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HIV self-testing: Breaking barriers

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When the Franks of Neno learnt that they were living with HIV, they grieved and relieved the pain as they recalled the children they have lost.
The couple lost four children to what they believed were ‘strange’ illnesses, but they later realised that they died from AIDS related illnesses.
Austin Frank explains that each time his wife conceived; she became so weak and had frequent illnesses.
“Some well-wishers advised us to go for HIV testing…We finally learnt that both of us were HIV positive. It was so tough when we realised that this is what had actually killed our children,” recalls Frank, whose wife was initiated on treatment immediately after the test. He was initiated later on.
Frank adds: “We were devastated and regretting at the same time because if we had tested earlier, we could have saved their lives.
Some people are not aware of their status and might be going through the same situation…”
Malawi’s Population-based HIV Impact Assessment (MPHIA) latest data shows that the country is one of the five high HIV burden countries in Africa.
Even though Malawi has made great strides in putting people on treatment, Ministry of Health and Population (MoH) says there are about 330,000 people who are living with HIV but are unaware of their HIV status.
Frank’s family might be one of the many that have lived without knowing their status for a long time.
Frank admits: “In my area, some people feel it’s a burden to go to the hospital to get tested.
But it’s good to know one’s status early to avoid situations like mine.”
Group Village Head Chapita of Neno says his village has greatly been affected by HIV and this is worsened by the fact that most of his subjects do not know about their status early enough. This is because health facilities are located far.
“Most of the times, out of desperation, people just cover the distance on foot so that they can get tested,” he says.
Roseby (not her real name) of the same area confesses that she never went for HIV testing because she could not trust the health workers that they could keep her status a secret.
“I was visited by a door-to-door counsellor who introduced me to HIV Self–Testing (HIVST).
I felt health workers would not keep my status a secret because there are usually lots of people at the hospital. But I was very willing to do it myself, as per the counsellor’s advice,” she said.
The counselling made her realise that it was entirely her responsibility to take care of her life in order to look after her children.
“I was happy because he said ‘Madam I’m leaving you.’ You are free to test yourself. It’s up to you to tell me your results or not. But this is confidential. I tested myself and I found out that I was HIV positive,” she said, adding that she went back to the counsellor who advised her to have a confirmatory test. She was initiated on treatment.
In 2015, the World Health Organisation (WHO) announced a new treatment guideline which requires the introduction of Antiretroviral (ARV) drugs to all people living with HIV. The Malawi MoH’s National Strategic Plan, has adopted this test and treat policy. The national test and treat implementation started in July 2016, demonstrating Malawi’s capacity and national commitment to control the epidemic and achieve the United Nations’ 90-90-90 goals by 2020.
The UN 90:90:90 targets aim at having 90 percent of all people living with HIV diagnosed; have 90 percent of those diagnosed on treatment and 90 percent of those on treatment having their viral load suppressed by year 2020.
HIV self-testing, which Roseby had, was scaled up after researchers from the London School of Hygiene and Tropical Medicine and the Malawi-Liverpool Welcome Trust
(MLW) Clinical Research Programme carried out a study on how well HIV self-testing would perform compared to home-based HIV testing and counselling, which requires heavy involvement of trained healthcare workers.
HIV self-testing involves training individuals to perform and interpret their own oral HIV test. A person collects a specimen, performs a rapid test and interprets the test result in private. According to the WHO, this means people can use oral fluid or blood-finger-pricks to discover their status in a private and convenient setting. Results are ready within 20 minutes or less. Those with positive results are advised to seek confirmatory tests at nearby health facilities.
In Malawi, it is currently implemented only at operational study sites; therefore, providers are not required to give out test kits to clients until a policy decision is made.
Henry Makasu is a Community Based Distribution Agent for Neno (Chifunga area) who affirms that most people are reluctant to get tested at a health facility because of the distance.
“Self-testing is not that different to testing at a health facility. When one is interested, I first have a little chat with them to determine their reasoning and understanding of HIV and AIDS issues. They are also counselled before I give them the testing kits,” he said.
When one is given the self-testing kit, they are also given a card which they are supposed to present at a health facility.
“It’s strongly emphasised that being diagnosed with HIV isn’t the end of life but rather the beginning of another.
People are advised go to the hospital as soon as possible,” Makasu said.
Team leader of Behaviour and Health Group at MLW, Nicola Desmond says research findings (since year 2010) through different types of populations have established that people can do it accurately.
“People are able to test themselves for HIV. Standard HIV testing which include access to health facilities and confidentiality issues (among others) are particularly addressed through self-testing. We are currently at the research phase. We are trying to explore the best approaches to delivery of HIV self-testing, according to the needs of particular target population(s),” she explains.
Desmond further discloses that there are two more years for the research phase.
“This research project is not only working in Malawi but also in Zambia and Zimbabwe and in phase two, the research is expanding to South Africa, Bostwana and Swaziland.” Desmond said.
HIV self-testing kits are currently available in districts where the pilot study is been conducted, namely; Mwanza Neno, Blantyre, Machinga, Mulanje and Chikwawa.
Population Services International (PSI) is implementing the self-testing research project.
Deputy Head of HIV Department at PSI, Richard Chilongosi says the first phase (which finished in July 2017) aimed at getting the proof of concept, to establish if self-testing could work or be acceptable in rural communities.
“Evidence shows that it’s acceptable and feasible to distribute HIV self-test kits in rural set ups. An increase in uptake by young people and men was also notable. It was also interesting to note that other people that used the self-testing kit had never tested for HIV before.”
“In phase two, we aim at improving on some challenges that were noted in the first phase such as strengthening the linkage of the people to treatment.
We got requests to also ensure that we provide treatment to them. This phase basically aims at assessing the public health impact of self-testing,” he said.
HIV Testing Services Officer within the department of HIV and AIDSs in the Ministry of Health, Khumbo Namachapa says there are several issues that have to be looked into before HIV self-testing becomes a policy.
“At the moment, we are implementing the (self-testing) research, so whatever comes out of the research will inform government to draw lessons and identify some gaps. As MoH, we need to come up with an implementation plan on how best we can implement HIV self-testing.”
“We are looking at communication issues and also the actual implementation on the ground. At the moment, it terms of HIV testing and programming in Malawi, we have the 90:90:90 targets by the UNAIDS.
So basing on the studies that have been conducted, for example, the MPHIA study and the Demographic Health Survey, we have identified some gaps in terms of testing,” she says.
Namachapa says there is need to reach out to adolescents, men and the key populations with HIV testing services.
Goal three of the United Nations Sustainable Development Goals (SDGs) aims at ensuring healthy lives and promote well-being for all, at all ages. One of the targets is to end the AIDS epidemic (among other diseases) by year 2030.
Facts about HIV
Self-Testing
– Is not recommended for HIV positive people who are on ARVs
– Is not recommended for children
– HIV ST is not yet a government policy
– HIV ST kits are only available in research participating districts
– After HIV ST one is still supposed to have a confirmatory test at a health facility.
A sample of the test kits

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