Australia’s Seventh National HIV Strategy sets a target of virtually eliminating HIV transmissions by 2020. It’s an ambitious goal that can only be achieved if frequent, easy testing for HIV and early diagnosis becomes the norm in this country.
There are currently a range of different HIV testing technologies and settings in Australia. This includes traditional testing with a doctor or clinician where blood is drawn from a vein and sent to the laboratory for analysis. In more recent years, community organisations have also started providing testing services operated by peers and in community spaces, including those that are open after hours or at different times than more traditional testing locations.
Australia has also introduced rapid (or point-of-care) HIV testing where a sample is taken from oral fluid or blood via a finger prick by a clinician or peer tester with results provided within 30 minutes. Confirmatory laboratory testing for reactive (preliminary positive) results are required for rapid HIV testing. A confirmatory laboratory test is where a health care worker draws blood from a vein and the blood sample is sent to the laboratory for analysis. The window periods (the time it can take to detect HIV after someone becomes HIV positive) of rapid HIV tests can be a little longer than traditional laboratory testing, so rapid HIV tests may not be the most appropriate tests for recent exposures to risk.
HIV self-testing uses similar technology to rapid HIV tests but are operated by the person in their home or a similar environment. Like rapid HIV testing, self-tests provide results within about 30 minutes, require confirmatory laboratory testing for reactive results, and have slightly longer window periods than traditional laboratory testing.
Although there are a number of testing options available, many people still experience a range of barriers to testing and do not test as frequently as required. Providing additional HIV testing options, like self-testing, are essential to help achieve the frequent, easy testing required to meet the ambitious goal of virtually eliminating HIV transmission by 2020.
The National HIV Strategy identifies self-testing as an important tool that can simplify the HIV testing process and address barriers such as cost, time and convenience. Self-testing empowers individuals as they know their own HIV status, can be better informed about HIV prevention and, in the event of a positive HIV diagnosis, they can commence treatment.
So where is HIV self-testing in Australia at the moment?
ASHM, the peak body for health professionals working in the areas of HIV, Viral Hepatitis and Sexual Health changed its National HIV Testing Policy in February 2017 to support self-test kits for personal use. However, the Therapeutic Goods Administration, which lifted its ban on the supply of HIV self-test devices back in July 2014, is yet to approve a product for sale in Australia.
It’s unfortunate, as trials of self-test products have shown promising results.
The FORTH study was a recent Australian study which provided free HIV self-test devices. It reported that there was a two-fold increase in the frequency of HIV testing among gay and bisexual men at high risk of HIV, and a nearly four-fold increase in testing among those who had gone more than two years without an HIV test or who had never had a test. Pleasingly, there was no reduction in the number of people utilising more traditional forms of HIV testing and no decline in testing for other sexually transmitted infections.
Would there have been the same rate of self-testing if the men who took part in the study had had to pay for the device?
While we do not know if the uptake of self-testing would have been the same among the study participants if they had to pay, we do know that access to HIV self-testing devices sold in Australia needs to be equitable and affordable.
In comparable countries where self-tests are sold (e.g. USA, UK and France), they are not cheap. People in those countries are looking at the equivalent of about AUD$40-$50 per test, plus postage. Three quarters of the participants surveyed in the FORTH study were willing to pay a maximum of AUD$30 for a self-test, with around half of the participants only willing to pay up to AUD$20. This is significantly less than the equivalent price of those sold in comparable countries. HIV self-tests approved for sale in Australia would need to be much more affordable in comparison.
It will also be important that GPs are ready to actively support the use of self-tests. They will be the first port of call after someone has a reactive result from a self-test and they need to be ready to provide information about what a reactive result means, confirmatory laboratory testing and treatment initiation, if a reactive result is confirmed.
Are self-tests right for everyone?
Self-tests are an exciting new development for populations with higher prevalence of HIV, primarily gay and other men who have sex with men (including trans men). However, we cannot assume that self-tests will be appropriate or acceptable to all communities.
Testing can be complex for some populations that may not have a contemporary understanding of HIV, so any promotion of testing needs to be part of a discussion, together with treatment, and what HIV means. This is also the case for some people from culturally and linguistically diverse communities.
It may also pose challenges for people living in rural and remote areas, including some Aboriginal and Torres Strait Islander communities, as a key to a successful self-testing regime is the availability of nearby services for confirmatory testing and linkage to care.
There are also some difficulties with self-testing in low HIV prevalence populations, including people who inject drugs or sex workers, as they are more likely to receive false reactive results. Other issues which needs to be managed include privacy of information and misuse of devices through coercion.
As with all HIV testing in Australia, self-testing should only occur in circumstances where the individual consents to its use. However, some people may feel pressured or coerced to test with a partner. This could result in unplanned or unwanted disclosure and an unexpected reactive result could occur in a potentially non-supportive and non-confidential setting.
HIV self-testing will be a highly valuable tool in the response to HIV in Australia. However, it is important to be aware of the considerations of different populations to help ensure self-testing is targeted appropriately, and to minimise the potential for misuse.
Keeping communities at the heart of a self-testing regime in Australia will ensure the success of this promising new development.