with HIV has undetectable viral load, as "undetectable equals untransmittable," is the only pathway towards ending AIDS," said Dr Ishwar Gilada, President of 14th National Conference of AIDS Society of India (ASICON) in Delhi, India, and also President of the AIDS Society of India (ASI) and Governing Council member of International AIDS Society. ASI is the nationwide network of HIV medical experts and researchers.

“Almost half of the countries (98) have included HIV self-testing policies, and one-fourth nations globally (52) are routinely implementing it. Self-tests for COVID-19, pregnancy, diabetes, etc have not only proven successful in increasing the uptake of tests but also how it links to care services, said Dr Ishwar Gilada. “There is no reason at all to delay full scale rollout of HIV self-testing in India as well as other countries which are missing leveraging upon this evidence-based intervention.”

In 2019, the UN health agency, the World Health Organization (WHO) recommended HIV self-testing as part of HIV care cascade as it is an important approach to address gaps in HIV diagnoses, especially among key populations.

14th National Conference of AIDS Society of India (ASI) and ASI calls upon the government of India and over half of other countries that have not yet included HIV self-testing in their HIV response, to do so without delay – as clock is ticking! All governments worldwide have promised to end AIDS by 2030, for which it is vital to ensure everyone living with HIV everywhere must know the status and receive full spectrum of HIV care services.

Bridge the gap

Since most nations could not meet 2020 AIDS targets, now the eyes are set on 2030 goalpost of 95-95-95 targets (95% of people living with HIV to know their status, 95% of them should be on ART, and 95% of these be virally suppressed). HIV self-test is one of the key cog-in-the-wheel to “reaching out to the last mile” for first-95 target.

Globally, 85% of all people living with HIV knew their HIV status in 2021. Among people who knew their status, 88% were accessing treatment. And among people accessing treatment, 92% were virally suppressed. In other words of all people living with HIV 85% knew their status, 75% were accessing treatment and 68% were virally suppressed in 2021.

In India, as on March 2022, 77% of people living with HIV knew their status, 84% of them were on antiretroviral therapy, and 85% of them had viral suppression. This translates into 55% of total people living with HIV in India being virally suppressed in 2021-22 against the target of getting 86% of them virally suppressed by 2025-26.

According to Government of India’s National AIDS Control Organization 2022 report, between 2010 and 2021, new infections declined by 46% whereas the goal was to reduce new HIV infections by 80% by 2025 - clearly we need to do a lot more to turn the tide.

Key populations cannot be left behind

While the overall adult prevalence remains low (0.21% in 2021), HIV prevalence among high-risk groups and the bridge population remains very high. HIV prevalence among migrants is 4 times, among truckers is 5 times, among inmates in central jails and female sex workers is 9 times, among men who have sex with men (MSM) is 16 times, among hijra/transgender people is 18 times and among people who use drugs is 43 times of the overall adult HIV prevalence.

The studies presented at International Conference on Retroviruses and Opportunistic Infections (CROI 2022) showed that even virtual approaches provided an additional entry point to increase uptake of HIV testing in those who are currently getting missed by traditional healthcare services – especially those from key populations. PATH report launched in 2022 showed HIV self-testing is acceptable to key populations and their partners in India.

HIV self-testing in India must become a reality without delay

India is among the countries that have not yet developed a national policy on HIV self-testing. ASICON and ASI call upon the government to do so without delay and ASI leaders nationwide are willing to offer their technical support in doing so.

Dr Gilada is right in reminding us that “All HIV testing services should continue to be provided in line with WHO's essential 5 Cs: Consent, Confidentiality, Counselling, Correct test results, and Connection/linkage to prevention, care and treatment.”

It is important to remember that HIV self-testing is not a standalone initiative but integrated into HIV care cascade where HIV testing services include: counselling (pre-test information and post-test counselling); linkage to appropriate HIV prevention, treatment and care services, and other clinical and support services; and coordination with laboratory services to support quality assurance and the delivery of correct results, among others.