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HIV self-testing in hospitals could significantly increase uptake in Malawi

Hester Phillips

26 February 2020

Malawi trial finds half of those offered the opportunity to self-test for HIV during an outpatient visit accepted it, compared to less than 15% of those offered provider-initiated testing.

A woman reads a magazine while sitting in a doctors waiting room
Photos are used for illustrative purposes. They do not imply health status or behaviour. Credit: iStock/DMEPhotography

The study, which was conducted in 15 outpatient departments at busy health centres and hospitals in central and southern Malawi, found the approach also markedly improved HIV testing among men and adolescents, and more than doubled the absolute number of people newly diagnosed with HIV – 70% of whom began treatment immediately.

The pilot is the first to evaluate the value of providing HIV self-testing in busy outpatient facilities in a resource-poor setting. Each facility was randomly selected and put into groups providing one of three HIV testing strategies. The first offered outpatients standard provider-initiated testing and counselling, in which people deemed to be at risk of HIV were referred to a separate HIV department for testing. The second group offered optimised provider-initiated testing and counselling, whereby additional training and job aids were provided to health workers and HIV testing was offered to people in a private room within the outpatient department itself.

In the third category, people performed and interpreted their own HIV test in a private space in the outpatient facility, after a group demonstration on how to use a self-testing kit. Optional post-test counselling was also offered to those in this group. Those who chose to disclose a positive self-test result were then given a confirmatory test and offered to start antiretroviral treatment (ART) immediately.

The proportion of people in each testing-category who took up HIV testing was captured through exit surveys.

Between September 2017 and February 2018, 5,885 outpatients completed a survey, roughly a third from each testing-category. Around 60% of survey respondents were female.

The likelihood that someone would agree to same-day HIV testing was found to be significantly higher in the HIV self-testing group compared to the other groups. Around half (51%) of those in the HIV self-testing group got tested, compared with 13% in the standard provider-initiated group and 14% in the optimised provider-initiated group.

In addition, around 4% of those tested in the provider-initiated groups felt coerced to test, and around 1% felt coerced to share test results. No coercion was reported in the HIV self-testing group.

Between 2 and 3% of participants in each group were diagnosed with HIV. Due to its high uptake, HIV self-testing resulted in more than double the absolute number of newly diagnosed HIV-positive people compared with the other groups.

Findings were similar across sexes – whereas, in real-world settings more women than men tend to test for HIV – with adolescents showing the greatest benefit from facility-based HIV self-testing compared with standard provider-initiated testing.

Uptake of HIV self-testing was high among those who reported high-risk sexual behaviour and those who had never been tested for HIV before, suggesting that providing HIV self-testing in health facilities could be an effective way to engage high-risk and previously hard-to-reach groups.

The study’s findings indicate that HIV self-testing could be easily integrated into routine outpatient services and drastically reduce staff workload related to HIV testing while increasing testing coverage. This could be particularly beneficial in busy outpatient departments in similar contexts, where staffing constraints mean provider-initiated HIV testing remains scare.

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