London School of Hygiene & Tropical Medicine

Self-testing for HIV using rapid diagnostic kits is becoming increasingly widely used, as it enables people, particularly in high-risk groups, to discretely and conveniently test their own HIV status. It is now recommended in the USA and Europe, was recently introduced in Kenya, and is being evaluated for introduction in several other countries in Africa. However, its use is controversial and remains illegal in many countries.

Recent research by Liz Corbett, Professor of Tropical Epidemiology, with colleagues and partners based in Malawi, published in the Journal of the American Medical Association in July 2014 has demonstrated that a combination of HIV self-testing and optional home initiation of care resulted in a significant increase in the proportion of adults initiating antiretroviral therapy (ART). More than 13,000 adults took part in the cluster randomised trial, funded by the Wellcome Trust.

The project has already proven highly influential, informing World Health Organization guidelines and technical advice. The team designed and piloted an innovative semi-supervised approach to community-based HIV self-testing, with trained volunteer community health workers having a key role in supporting diagnosis and treatment. This approach was shown to be significantly more effective than facility-based care in encouraging HIV-positive individuals to initiate and continue antiretroviral therapy.

Building on the success of this work, UNITAID is investing $23 million to accelerate access to HIV testing through simple HIV self-tests in three high-burden African countries over the next two years.  With the support of UNITAID, Population Services International (PSI) and its partners, the London School of Hygiene & Tropical Medicine, the Liverpool School of Tropical Medicine, University College London and the World Health Organization, will conduct the world's largest evaluation of HIV self-testing to date.

The project team plans to deliver 750,000 self-tests during the 2 year project in Malawi, Zimbabwe and South Africa, with London School of Hygiene & Tropical Medicine leading the research evaluation components.

Professor Corbett said: "This project aims to establish HIV self-testing as an acceptable and easily accessible way for Africans to known their status.  Only half of Africans living with HIV are aware of their status, so there is huge need to increase the coverage and frequency of HIV testing, especially for young adults, men, and the poorest communities. Self-testing is uniquely enabling, allowing people living in high HIV communities to take control over when and how they want to test and to fit testing in with the rest of their lives.  It brings testing right into the household and is the most common choice for preferred "next HIV test" among our participants in Malawi.

"I'm very excited about the potential impact on HIV testing, care and prevention. Our partnership includes internationally leading expertise in different disciplines and will provide implementation on a large scale using different approaches to distribution and sale of test kits, accompanied by careful evaluation and projection.  This will allow our partners in WHO to develop evidence-based guidelines, which in turn will provide national decision-makers and donors with the endorsement they need to factor in self-testing to their country plans"

UNITAID uses innovative financing to increase funding for greater access to treatments and diagnostics for HIV/AIDS,malaria and tuberculosis in low-income countries. It is the first global health organisation to use buy-side market leverage to make life-saving health products better and more affordable for developing countries. Based in Geneva and hosted by the World Health Organization, approximately half of UNITAID's finances come from a levy on air tickets.

• UNITAID invests to identify some of the 19 Million HIV undetected  - Press Release, UNITAID website

Reference: Effect of Optional Home Initiation of HIV Care Following HIV Self-testing on Antiretroviral Therapy Initiation Among Adults in Malawi: A Randomized Clinical Trial. JAMA. 2014;312(4):372-379. doi:10.1001/jama.2014.6493.