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PROGRAMME
Year : 2020  |  Volume : 152  |  Issue : 1  |  Page : 164-167

HIV self-test during the time of COVID-19, India


Division of Clinical Sciences, ICMR-National AIDS Research Institute, Pune 411 026, Maharashtra, India

Date of Submission12-Jun-2020
Date of Web Publication17-Sep-2020

Correspondence Address:
Amrita Rao
Division of Clinical Sciences, ICMR-National AIDS Research Institute, Pune 411 026, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijmr.IJMR_2521_20

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How to cite this article:
Rao A. HIV self-test during the time of COVID-19, India. Indian J Med Res 2020;152:164-7

How to cite this URL:
Rao A. HIV self-test during the time of COVID-19, India. Indian J Med Res [serial online] 2020 [cited 2021 Apr 19];152:164-7. Available from: https://www.ijmr.org.in/text.asp?2020/152/1/164/294520



The Joint United Nations Programme on HIV/AIDS (UNAIDS) has set a target of achieving 90:90:90 by 2020. This means that 90 per cent of people living with HIV (PLHIV) should know their status, of whom 90 per cent of those detected should be on anti-retroviral therapy (ART) and 90 per cent of those on ART should be virally suppressed by 2020[1]. Despite all the efforts made by the National AIDS Control Programme (NACP) of India, only 76 per cent of the PLHIV know their status and just over a half of these are under the umbrella of ART[2]. The HIV epidemic is mainly concentrated among the key population groups. There are still pockets of untested and unreached population groups who need to be identified.

The World Health Organization (WHO) introduced HIV self-testing guidelines in 2016[3]. HIV self-test is an approach where a person collects his or her own specimen (blood or saliva), and performs this test and interprets the results either alone or in the presence of someone he or she trusts[3]. The WHO pre-qualification programme was initiated to facilitate the quality diagnostic and treatment facilities for HIV, tuberculosis and malaria. As yet, there are four HIV self-tests that have been pre-qualified by the WHO. The pre-qualification process approximately takes three months or more[4]. Locally available HIV self-test kits have received national-level approval in countries such as Belarus, Brazil and Nigeria; however, the quality of these kits is still unknown[5]. HIV self-screening is viewed by the WHO as a triage strategy that stands to complement facility-based testing. Africa is presently leading in the implementation of HIV self-test, and there are some countries in the Asian Pacific regions that have included this in their national guidelines or strategic plan[6],[7]. These screening tests have the potential to increase the access to HIV testing across all population groups. The latest evidence suggests that HIV self-testing when directed towards those who are at risk of HIV infection is cost-effective and also plays an important role in early diagnosis[8],[9].

The policy for HIV self-testing is in varying stages of acceptance across different countries around the world. France, United States of America and United Kingdom have legally introduced HIV self-test kits, while India is yet to adopt such a strategy[3]. In the last two decades, various studies have been conducted in high- and low-income country settings in different population groups with different supervised and unsupervised self-testing approaches. The evidence generated from these studies suggests a high level of acceptability for HIV self-test[10],[11].

The current National Strategic Plan of India mentions the need to generate evidence around HIV self-testing for the containment of this disease; however, there is no policy around HIV self-testing in the country[12]. Globally, the concerns around HIV self-test vary from accuracy, stigma, misuse of the test and linkage to care and treatment[13]. These could also be the reasons for apprehension among Indian policy makers. The fact remains that India is lagging behind other developing countries in implementing and evaluating HIV self-tests and studies pertaining to HIV self-test from the country are also sparse. In most of these studies HIV self-test manufactured by OraQuick (which was approved by the U.S. Food and Drug Administration in 2002[14] and also evaluated in many countries[15],[16]) was used. Pai et al17,18 examined the feasibility of using oral self-tests during labour and its impact in reducing transmission of HIV to new-borns in rural India. Currently, there is no indigenous HIV self-test available in India and HIV self-test approach is yet to be an integral part of the NACP. An appropriate policy framework and guidance is urgently required in this respect.

Recently a study conducted in the red-light area of Pune city, India, revealed that the concept of HIV self-test was acceptable among female sex workers due to its convenience, comfort and ease of doing the self-test[19]. These reasons were echoed across various high risk population groups such as men having sex with men, transgender women and female sex workers groups in Mumbai[20]. Evidence generated across all strata of population in a country will help understand the implementation of HIV self-test as socio-cultural difference varies across different countries.

As stated above, the NACP in India aims to achieve HIV test among 90 per cent of PLHIV Community-based testing, which uses rapid finger-prick test, has been initiated to such effect and is yet to gain its full potential[21]. On the other hand, Nepal has explored the possibility of community-based HIV self-testing among the key and vulnerable population groups and is working towards developing a policy for the same[22].

The realities of this programme need to be examined, in the context of the SARS-CoV-2 pandemic. In view of the rise in the number of people affected by COVID-19, the Government of India implemented a nationwide lockdown towards the end of March 2020 initially for 21 days and later extended further because of the escalation in cases[23]. Although the lockdown was needed for the management of the COVID-19 pandemic, it limited the movement of the people and access to quality healthcare. A shift in the priorities in the health system affected all the health programmes not only in India but the world over. All the resources were diverted towards the COVID-19 pandemic, resulting in disruption of the ongoing activities for communicable and non-communicable diseases. Thus, the promotive, preventive, treatment and curative services across the country were affected. HIV/AIDS was no different and had to bear the brunt of the pandemic. A modelling exercise conducted by the WHO along with UNAIDS for Sub-Saharan Africa revealed that an interruption in the ART supply and prevention services could lead to a rise in the HIV-related deaths and new infections across the region. As a precautionary measure, the countries were asked to build their own strategy to ensure continuity of HIV prevention and treatment services during the COVID-19 pandemic[24]. It was warned that without immediate actions to ensure continuous supply of medicines and access to preventive services, the gains that the countries had achieved would be negated.

India has a long way to go in terms of achieving the targets of 90:90:90. Despite creating awareness around HIV, nearly a fourth of PLHIV are yet to know their status and less than half are yet to be linked to the ART centres[12]. It is quintessential to continue accessing these population groups without hampering the HIV testing and care services. The good thing is that the national programme in India, in the time of COVID-19, ensured multi-medicine dispensing and encouraged local action plans to be developed by the State AIDS Control Societies to ensure uninterrupted services[25]. The needs for maintaining social distancing at the HIV Integrated Counselling and Testing Centres (ICTC) and Targeted Intervention sites were also urged upon. The number of people attending the ICTCs for HIV testing has dwindled primarily due to the fear of contracting the COVID-19 infection and also due to the restriction of travel. Amidst the COVID-19 pandemic, the US Centers of Disease Control and Prevention (CDC) has recommended the use of HIV self-test for those who are at a risk of contracting the disease[26].

In a country like ours with the current prevailing situation of COVID-19 and with a limited population movement and access to healthcare services, HIV self-test can certainly be beneficial. Innovative plans for linking people with positive HIV self-test results with confirmatory diagnostic services and treatment would be required. The strategic framework serves as a brief guide for preparation, implementation and monitoring of HIV self-test in countries that are planning, starting or scaling up implementation of HIV self-test. Examples can be drawn from other countries that have already adapted HIV self-test[27]. Finally, in the current COVID-19 pandemic situation, the WHO pre-qualification for HIV self-test kits needs to be expedited for promising candidates and concurrent approval by the regulatory bodies under the Government of India and NACP would help in early incorporation of such kits in the programme. The dream of ending AIDS, for its fruition, demand such multi-partner collaboration, where listening to the voices of people and responding to their needs remain central.

Financial support & sponsorship: None.

Conflicts of Interest: None.



 
   References Top

1.
Joint United Nations Program on HIV/AIDS. 90-90-90: An ambitious treatment target to help end the AIDS epidemic; 2014. Available from: https://www.unaids.org/sites/default/files/media_asset/90-90-90_en.pdf, accessed on March 30, 2020.  Back to cited text no. 1
    
2.
National AIDS Control Organisation. HIV Estimations Report 2017: Technical Report. New Delhi: Ministry of Health and Family Welfare, Government of India; 2018.  Back to cited text no. 2
    
3.
World Health Organization. Guidelines on HIV self-testing and partner notification: Supplement to consolidated guidelines on HIV testing services. Geneva: WHO; 2016.  Back to cited text no. 3
    
4.
World Health Organization. In vitro Diagnostics and Laboratory Technology. Available from: https://www.who.int/diagnostics_laboratory/evaluations/pq-list/self-testing_public-report/en/, accessed on July 19, 2020.  Back to cited text no. 4
    
5.
Unitaid, WHO. Market and technology landscape: HIV rapid test diagnostic tests for self-testing. 4th ed. Geneva: WHO; 2018.  Back to cited text no. 5
    
6.
Harichund C, Moshabela M. Acceptability of HIV self-testing in Sub-Saharan Africa: Scoping study. AIDS Behav 2018; 22 : 560-8.  Back to cited text no. 6
    
7.
Unitaid, UNAIDS, WHO. Building capacity for the roll-out of PrEP and HIV testing innovations in Asia and Pacific. Available from: https://unitaid.org/assets/HIVST-PrEP-Report-2019.pdf, accessed on July 19, 2020.  Back to cited text no. 7
    
8.
Shrestha RK, Chavez PR, Noble M, Sansom SL, Sullivan PS, Mermin JH, et al. Estimating the costs and cost-effectiveness of HIV self-testing among men who have sex with men, United States. J Int AIDS Soc 2020; 23 : e25445.  Back to cited text no. 8
    
9.
Neuman M, Indravudh P, Chilongosi R, d'Elbée M, Desmond N, Fielding K, et al. The effectiveness and cost-effectiveness of community-based lay distribution of HIV self-tests in increasing uptake of HIV testing among adults in rural Malawi and rural and peri-urban Zambia: Protocol for STAR (self-testing for Africa) cluster randomized evaluations. BMC Public Health 2018; 18 : 1234.  Back to cited text no. 9
    
10.
Choko AT, MacPherson P, Webb EL, Willey BA, Feasy H, Sambakunsi R, et al. Uptake, accuracy, safety, and linkage into care over two years of promoting annual self-testing for HIV in Blantyre, Malawi: A community-based prospective study. PLoS Med 2015; 12 : e1001873.  Back to cited text no. 10
    
11.
Krause J, Subklew-Sehume F, Kenyon C, Colebunders R. Acceptability of HIV self-testing: a systematic literature review. BMC Public Health 2013; 13 : 735.  Back to cited text no. 11
    
12.
National AIDS Control Organisation. National Strategic Plan for HIV/AIDS and STI 2017-2024: Paving way for an AIDS free India. New Delhi: Ministry of Health and Family Welfare, Government of India; 2017.  Back to cited text no. 12
    
13.
Pai NP, Sharma J, Shivkumar S, Pillay S, Vadnais C, Joseph L, et al. Supervised and unsupervised self-testing for HIV in high- and low-risk populations: A systematic review. PLoS Med 2013; 10 : e1001414.  Back to cited text no. 13
    
14.
Centers for Disease Control and Prevention. Notice to readers: Approval of a new rapid test for HIV antibody. MMWR Morb Mortal Wkly Rep 2002; 51 :1051-2.  Back to cited text no. 14
    
15.
Belete W, Deressa T, Feleke A, Menna T, Moshago T, Abdella S, et al. Evaluation of diagnostic performance of non-invasive HIV self-testing kit using oral fluid in Addis Ababa, Ethiopia: A facility-based cross-sectional study. PLoS One 2019; 14 : e0210866.  Back to cited text no. 15
    
16.
Zelin J, Garrett N, Saunders J, Warburton F, Anderson J, Moir K, et al. An evaluation of the performance of OraQuick ADVANCE Rapid HIV-1/2 Test in a high-risk population attending genitourinary medicine clinics in East London, UK. Int J STD AIDS 2008; 19 : 665-7.  Back to cited text no. 16
    
17.
Pai NP, Joshi R, Dogra S, Taksande B, Kalantri SP, Pai M, et al. Evaluation of diagnostic accuracy, feasibility and client preference for rapid oral fluid-based diagnosis of HIV infection in rural India. PLoS One 2007; 2 : e367.  Back to cited text no. 17
    
18.
Pai NP, Barick R, Tulsky JP, Shivkumar PV, Cohan D, Kalantri S, et al. Impact of round-the-clock, rapid oral fluid HIV testing of women in labor in rural India. PLoS Med 2008; 5 : e92.  Back to cited text no. 18
    
19.
Chang YM, Sevekari T, Duerr A, Molina Y, Gilada T. HIV self-testing in Pune, India: Perspectives and recommendations of female sex workers and peer educators. AIDS Care 2020; 32 : 182-5.  Back to cited text no. 19
    
20.
Community perspective on making HIV self-testing accessible as a comprehensive prevention package. Available from: http://naco.gov.in/sites/default/files/Technical%20Brief %20on%20HIV%20Self%20testing.pdf, accessed on August 14, 2020.  Back to cited text no. 20
    
21.
National AIDS Control Organisation. National HIV counselling and testing services guidelines. New Delhi: Ministry of Health and Family Welfare, Government of India; 2016.  Back to cited text no. 21
    
22.
Nepal Health Research Council. Report of exploring the uptake and acceptability of HIV self-testing for men who have sex with men, male sex workers and transgender people in Nepal. Available from: https://www.fhi360.org/sites/default/files/media/documents/resource-nepal-hivst-report.pdf, accessed on August 14, 2020.  Back to cited text no. 22
    
23.
Press Information Bureau. Government of India issues orders prescribing lockdown for containment of COVID-19 epidemic in the country. New Delhi: Government of India; 24 March, 2020. Available from: https://www.mha.gov.in/sites/default/files/PR_NationalLockdown_26032020_0.pdf, accessed on June 10, 2020.  Back to cited text no. 23
    
24.
Jewell BL, Mudimu E, Stover J, Ten Brink D, Phillips AN, Smith JA, et al. Potential effects of disruption to HIV programmes in Sub-Saharan Africa caused by COVID-19: Results from multiple mathematical models. Lancet HIV 2020; S2352-3018(20)30211-3.  Back to cited text no. 24
    
25.
National AIDS Control Organisation, Ministry of Health and Family Welfare, Government of India. Guidance note for persons engaged in HIV/AIDS response under National AIDS Control Programme in view of the COVID-19 scenario. Available from: http://naco.gov.in/sites/default/files/Guidance%20Note-COVID-19.pdf, accessed on June 11, 2020.  Back to cited text no. 25
    
26.
Centers for Disease Control and Prevention. HIV self-testing guidance. Available from: https://www.cdc.gov/nchhstp/dear_colleague/2020/dcl-042820-HIV-self-testing-guidance.html, accessed on June 9, 2020.  Back to cited text no. 26
    
27.
World Health Organization. HIV self-testing strategic framework: A guide for planning, introducing and scaling up HIV testing services. Geneva: WHO; 2018.  Back to cited text no. 27
    




 

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