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HIV self-testing: The key to unlock the first 90 in West and Central Africa

  • Didier K. Ekouevi
    Correspondence
    Corresponding author at: Université de Lomé (Togo), Faculté des Sciences de la Santé, Département de Santé Publique, Togo.
    Affiliations
    Université de Lomé, Faculté des Sciences de la Santé, Lomé, Togo

    Centre Africain de Recherche en Epidémiologie et en Santé Publique, Lomé, Togo

    ISPED, Université de Bordeaux & Centre INSERM U1219 – Bordeaux Population Health, Bordeaux, France
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  • Alexandra M. Bitty-Anderson
    Affiliations
    ISPED, Université de Bordeaux & Centre INSERM U1219 – Bordeaux Population Health, Bordeaux, France

    Programme PACCI, site ANRS, Abidjan, Cote d’Ivoire
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  • Fifonsi A. Gbeasor-Komlanvi
    Affiliations
    Université de Lomé, Faculté des Sciences de la Santé, Lomé, Togo

    Centre Africain de Recherche en Epidémiologie et en Santé Publique, Lomé, Togo
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  • Ahuatchi P. Coffie
    Affiliations
    Programme PACCI, site ANRS, Abidjan, Cote d’Ivoire

    Unité pédagogique de Dermatologie et Infectiologie, Unité de Formation et de Recherche en Sciences Médicales, Université Félix Houphouët-Boigny, Abidjan, Cote d’Ivoire

    Centre de Recherche sur les Maladies Infectieuses et les Pathologies Infectieuses, Université Félix Houphouët-Boigny, Abidjan, Cote d’Ivoire
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  • Serge Paul Eholie
    Affiliations
    Programme PACCI, site ANRS, Abidjan, Cote d’Ivoire

    Unité pédagogique de Dermatologie et Infectiologie, Unité de Formation et de Recherche en Sciences Médicales, Université Félix Houphouët-Boigny, Abidjan, Cote d’Ivoire

    Centre de Recherche sur les Maladies Infectieuses et les Pathologies Infectieuses, Université Félix Houphouët-Boigny, Abidjan, Cote d’Ivoire
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Open AccessPublished:February 15, 2020DOI:https://doi.org/10.1016/j.ijid.2020.02.016

      Highlights

      • HIV self-testing could be an additional approach to overcome barriers to diagnose HIV infected patients.
      • HIV self-testing is an opportunity and a key to unlock the first 90 in West and Central Africa.
      • Implementing HIV self-testing is challenging in low prevalence settings.
      • Research and implementation of HIV self-testing are limited in West Africa and Central Africa.

      Abstract

      The West and Central African region (WCAR) still registers some of the highest rates of new HIV infections worldwide (16%) despite a low prevalence of HIV (1.9%). In this region, only 48% of people living with HIV are aware of their HIV status. To fill this gap, HIV Self testing (HIVST) could potentially be an additional approach to overcome the barriers to diagnose HIV infected patients, therefore being one of the keys to unlock the first 90 as recommended by the World Health Organization (WHO) since 2016. However, many challenges remain for the adoption of HIVST in routine clinical practice in low prevalence settings and need to be contextualized to WCAR settings. We report in this paper some of the challenges and discuss opportunities for a successful implementation of HIVST in the WCAR.

      Keywords

      Introduction

      In 2014, the Joint United Nations Program on HIV/AIDS (UNAIDS) introduced a strategy aimed at eliminating the HIV epidemic by 2030, by achieving the following goals: diagnose 90% of all HIV-positive persons, provide antiretroviral therapy (ART) to 90% of those diagnosed and achieve viral suppression for 90% of those threated, by 2020 (
      • Levi J.
      • Raymond A.
      • Pozniak A.
      • Vernazza P.
      • Kohler P.
      • Hill A.
      Can the UNAIDS 90-90-90 target be achieved? A systematic analysis of national HIV treatment cascades.
      ). Since then, there has been a global surge from national entities with the goal of reaching those goals by 2020.
      Sub-Saharan Africa (SSA) is the region of the world with the highest burden of the HIV epidemic. The West and Central African region (WCAR), which comprises 25 countries, is home to 7% of the world population and to 17% (6.1 million) of all people living with HIV (PLHIV) worldwide (
      • Joint United Nations Programme on HIV/AIDS (UNAIDS)
      Global HIV & AIDS statistics -2019 fact sheet.
      ). The average prevalence of HIV in WCAR is relatively low compared to that of Eastern and Southern Africa with 1.9% vs. 6.8% in 2017 (
      • AVERT
      HIV and AIDS in West and Central Africa Overview.
      ,
      • AVERT
      HIV and AIDS in East and Southern Africa regional overview.
      ), but WCAR still registers some of the highest rates of new HIV infections worldwide (16%) (AVERT, 2020;

      Joint United Nations Programme on HIV/AIDS (UNAIDS). West and Central Africa [Available from]: https://www.unaids.org/en/regionscountries/westandcentralafrica. [Accessed 27 June 2019] 2020.

      ) and 21% of AIDS-related deaths (
      • AVERT
      West and Central Africa 90-90-90 progress.
      ). The WCAR continues to lag behind the rest of SSA with only 8% and 24% declines in new infections and AIDS related deaths, respectively, since 2010, while new infections declined by 29% in the Eastern and Southern Africa region over the same period (
      • UNAIDS
      UNAIDS Data.
      ). In regard to the cascade of care, only 48% of PLHIV are aware of their HIV status, 40% of PLHIV are on antiretroviral therapy (ART) and 29% are virally suppressed (
      • AVERT
      West and Central Africa 90-90-90 progress.
      ). The latest report of UNAIDS underlines these disparities in WCAR where less than 60% of the HIV population is tested. The report also pointed out the difficulties in this region specifically in key and vulnerable populations, which are still stigmatized and discriminated in this region more than in other settings in SSA (
      • UNAIDS
      UNAIDS Data.
      ).
      Based on these gaps, HIV Self testing (HIVST) could potentially be an additional approach to overcome the barriers to diagnose HIV-infected patients, therefore being one of the keys to unlock the first 90 as recommended by the World Health Organization (WHO) since 2016 (
      • World Health Organization
      WHO recommends HIV self-testing. World Health Organization (WHO).
      ).
      Self-testing is defined as a process in which a person who wants to know his or her HIV status uses a kit to collect a specimen, performs a test and interprets the test results for himself or herself (
      • World Health Organization
      WHO recommends HIV self-testing. World Health Organization (WHO).
      ). Multi-country evidence from Eastern and Southern Africa confirms high feasibility, acceptability and accuracy of HIVST across many delivery models and populations, including adolescents, men and female sex workers, with reassuringly minimal harm (
      • World Health Organization
      WHO recommends HIV self-testing. World Health Organization (WHO).
      ,
      • Figueroa C.
      • Johnson C.
      • Verster A.
      • Baggaley R.
      Attitudes and acceptability on HIV self-testing among key populations: a literature review.
      ,
      • Choko A.T.
      • Nanfuka M.
      • Birungi J.
      • Taasi G.
      • Kisembo P.
      • Helleringer S.
      A pilot trial of the peer-based distribution of HIV self-test kits among fishermen in Bulisa, Uganda.
      ,
      • Choko A.
      • MacPherson P.
      • Webb E.L.
      • Willey B.A.
      • Feasy H.
      • Sambakunsi R.
      • et al.
      Uptake, accurary, safety, and linkage into care over two years of promoting annual self-testing for HIV in Blantyre, Malawi: a community-based prospective study.
      ,
      • Lippman S.A.
      • Gilmore H.J.
      • Lane T.
      • Radebe O.
      • Chen Y.-H.
      • Mlotshwa N.
      • et al.
      Ability to use oral fluid and fingerstick HIV self-testing (HIVST) among South African MSM.
      ,
      • van Dyk A.C.
      Client-initiated, provider-initiated, or self-testing for HIV: What do South Africans prefer?.
      ). Two pilot studies on HIVST were funded by UNITAID in sub-Saharan Africa (SSA). The ongoing STAR Initiative is a five-year project divided into two phases. The first phase (2015–2017) in Malawi, Zambia, and Zimbabwe generated information about how to distribute HIVST products effectively, ethically, and efficiently, and answered questions about the feasibility and acceptability of HIVST in the general population (
      • Ingold H.
      • Mwerinde O.
      • Ross A.L.
      • Leach R.
      • Corbett E.L.
      • Hatzold K.
      • et al.
      The Self-Testing AfRica (STAR) Initiative: accelerating global access and scale-up of HIV self-testing.
      ,
      • Hatzold K.
      • Gudukeya S.
      • Mutseta M.N.
      • Chilongosi R.
      • Nalubamba M.
      • Nkhoma C.
      • et al.
      HIV self-testing: breaking the barriers to uptake of testing among men and adolescents in sub-Saharan Africa, experiences from STAR demonstration projects in Malawi, Zambia and Zimbabwe.
      ). The second phase of this project is ongoing with added countries of South Africa, Swaziland and Lesotho, and will distribute 4.8 million HIVST kits by 2020. The second project, ATLAS, launched in 2018 aiming to assess the feasibility and acceptability of HIVST among people with the highest risk of contracting HIV in three countries in West Africa: Côte d’Ivoire, Mali, and Senegal (

      UNITAID, UNITAID. The ATLAS project in West Africa: a big innovation at local level to achieve the global HIV screening goal by 2020 [Internet], Unitaid. [cited 2019 Jun 19]. [Available from]: https://unitaid.org/news-blog/avec-le-projet-atlas-en-afrique-de-louest-une-innovation-majeure-au-plus-pres-du-terrain-pour-atteindre-lobjectif-mondial-lie-au-depistage-du-vih-dici-2020. [Accessed 2 February 2020] UNITAID 2019.

      ). A recent study conducted in the Democratic Republic of Congo has shown the same findings and an excellent practicability comparable to Eastern and Southern Africa (
      • Tonen-Wolyec S.
      • Mbopi-Kéou F.X.
      • Batina-Agasa S.
      • Kalla G.
      • Noubom M.
      • Bouassa R.S.
      • et al.
      Acceptability of HIV self-testing in African Students: a cross-sectional survey in the Democratic Republic of Congo - PubMed.
      ). To date, 18 WCAR countries have adopted HIVST in their national HIV testing policy guidelines, nine set up pilot studies, and only one (Nigeria) has implemented it with a roll out plan (
      • WHO
      HIV self-testing.
      ). Many challenges remain for the adoption of HIVST in routine clinical practice in low prevalence settings and need to be contextualized to WCAR settings. The objective of this paper is to examine these challenges and discuss opportunities for a successful implementation.

      First challenge: identify the best the target population

      Public health strategies should target and prioritize three populations: men, adolescents and well-known key populations. HIV testing is a public health priority especially among key populations such as female sex workers (FSWs), clients of female sex workers, sex partners of other key populations and men who have sex with men. In WCAR, 64% of new HIV infections occurred in these populations (
      • UNAIDS
      UNAIDS Data.
      ). However, the population of WCAR is predominantly young, with more than 64% of the population under the age of 24 (
      • United Nations Population Fund
      Adolescents and Youth report: West and Central Africa.
      ). This population, with 62,000 adolescents newly infected with HIV in 2016, has the highest rate of HIV incidence (
      • UNAIDS
      West and Central Africa left behind in global HIV response [Internet].
      ). In general, adolescents rarely have a point of entry into the health care system and structures of HIV testing and counseling (HTC) specifically dedicated to them are practically non-existent, which makes them particularly vulnerable. HIVST would offer the opportunity for adolescents to access HIV testing and would contribute to increasing the rates of HIV testing in this population. For adolescents, there are multiple approaches that could be used to promote access to HIVST: the door-to-door HIVST approach which constitutes an innovative way to distribute self-test kits; m-Health including social media platforms in local languages to raise awareness and to present the video-based instructions for use of the HIVST; and facilitating the delegation of tasks allowing community health workers to facilitate access to HIVST by adolescents in a community-based approach (
      • Tonen-Wolyec S.
      • Mbopi-Kéou F.X.
      • Koyalta D.
      • Filali M.
      • Batina-Agasa S.
      • Bélec L.
      Human immunodeficiency virus self-testing in adolescents living in Sub-Saharan Africa: an advocacy - PubMed.
      ).
      In WCAR, although women are disproportionally affected by the HIV epidemic with higher prevalence and incidence of HIV compared to men, men are still important in breaking the cycle of heterosexual HIV transmission (
      • Kharsany A.B.M.
      • Karim Q.A.
      HIV Infection and AIDS in Sub-Saharan Africa: current status, challenges and opportunities.
      ,
      • Sileo K.M.
      • Fielding-Miller R.
      • Dworkin S.L.
      • Fleming P.J.
      What role do masculine norms play in men’s HIV testing in Sub-Saharan Africa?: A scoping review.
      ). There are no dedicated services for men for HIV testing similar to those for women, who are systematically offered HIV testing during antenatal consultation. Moreover, men are less likely to access HIV care services, including HIV testing services due to cultural and gender norms, and other structural barriers (facility operating hours, lack of confidentiality) (
      • Camlin C.S.
      • Ssemmondo E.
      • Chamie G.
      • El Ayadi A.M.
      • Kwarisiima D.
      • Sang N.
      • et al.
      Men “missing” from population-based HIV testing: insights from qualitative research.
      ). For this population, HIVST would palliate to those barriers and contribute to men having access to health care.
      For key populations, HIVST should be a strategy additional to other available approaches since the prevalence and incidence of HIV in these populations is still elevated (
      • Joint United Nations Programme on HIV/AIDS (UNAIDS)
      New HIV infections by mode of transmission in West Africa: A multi-country analysis.
      ). Table 1 summarizes the barriers to expanding HIV testing in WCAR according to the population.
      Table 1HIV self-testing barriers.
      Barriers
      MSM
      • ˗
        Stigmatization and discrimination
      • ˗
        Limited access to HIV services for testing
      • ˗
        Inadequate services
      FSW
      • ˗
        Stigmatization and discrimination
      • ˗
        Limited access to care
      • ˗
        Negative attitude of health care workers
      • ˗
        Limited accessibility to health care services
      DU
      • ˗
        Stigmatization and discrimination
      • ˗
        Personal isolation
      • ˗
        Criminalisation
      • ˗
        Lack of services for testing and treating HIV
      Adolescents
      • ˗
        No entry points into the health care system
      • ˗
        Lack of health care structures for HIV testing
      • ˗
        Low level of knowledge on HIV
      • ˗
        Low risk perception
      Men
      • ˗
        Fear and worry of knowing HIV status
      • ˗
        Accessibility of health services
      Women
      • ˗
        Drugs and reagents stock out
      • ˗
        Long waiting lines at clinics
      • ˗
        Late antenatal visits
      Couples
      • ˗
        Lack of provision for testing of couples
      • ˗
        Lack of social support
      DU: Drug users; FSW: Female sex workers; MSM: Men who have sex with men.

      Second challenge: acceptability of HIVST

      Overall, interventions on the implementation of HIVST in SSA have proven to be successful with higher rates of HIV testing uptake with HIVST compared to the standard of care (
      • Bateganya M.
      • Abdulwadud O.A.
      • Kiene S.M.
      WITHDRAWN: Home-based HIV voluntary counseling and testing in developing countries.
      ). Different strategies could be put in place to implement HIVST in SSA: community-based or health facilities based (supervised) HIVST. In both strategies, the main reason for the preference for self-tests is the fact that testing is initiated by the client rather than the health care provider, compared to classic HIV testing and counselling, which are initiated by the provider and remove the patient’s autonomy and potentially in the African context, confidentiality (
      • van Dyk A.C.
      Client-initiated, provider-initiated, or self-testing for HIV: What do South Africans prefer?.
      ). Community-based HIVST consists in providing HIV self-tests to residents of community clusters, with pre- and post-counseling offered by community workers. This strategy has been shown to be successful in the uptake and increase of the number of people getting tested and being linked to HIV care, especially due to community workers (
      • Choko A.
      • MacPherson P.
      • Webb E.L.
      • Willey B.A.
      • Feasy H.
      • Sambakunsi R.
      • et al.
      Uptake, accurary, safety, and linkage into care over two years of promoting annual self-testing for HIV in Blantyre, Malawi: a community-based prospective study.
      ,
      • Mulubwa C.
      • Hensen B.
      • Phiri M.M.
      • Shanaube K.
      • Schaap A.J.
      • Floyd S.
      • et al.
      Community based distribution of oral HIV self-testing kits in Zambia: a cluster-randomised trial nested in four HPTN 071 (PopART) intervention communities.
      ). HIVST at health facilities refers to the self-administration of an HIV self-test inside the site often under the supervision of the health care provider (
      • van Dyk A.C.
      Client-initiated, provider-initiated, or self-testing for HIV: What do South Africans prefer?.
      ). In both cases, HIVST has the advantages of being highly acceptable and of increasing HIV testing uptake among populations that are difficult to reach with routine HTC (male partners, young women, adolescents, students, female sex workers (
      • Hatzold K.
      • Gudukeya S.
      • Mutseta M.N.
      • Chilongosi R.
      • Nalubamba M.
      • Nkhoma C.
      • et al.
      HIV self-testing: breaking the barriers to uptake of testing among men and adolescents in sub-Saharan Africa, experiences from STAR demonstration projects in Malawi, Zambia and Zimbabwe.
      ,
      • Tonen-Wolyec S.
      • Mbopi-Kéou F.X.
      • Batina-Agasa S.
      • Kalla G.
      • Noubom M.
      • Bouassa R.S.
      • et al.
      Acceptability of HIV self-testing in African Students: a cross-sectional survey in the Democratic Republic of Congo - PubMed.
      ,
      • Mulubwa C.
      • Hensen B.
      • Phiri M.M.
      • Shanaube K.
      • Schaap A.J.
      • Floyd S.
      • et al.
      Community based distribution of oral HIV self-testing kits in Zambia: a cluster-randomised trial nested in four HPTN 071 (PopART) intervention communities.
      ,
      • Harichund C.
      • Moshabela M.
      Acceptability of HIV Self-Testing in Sub-Saharan Africa: scoping study.
      ,
      • Pintye J.
      • Drake A.L.
      • Begnel E.
      • Kinuthia J.
      • Abuna F.
      • Lagat H.
      • et al.
      Acceptability and outcomes of distributing HIV self-tests for male partner testing in Kenyan maternal and child health and family planning clinics.
      ). HIVST has several benefits. Several studies reported increased confidentiality and privacy, decreased burden on the healthcare system, decreased coercive testing by healthcare workers, and decreased stigma and discrimination associated with HIVST (
      • Harichund C.
      • Moshabela M.
      Acceptability of HIV Self-Testing in Sub-Saharan Africa: scoping study.
      ). Autonomy to make one’s own choice of HIV testing method was also cited as advantageous by van Dyk et al. (
      • van Dyk A.C.
      Client-initiated, provider-initiated, or self-testing for HIV: What do South Africans prefer?.
      ). Makusha et al., reported that HIVST has the potential to address gender disparate barriers to testing, often encountered by males at HIV testing centers, such as non-male friendly testing spaces, inconvenient operating hours and healthcare provider attitudes that may not be sensitive to men’s needs (
      • Makusha T.
      • Knight L.
      • Taegtmeyer M.
      • Tulloch O.
      • Davids A.
      • Lim J.
      • et al.
      HIV self-testing could “Revolutionize Testing in South Africa, but It Has Got to Be Done Properly”: perceptions of key stakeholders.
      ). Also, study outcomes from current literature on the advantages of HIVST reiterate the argument that HIVST should be offered as a complementary HIV diagnosis or screening method to overcome current barriers associated with conventional HIV testing approaches (voluntary counselling and testing, provider-initiated counselling and testing, etc.) (
      • Harichund C.
      • Moshabela M.
      Acceptability of HIV Self-Testing in Sub-Saharan Africa: scoping study.
      ).

      Third challenge: strategies for the distribution of HIVST

      Two complementary approaches have been suggested by the WHO and the Liverpool School of Tropical Medicine in 2013 for the implementation of self-testing. In the first approach, “supervised testing”, a health care worker from the community or the health center is involved at several steps in the provision, in the administration and interpretation of the self-test. In the “unsupervised approach” to self-testing, HIV self-tests would be distributed by health care workers in health care centers or would be provided from a regular pharmacy (
      • Johnson C.
      • Baggaley R.
      • Forsythe S.
      • van Rooyen H.
      • Ford N.
      • Napierala Mavedzenge S.
      • et al.
      Realizing the potential for HIV self-testing.
      ). Access to self-tests could be facilitated by vending machines, as is the case for condom distribution. The level of education of people using HIVST would then be the main factor of choice for the supervised or unsupervised HIVST. Hence, for those with high levels of education, the probability of errors in reading the results of the test and interpreting is low. On the contrary, among those with low educational levels, the “supervised testing” would be the recommended approach to limit the risk of errors. In the African context, studies have demonstrated that the preferred choice of HIVST between the oral fluid self-test and the finger-prick self-test, was the first method, due to the ease of use and painlessness (
      • Indravudh P.P.
      • Choko A.T.
      • Corbett E.L.
      Scaling up HIV self-testing in sub-Saharan Africa: a review of technology, policy and evidence.
      ,
      • Sibanda E.L.
      • d’Elbée M.
      • Maringwa G.
      • Ruhode N.
      • Tumushime M.
      • Madanhire C.
      • et al.
      Applying user preferences to optimize the contribution of HIV self-testing to reaching the “first 90” target of UNAIDS Fast-track strategy: results from discrete choice experiments in Zimbabwe.
      ). HIV pre-and post-counseling are an essential aspect of HIV testing, for the psychological support of people willing to test for HIV (
      • van Rooyen H.
      • Tulloch O.
      • Mukoma W.
      • Makusha T.
      • Chepuka L.
      • Knight L.C.
      • et al.
      What are the constraints and opportunities for HIVST scale-up in Africa? Evidence from Kenya, Malawi and South Africa.
      ). Depending on the approach to self-testing, on the level of education and on socio-economic factors, the counseling modalities vary. The ATLAS project is an example of an implementation project that could help to better describe the type of HIV self-testing kit and counselling (e.g., phone, regular clinical visit) that could be delivered to West and Central African communities.

      Fourth challenge: linkage to HIV prevention and care services/facilities

      This challenge is particularly important to achieve the second and third 90 targets. There is also the issue of post-test counseling and linkage to care, which in the context of SSA and WCAR remains an important issue. The goal of increasing the number of people who get tested for HIV is to be able to get people under treatment and to ultimately have PLHIV with undetectable viral load. Ensuring linkage to care should then be a condition for self-testing to be effective, in addition to post-test counseling for behavioral change in the case of a negative HIV test (
      • Bain L.E.
      • Ditah C.M.
      • Awah P.K.
      • Ekukwe N.C.
      Ethical implications of HIV self-testing: the game is far from being over.
      ). Linkage to care is limited in WCAR, with a weak health system and a lack of policies on HIVST. To increase the linkage to care after using HIVST, some strategies are tested such as the use of smartphone applications and mHealth interventions (
      • Adeagbo O.
      • Herbst C.
      • Blandford A.
      • McKendry R.
      • Estcourt C.
      • Seeley J.
      • et al.
      Exploring people’s candidacy for mobile health-supported HIV testing and care services in rural KwaZulu-Natal, South Africa: qualitative study.
      ,
      • Balán I.C.
      • Lopez-Rios J.
      • Nayak S.
      • Lentz C.
      • Arumugam S.
      • Kutner B.
      • et al.
      SMARTtest: a smartphone app to facilitate HIV and syphilis self- and partner-testing, interpretation of results, and linkage to care.
      ). Innovative approaches are needed to refer HIV-infected patients in the context of low prevalence of HIV.

      Fifth challenge: funding/sustainability/susbsidy

      Cost is one of the major concerns for policies that would like to implement HIVST. However, the largest gap between resource availability and the 2020 resources needs target has been observed in WCAR. At the same time, international funding support tended to slow down in the recent years. Funding, cost, and quantification/forecasting of HIVST are other critical aspects to take into consideration. Information is scarce and insufficient to estimate the needs of HIVST at the national level in a scaling up process. A study in Malawi explored cost-effectiveness of HIVST compared to facility-based HTC, and found that HIVST cost was significantly lower than facility-based HTC for the client; however, it was more costly than facility-based HTC when needing to identify HIV-positive individuals and administer treatments, hence a heavier burden for health care providers (
      • Maheswaran H.
      • Petrou S.
      • MacPherson P.
      • Choko A.T.
      • Kumwenda F.
      • Lalloo D.G.
      • et al.
      Cost and quality of life analysis of HIV self-testing and facility-based HIV testing and counselling in Blantyre, Malawi.
      ). In another study on costs of HIVST, respondents indicated that the government should be responsible for the procurement of tests, and should be paying at least some part of the cost of test kits; respondents also drew a parallel between the distribution and availability of self-tests and that of condoms (
      • van Rooyen H.
      • Tulloch O.
      • Mukoma W.
      • Makusha T.
      • Chepuka L.
      • Knight L.C.
      • et al.
      What are the constraints and opportunities for HIVST scale-up in Africa? Evidence from Kenya, Malawi and South Africa.
      ). Since 2017, financial support provided by donors to bring the unit cost of the OraQuick self-test kit down to US$2 in selected sub-Saharan African, removed a critical cost barrier to HIVST expansion (
      • Indravudh P.P.
      • Choko A.T.
      • Corbett E.L.
      Scaling up HIV self-testing in sub-Saharan Africa: a review of technology, policy and evidence.
      ,

      OraSure Technologies. OraSure Technologies - OraQuick® Self-Test [Internet], [cited 2019 Oct 31]. [Available from]: https://www.orasure.com/products-infectious/products-infectious-oraquick-self-test.asp. OraSure Technologies 2013.

      ). Funding for self-tests could in fact be subsidized by local government, within the framework of controlling the HIV/AIDS epidemic. Hopefully, the Global Fund (GF) and PEPFAR would expand access and support for HIVST in SSA (
      • Resource Mobilization
      Resource Mobilization — The Global Fund to Fight AIDS, Tuberculosis and Malaria.
      ,
      • PEPFAR
      Annual Report to congress 15 years of saving lives through American generosity and partnership.
      ). The recent pledges of 14 billion USD for the replenishment of GF offer an expectation to reinforce programs in global health for HIV testing through novel differentiated services and facilities models adapted to low-prevalence HIV settings such as WCAR countries (
      • Resource Mobilization
      Resource Mobilization — The Global Fund to Fight AIDS, Tuberculosis and Malaria.
      ). This donor funding, historically reduced in WCAR, will probably help countries in this region to unlock the first 90 and reach UNAIDS 95-95-95 to ending AIDS in 2030 (

      The Lancet HIV, The Lancet HIV. Divergent paths to the end of AIDS [Editorial]. The Lancet HIV, [Available from]: https://www.thelancet.com/journals/lanhiv/article/PIIS2352-3018(17)30157-1/fulltext. [Accessed 4 February] 9 The Lancet HIV 2017.

      ). The sustainability of HIV testing depends not only on the acceptability and feasibility of HIVST but also on the financial support which can have a critical effect on HIVST accessibility. First, a needs assessment is crucial to identify the target population. The private sector implication will be essential, as well as a private and public partnership. Also, a cost-effectiveness of various delivery models is needed to identify the best population to prioritize in order to achieve the first 90.

      Sixth challenge: research gaps

      In WCAR, research on HIV self-testing is limited (Table 2). Only two research studies are planned in Nigeria. The first (NCT03874663) is to study the acceptability and performance of HIVST in a youth population aged 14–24 years, and the second one (NCT 04070287), with the enrolment of youth aged 14–24, is a prospective one-year assessment of five youth participatory interventions. Further research is needed to ensure the feasibility of HIVST, and the adaptation of the best approach for a successful scale up in an integrated and comprehensive package of HIV diagnosis in the context of WCAR. The project ATLAS, which is not a research project, launched in 2018 falls within this approach, by targeting populations that have never been tested before and key populations. The project provided these populations with a total of 500,000 HIV oral self-tests in three francophone countries of West Africa, Mali, Senegal and Côte d’Ivoire. The study will document the impact of HIVST as a complementary screening strategy, will assess the necessary requirements for the scale-up of HIVST strategy by local governments and will identify the distribution models that are most cost-effective (

      UNITAID, UNITAID. The ATLAS project in West Africa: a big innovation at local level to achieve the global HIV screening goal by 2020 [Internet], Unitaid. [cited 2019 Jun 19]. [Available from]: https://unitaid.org/news-blog/avec-le-projet-atlas-en-afrique-de-louest-une-innovation-majeure-au-plus-pres-du-terrain-pour-atteindre-lobjectif-mondial-lie-au-depistage-du-vih-dici-2020. [Accessed 2 February 2020] UNITAID 2019.

      ). Finally, the lack of studies and interventions on HIVST in WCAR represent a challenge to the effective implementation of HIVST in WCAR. Very few studies and interventions have explored the different aspects of the implementation of HIVST in the context of the WCAR. Additional research groups should focus on identifying the challenges and opportunities for the successful implementation of HIVST in the cultural, political and social context of the WCAR. We are urgently calling for more research in this region to inform stakeholders of HIV self-testing opportunities. This could be an additional strategy to increase the first 90 in this region.
      Table 2Summary on main results on HIV self-testing in West and Central Africa.
      Reference NumberCountryPopulationHIV ST kitsMain results
      • Tonen-Wolyec S.
      • Mbopi-Kéou F.X.
      • Batina-Agasa S.
      • Kalla G.
      • Noubom M.
      • Bouassa R.S.
      • et al.
      Acceptability of HIV self-testing in African Students: a cross-sectional survey in the Democratic Republic of Congo - PubMed.
      DRC – BuniaN = 1,012 University StudentsBlood based HIV ST
      • ˗
        81.4% acceptability of HIVST
      • ˗
        Better acceptability among students >24-year-old
      • ˗
        Acceptability associated with prior knowledge of HIV self-testing
      • ˗
        Posttest counseling supported by 86.9% of older students (>24 years old) and by 80.7% of younger students (<24 years old)
      • Tonen-Wolyec S.
      • Batina-Agasa S.
      • Muwonga J.
      • Mboumba Bouassa R.-S.
      • Kayembe Tshilumba C.
      • Bélec L.
      Acceptability, feasibility, and individual preferences of blood-based HIV self-testing in a population-based sample of adolescents in Kisangani, Democratic Republic of the Congo.
      DRC - KisanganiN = 628

      Adolescents (15 to 19 years old)
      Blood based HIV ST

      (Exacto Test HIV kit)
      • ˗
        95.1% acceptability of HIV testing
      • ˗
        96.1% correctly used the self-test
      • Lyons C.E.
      • Coly K.
      • Bowring A.L.
      • Liestman B.
      • Diouf D.
      • Wong V.J.
      • et al.
      Use and acceptability of HIV self-testing among first-time testers at risk for HIV in Senegal | SpringerLink.
      SenegalN = 1,149

      Through convenience sample
      Oral test

      (OraQuick HIV self-test kit)
      • ˗
        94.3% reported using HIVST
      • ˗
        74.5% reported being comfortable using HIVST
      • ˗
        86.1% found the instructions easy to follow
      • Grésenguet G.
      • Longo J.D.D.
      • Tonen-Wolyec S.
      • Mboumba Bouassa R.-S.
      • Belec L.
      Acceptability and usability evaluation of finger-stick whole blood HIV self-test as An HIV screening tool adapted to the general public in the Central African Republic.
      Central African Republic – BanguiN = 300 adult volunteersBlood based test

      (Exacto Test HIV kit)
      • ˗
        96.9% of HIV self-test were correctly interpreted
      • ˗
        91.6% correctly performed the HIV self-test and 23% asked for oral assistance
      • Izizag B.
      • Situakibanza H.
      • Mbutiwi T.
      • Ingwe R.
      • Kiazayawoko F.
      • Nkodila A.
      • et al.
      Factors associated with acceptability of HIV self-testing (HIVST) among university students in a Peri-Urban Area of the Democratic Republic of Congo (DRC).
      DRC - Kikwit universityN = 290

      University Students

      Media
      Not mentioned
      • ˗
        Acceptability of HIVST: 81.4%
      • ˗
        Willingness to confirm a HIV positive self-test result at a local health care facility: 66.1%
      • Tun W.
      • Vu L.
      • Dirisu O.
      • Sekoni A.
      • Shoyemi E.
      • Njab J.
      • et al.
      Uptake of HIV self-testing and linkage to treatment among men who have sex with men (MSM) in Nigeria: a pilot programme using key opinion leaders to reach MSM.
      NigeriaN = 257 MSM

      Median age 25 years old
      Oral test

      (OraQuick HIV antibody test)
      • ˗
        97.7% reported having used the HIV self-test kits
      • ˗
        Post-test counseling was sought for all 14 who tested positive
      • Tonen-Wolyec S.
      • Batina-Agasa S.
      • Muwonga J.
      • Fwamba N’kulu F.
      • Mboumba Bouassa R.S.
      • Bélec L.
      Evaluation of the practicability and virological performance of finger-stick whole-blood HIV self-testing in French-speaking sub-Saharan Africa.
      DRC – Kisangani and BuniaN = 322

      General population and health care workers

      Mean age = 30 years old
      Blood based test

      (Exacto Test HIV kit)
      • ˗
        79.6% of participants correctly understood the instructions for use of the test
      • ˗
        90.2% of tests were correctly interpreted

      Conclusion

      HIVST represents an opportunity and a key to unlock the first 90 in WCAR and catch up to the rest of the continent and the world. With the urgent need to implement such an opportunity in WCAR, a framework that would take into account priority populations such as key populations and also adolescents and men is needed. This strategy should rely on community health workers and should be integrated into national strategic policies. Additional research is needed to address some challenges that would remain, such as linkage to care and cost-effectiveness of this strategy.

      Conflict of interest

      The authors have no conflicts interest to declare.

      Funding source

      This opinion paper was not funded.

      Ethics approval and consent to participate

      This study was opinion paper and ethical approval was not requested.

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