tag:theconversation.com,2011:/ca/topics/self-testing-57261/articlesSelf-testing – The Conversation2023-10-02T12:38:37Ztag:theconversation.com,2011:article/2137262023-10-02T12:38:37Z2023-10-02T12:38:37ZHIV self-test kits are meant to empower those at risk − but they don’t necessarily lead to starting HIV treatment or prevention<figure><img src="https://images.theconversation.com/files/550089/original/file-20230925-29-kvx1ps.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C3058%2C2000&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Regular testing for HIV protects you and those around you.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/focus-on-an-hiv-self-test-with-seronegative-result-royalty-free-image/930075664">pixinoo/iStock via Getty Images Plus</a></span></figcaption></figure><p>HIV self-test kits were developed to make it easier for people to access HIV testing. However, <a href="https://scholar.google.com/citations?user=7RB_bZUAAAAJ&hl=en">our</a> <a href="https://scholar.google.nl/citations?user=weevnFsAAAAJ&hl=en">research</a> <a href="https://www.researchgate.net/profile/Oluwaseun-Badru">team</a> has found that many people who use self-test kits <a href="https://doi.org/10.1007/s10461-023-04162-5">do not go on to receive needed HIV treatment</a> or start preexposure prophylaxis, or PrEP, to prevent future infection.</p>
<p>In 2016, the World Health Organization <a href="https://www.who.int/publications/i/item/WHO-CDS-HIV-19.36">recommended HIV self-test kits</a> as a way for people to confidentially test for HIV in their homes or other private places. Each kit contains detailed instructions on how to administer the test and read the results without the help of a clinician. However, the instructions advise confirming results in a health facility to improve access to care, especially for those with a positive reading.</p>
<p>Our team conducted a systematic review and meta-analysis of published research and data to understand how HIV self-testing influences access to HIV care and sexual behavior. Specifically, we looked at whether a positive test result led someone to seek care in a hospital or health facility to start treatment and whether a negative test result led someone at risk of contracting HIV to take preventive measures. We also looked at whether test results affected the number of sexual partners, engagement in anal sex without a condom and frequency of condom use.</p>
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<figcaption><span class="caption">HIV self-test kits provide quick results.</span></figcaption>
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<p>Based on the 15 studies that met our criteria, we found that while HIV self-testing increased a person’s chances of finding an HIV clinic or doctor by 8%, many people <a href="https://doi.org/10.1007/s10461-023-04162-5">did not initiate HIV treatment or PrEP</a> following self-testing.</p>
<p><a href="https://doi.org/10.1007/s10461-023-04162-5">Female sex workers</a> who used HIV self-test kits were 47% more likely to seek medical care, but this did not reduce the number of clients they saw per night.</p>
<p>For <a href="https://doi.org/10.1007/s10461-023-04162-5">men who have sex with men</a>, using HIV self-test kits may have increased the amount of condomless anal sex they have, according to <a href="https://doi.org/10.1097/QAI.0000000000001709">one U.S. study</a>. Those who use HIV self-test kits were more likely to have condomless anal sex with HIV-positive and HIV-negative partners, as reported by <a href="https://doi.org/10.1007/s10461-022-03804-4">one Chinese study</a>.</p>
<h2>Why it matters</h2>
<p>Many people are living with HIV and receiving treatment. However, some HIV-positive people are unaware of their HIV status and are at risk of infecting other people. Routinely checking your HIV status is important to prevent the spread of HIV.</p>
<p>Unfortunately, HIV testing is low in many regions of the world. Researchers from <a href="https://doi.org/10.4102/sajhivmed.v22i1.1273">South Africa</a>, the <a href="https://doi.org/10.1136/bmjopen-2015-009480">Netherlands</a> and the <a href="https://doi.org/10.1080/09540121.2020.1766663">United States</a> have reported a lack of HIV testing among different parts of the population, including <a href="https://theconversation.com/men-who-have-sex-with-men-originated-during-the-hiv-pandemic-to-focus-on-behavior-rather-than-identity-but-not-everyone-thinks-the-term-helps-189619">men who have sex with men</a>. There are many barriers to HIV testing, including <a href="https://doi.org/10.1186/s12905-021-01590-0">lack of knowledge about HIV</a> and <a href="https://doi.org/10.1080/09540121.2020.1742867">fear of</a> <a href="https://theconversation.com/people-living-with-hiv-face-harmful-stigma-daily-dababys-rant-was-just-more-public-than-most-165443">stigma and discrimination</a>. </p>
<p>Despite the availability of HIV test kits, many people at heightened risk have never been tested for HIV. As our research shows, some of those who test positive don’t receive treatment. Nor do all those who test negative but are at risk of infection receive preventive treatment or change their sexual behavior.</p>
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<a href="https://images.theconversation.com/files/550092/original/file-20230925-29-e1or2l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Clinician handing patient condoms" src="https://images.theconversation.com/files/550092/original/file-20230925-29-e1or2l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/550092/original/file-20230925-29-e1or2l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/550092/original/file-20230925-29-e1or2l.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/550092/original/file-20230925-29-e1or2l.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/550092/original/file-20230925-29-e1or2l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=502&fit=crop&dpr=1 754w, https://images.theconversation.com/files/550092/original/file-20230925-29-e1or2l.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=502&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/550092/original/file-20230925-29-e1or2l.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=502&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Public health officials recommend talking to a doctor about HIV self-test results.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/the-doctor-advised-the-young-man-to-prevent-royalty-free-image/1210961713">Wasan Tita/iStock via Getty Images Plus</a></span>
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<h2>What still isn’t known</h2>
<p>We found only one study that looked at how HIV self-testing influences PrEP use among men who have sex with men. </p>
<p>More research is needed to better understand the link between HIV self-testing and HIV prevention.</p>
<h2>What’s next</h2>
<p>Our next step is to understand why people did or did not receive care following HIV self-testing. We plan on interviewing HIV self-test kit users about their experience using the self-test and whether they went on to receive care.</p>
<p>We hope the results of this study will help us build an intervention to increase access to care following an HIV self-test. This will contribute toward the national plan to <a href="https://www.hiv.gov/federal-response/ending-the-hiv-epidemic/overview/">end the HIV epidemic by 2030</a> in the U.S.</p>
<p><em>The <a href="https://theconversation.com/us/topics/research-brief-83231">Research Brief</a> is a short take on interesting academic work.</em></p><img src="https://counter.theconversation.com/content/213726/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Adeagbo Oluwafemi Atanda receives funding from University of Iowa and National Institutes of Health. </span></em></p><p class="fine-print"><em><span>Engelbert Bain Luchuo and Oluwaseun Abdulganiyu Badru do not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Many people at heightened risk for HIV have never been tested. Those who have self-tested for HIV often don’t go on to receive care or change their sexual behavior.Oluwafemi Atanda Adeagbo, Assistant Professor of Public Health, University of IowaEngelbert Bain Luchuo, Senior Research Associate, University of JohannesburgOluwaseun Abdulganiyu Badru, Ph.D. Candidate in Community and Behavioral Health, University of IowaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1766162022-02-17T13:58:04Z2022-02-17T13:58:04ZCOVID-19 self-testing: it’s time developing countries took the leap<figure><img src="https://images.theconversation.com/files/445655/original/file-20220210-19-xve0n8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">COVID self-testing is widespread in developed countries. </span> <span class="attribution"><span class="source">George Frey/Getty Images</span></span></figcaption></figure><p>Laboratory testing plays a critical role for diagnosis of COVID-19. It’s the cornerstone of the global public health response, informing control measures and preventing transmission of SARS-CoV-2. </p>
<p>The basis of infectious disease testing depends on the pathophysiology of the infection and the disease that it causes, the clinical course as well as the host immune response. </p>
<p>There are two types of tests for acute SARS-CoV-2 infection whether it is symptomatic or asymptomatic: COVID-19 PCR and antigen tests also called “lateral flow tests”. Both detect viral components, but differ in design and complexity. </p>
<p>COVID-19 antigen tests are a game-changer, even at this stage of the pandemic when the world is no longer hoping to achieve containment of SARS-CoV-2 but rather looking at mitigating strategies to prevent infection in those who face the biggest threat from the virus. </p>
<p>Antigen tests are cheap and quick. They can help identify infected individuals and interrupt viral transmission by quarantining infected individuals immediately. In South Africa the proportion of COVID-19 antigen tests compared to PCR remains low. In <a href="https://www.nicd.ac.za/wp-content/uploads/2022/01/COVID-19-Testing-Summary-Week-3-2022.pdf">week 3</a> of January 191,510 COVID-19 tests were done. Only 22.8% of these were antigen tests. None of these tests were done by individuals – this <a href="https://www.groundup.org.za/article/covid-19-it-time-allow-home-testing/">isn’t allowed</a> under the country’s regulations. </p>
<p>It is difficult to discern why countries in Africa have not taken up COVID-19 antigen testing. Access and price don’t seem to be the issue. The <a href="https://africacdc.org/news-item/new-guidance-to-expand-rapid-antigen-testing-for-covid-19-response-in-Africa-released/">Africa Centres for Disease Control</a> has even published clear guidelines on how to use them. But there is a lingering mistrust in test quality that has limited their use. </p>
<p>It is true that there are concerns about <a href="https://www.who.int/publications/i/item/antigen-detection-in-the-diagnosis-of-sars-cov-2infection-using-rapid-immunoassays">self-testing</a>. But, in my view, the benefits are substantial. Individuals are able to access cheaper and faster tests. This, in turn, helps limit exposure to those at risk of infection. Public health specialists in developing countries are putting <a href="https://t.co/1OWMfQWFY2">pressure</a> on authorities for greater use of antigen tests – particularly for self-testing to be allowed. </p>
<h2>The two tests</h2>
<p>COVID-19 <a href="https://link.springer.com/article/10.1007/s10096-020-03913-9">PCR tests</a> amplify viral gene targets and are very sensitive. Over 1000 commercial ones are now <a href="https://www.theglobalfund.org/media/9629/covid19_diagnosticproducts_list_en.pdf">available</a>. They are able to detect viral components slightly before symptoms start in infected individuals and many weeks after infection – even when there is no longer any risk of transmissibility. </p>
<p>The COVID-19 PCR tests have their drawbacks. For example, measures have been put in place – such as hospital admissions and travel bans – on the basis of positive results even though this hasn’t been strictly necessary. </p>
<p>COVID-19 PCR test performance depends on several factors. These include design, the clinical characteristics of the patient, timing of the sample, sample type and transport conditions and laboratory techniques. They are also expensive, technically difficult, require specialised staff and reagents, specimen transport and processing.</p>
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Read more:
<a href="https://theconversation.com/antibody-tests-arent-a-covid-19-panacea-but-theyre-a-useful-additional-tool-142516">Antibody tests aren't a COVID-19 panacea. But they're a useful additional tool</a>
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<p>For their part, COVID-19 antigen tests are immunoassay rapid diagnostic tests that have different viral antigenic targets and designs. </p>
<p>Rapid diagnostic tests are used extensively for the diagnosis of other respiratory infectious diseases like influenza in clinics, community settings and home-based self-testing. Most use a nitrocellulose membrane embedded in a plastic cassette which contains two lines. The one is a control line to inform that the test is working and the second is a detection line to indicate the presence of the virus. The reaction is based on coloured labels (nanoparticles) that change colour when they encounter the target.</p>
<p>COVID-19 antigen tests perform better when there is a high viral load and in patients that are symptomatic. They are usually positive from 5 and up to 12 days after onset of symptoms. They correlate with competent <a href="https://journals.asm.org/doi/10.1128/JCM.00469-21">viral replication</a> and thus transmission potential. </p>
<h2>Self-testing</h2>
<p>Self-testing with COVID-19 antigen tests was first <a href="https://www.fda.gov/news-events/press-announcements/coronavirus-covid-19-update-fda-authorizes-first-covid-19-test-self-testing-home">authorised</a> by the US Food and Drug Administration in November 2020 to allow symptomatic people and those that had COVID-19 contacts to test themselves. </p>
<p>By 2021 antigen tests and <a href="https://ec.europa.eu/info/live-work-travel-eu/coronavirus-response/public-health/high-quality-covid-19-testing_en">self testing</a> was firmly entrenched in most <a href="https://www.healthdirect.gov.au/blog/what-are-covid-19-rapid-antigen-tests">developed countries</a>. Their widespread use for self-testing has sparked a range of <a href="https://www.nature.com/articles/d41586-021-00332-4">debates</a>. They hinge on three issues: </p>
<p><strong>Is the test sensitive enough?</strong> </p>
<p>A test’s sensitivity is its ability to identify the infection if it is present and also not to miss infections. Sensitivity depends on the test design which in turn impacts its level of detection. Antigen tests differ in sensitivities. Some are excellent compared to PCR tests. </p>
<p><strong>Is the sample adequate?</strong> </p>
<p>Simplifying the sample type to include saliva – which is an easier and more standardised sample to access – has increasingly been the direction of <a href="https://www.medrxiv.org/content/10.1101/2021.02.17.21251863v1">most COVID-19 antigen tests</a>. </p>
<p><strong>Is the test result easy to read and interpret?</strong> </p>
<p>Reading a rapid COVID-19 antigen test visually may sometimes be difficult. Sometimes faint lines appear in the detection window and it is difficult to work out if the test is positive or negative.</p>
<p>Interpretation is also critical. This is particularly true with negative results. These may not definitively exclude infection. A retest may then be necessary. </p>
<p>In addition, interpreting the result correctly is complex even if clear instructions are provided.</p>
<p>In a large US <a href="https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2788656">study</a> on self-testing showed that 1 in 3 individuals misinterpreted their COVID-19 antigen result. The study found that clarity of the information given to the patients doing the self-testing via a variety of different formats was extremely important to a good test outcome. </p>
<p>Individuals in the study drew false reassurance from a negative results. </p>
<p>A recent study also showed that trained <a href="https://www.medrxiv.org/content/10.1101/2021.01.13.21249563v2.full.pdf">laboratory personnel</a> do the tests better than individuals. </p>
<h2>What next?</h2>
<p>It’s clear that there are a number of caveats to self-testing with antigen tests.</p>
<p>However, on balance, I still believe that they should be allowed more widely in countries like South Africa.</p>
<p>One reason is that the failure to authorise the tests is driving a thriving <a href="https://www.businesslive.co.za/fm/features/2022-02-03-why-covid-home-tests-remain-illegal-in-sa/">black market</a> in them. Many are of unknown quality. </p>
<p>Secondly, if used widely they could help control transmission risks as more people would know their status. </p>
<p>However, governments need to issue national guidelines and provide appropriate instructions.</p><img src="https://counter.theconversation.com/content/176616/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Eftyhia Vardas does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>One of the consequences of the failure of developing countries like South Africa to authorise self-testing is that it is driving a thriving black market.Eftyhia Vardas, Clinical specialist Virology, Stellenbosch UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1696282021-11-08T03:02:10Z2021-11-08T03:02:10ZCervical cancer screening in New Zealand: self-testing at home will improve equity of outcomes for non-European women<figure><img src="https://images.theconversation.com/files/430649/original/file-20211107-69725-1a5p26h.jpg?ixlib=rb-1.1.0&rect=24%2C49%2C2716%2C1557&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock/Siriluk ok</span></span></figcaption></figure><p>Despite New Zealand’s national cervical screening programme (<a href="https://www.nsu.govt.nz/health-professionals/national-cervical-screening-programme">NCSP</a>), Māori women are <a href="https://www.thelancet.com/journals/lanonc/article/PIIS1470-2045(21)00206-0/fulltext">more than twice as likely</a> as European women to be diagnosed with, and die from, cervical cancer.</p>
<p>Similarly, the screening programme has not been equitable for Pasifika and Asian women. Like Māori women, Pasifika women have lower screening rates and higher rates of <a href="https://www.nsu.govt.nz/system/files/resources/final_ncsp-guidelines-for-cervical-screening-new-zealand-5_june_2020.pdf">cervical cancer incidence and mortality</a> than European women. Asian women also have lower screening rates but lower incidence and similar mortality to European women. </p>
<p>Women who don’t access the screening programme are often referred to as “hard-to-reach” or “disengaged” but, in reality, the inequities are a systems issue. These groups are under-served and suffer the majority of <a href="https://www.health.govt.nz/system/files/documents/publications/unequal-impact-ii..pdf">cases of cervical cancer</a>. </p>
<p>Our <a href="https://www.thelancet.com/journals/lanwpc/article/PIIS2666-6065(21)00174-7/fulltext">study</a> explored whether self-testing would help the least-served groups. We show self-testing, particularly at home, raises screening rates among women who have never or rarely accessed the screening programme and experience the most barriers.</p>
<h2>Clear preference for home testing</h2>
<p>This is the first evaluation of the effectiveness of mailed self-testing kits for cervical cancer screening in Aotearoa New Zealand. </p>
<p>We invited Māori, Pasifika and Asian women between the ages of 30 and 69, who had never been screened or were more than five years overdue, to take part in a community-based, randomised controlled trial with three different tracks. </p>
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<p>Our aim was to assess whether two invitation methods for self-testing improved screening participation over usual care (the third track). Women were either invited to take a self-test at their usual general practice or were mailed a kit to take a self-test at home. </p>
<p>We compared participation rates with the usual care process of an invitation to come to the GP clinic for collection of a standard Pap smear.</p>
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Read more:
<a href="https://theconversation.com/self-collected-cervical-screening-is-a-great-way-to-prevent-cervical-cancer-how-can-we-get-more-people-doing-it-163360">Self-collected cervical screening is a great way to prevent cervical cancer. How can we get more people doing it?</a>
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<p>There were 3,553 women in the study. Although the absolute level of participation was modest, we showed that participation was statistically significantly higher for self-testing at home, compared to the usual Pap smear at the GP clinic. </p>
<p>Māori were 9.7 times more likely to agree to self-test at home. For Pasifika women, participation was six times more likely; for Asian women it was 5.1 times more likely. </p>
<p>Self-testing at the clinic was preferred, respectively 4.1, 3.3 and 1.6 times over the Pap smear. Overall, our results show access to screening at home is much preferred over other options.</p>
<h2>A brief history of cervical cancer screening</h2>
<p>Our understanding of cervical cancer goes back to the 1928 discovery by George Papanicolaou (hence Pap smear) of profound abnormalities in cervical cells. He realised this could be used as a method of early cancer diagnosis. </p>
<p>The process was subsequently <a href="https://pubmed.ncbi.nlm.nih.gov/15405936/">refined in the 1950s</a> after which the Pap smear was increasingly used for screening and early diagnosis.</p>
<p>By the 1970s, there was clear circumstantial evidence that cervical cancer was caused by a sexually transmitted agent, which was later identified as the human papillomavirus (HPV). This has allowed two crucial developments in the control of cervical cancer: effective vaccines with increasing coverage against high-risk HPVs and reliable screening using a vaginal swab.</p>
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Read more:
<a href="https://theconversation.com/hpv-vaccine-cuts-cervical-cancer-cases-by-almost-90-but-one-in-ten-girls-still-havent-been-vaccinated-170887">HPV vaccine cuts cervical cancer cases by almost 90% – but one in ten girls still haven’t been vaccinated</a>
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<p>From 2015, and increasingly around the world, vaginal samples (collected using a swab by women themselves or by healthcare professionals) have been used to identify the presence of HPVs with a <a href="https://pubmed.ncbi.nlm.nih.gov/26209409/">high degree of reliability</a>. </p>
<p>This screening approach does not need to involve any other person and has a number of advantages over a standard clinically obtained Pap smear. It allows collection at home and caters to those who prefer greater privacy or have less time. It is empowering because it places health management in a woman’s own hands. </p>
<p>This is an exact parallel with self-collected swabs for sexually transmitted infections (STIs), which are well accepted as standard of care. Self-testing for cervical cancer screening is increasingly available around the world.</p>
<p>The accuracy of HPV self-testing is <a href="https://www.thelancet.com/journals/lanonc/article/PIIS1470-2045%2813%2970570-9/fulltext">similar</a> to <a href="https://pubmed.ncbi.nlm.nih.gov/22907569/">professionally taken samples</a> and it <a href="https://www.ncbi.nlm.nih.gov/books/NBK184624/">improves participation</a>. However, most studies have not targeted Indigenous or ethnic minority women. They remain under-served <a href="https://pubmed.ncbi.nlm.nih.gov/31809806/">essentially everywhere</a>.</p>
<h2>How to ensure equity</h2>
<p>Aotearoa New Zealand already has extensive experience with free mail-out screening for bowel cancer. Giving women the opportunity to self-test at home at no cost will result in the greatest impact toward improving equity of access to cervical cancer screening. </p>
<p>However, the National Cervical Screening Programme indicated that self-testing at home is not an option in their initial rollout of screening based on the <a href="https://pubmed.ncbi.nlm.nih.gov/4367340/">detection of human papillomavirus</a> (<a href="https://www.immune.org.nz/diseases/human-papillomavirus-hpv">HPV</a>), the leading <a href="https://pubmed.ncbi.nlm.nih.gov/10451482/">cause of cervical cancer</a>. </p>
<p>This will be a serious missed opportunity to improve equity. The key to achieving equity is for all women to access screening, including those who may agree only to testing at home.</p><img src="https://counter.theconversation.com/content/169628/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>John Donne Potter received funding from the Health Research Council of New Zealand for this work. </span></em></p><p class="fine-print"><em><span>Naomi Brewer does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>New Zealand is already using self-screening kits for bowel cancer. Giving women the opportunity to self-test for cervical cancer at home will improve equity and lift participation.John Donne Potter, Professor, Research Centre for Hauora and Health, Massey UniversityNaomi Brewer, Research Fellow, Research Centre for Hauora and Health, Massey UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1077402018-11-30T15:36:11Z2018-11-30T15:36:11ZWhy nurses should take the HIV self-test<figure><img src="https://images.theconversation.com/files/248106/original/file-20181130-194935-1p6eu85.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/133031549?src=8tO9cvRVCD6Y9ut5ZrWuPQ-1-2&size=medium_jpg">michaeljung/Shutterstock</a></span></figcaption></figure><p>The United Nations has set a goal that <a href="http://www.unaids.org/en/goals/unaidsstrategy">90% of people with HIV should know their status by 2030</a>. As a result, increasing numbers of people are expected to undertake self-tests to see if they may have HIV. </p>
<p>HIV testing can be done in a number of ways. Some clinics offer a simple blood test, with results provided in a few days. Others use saliva or a finger-prick sample of blood and offer results immediately. Home sampling kits, designed to be sent back to the clinic for results, are available in the UK through <a href="https://www.test.hiv/">this link</a>. Then there are home testing kits that provide results straight away, known as self-test. </p>
<p>For self-test, the person swabs their gums with a testing strip. The testing strip is then placed in a tube that analyses the strip for the presence of HIV antibodies. It looks similar to a pregnancy test – a window in the <a href="http://www.oraquick.com/what-is-oraquick/how-oral-testing-works">testing kit</a> shows lines to show a result of positive or negative.</p>
<p>Knowing an HIV status is essential for two reasons. One, HIV-positive people can take measures, such as practising safe sex, to avoid transmitting the virus to others. And two, HIV treatment increases a person’s T-cell count (important immune cells for fighting infection) and reduces levels of HIV in the body. Without treatment, <a href="https://www.nat.org.uk/we-inform/do-i-understand-hiv?gclid=EAIaIQobChMIr9-XlMH53gIVCbDtCh3p7wBoEAAYASAAEgLTKPD_BwE">HIV can turn into AIDS</a>, which is a life-threatening condition. </p>
<p>Although the test is physically easy – just a quick mouth swab – it can be emotionally difficult. Nurses who dispense these tests are often asked to support, guide and counsel the people taking the test – but their practice must be based on the most up-to-date information available. Consequently, nurse educators must find ways to promote learning in the most effective way possible. </p>
<h2>Valuable insights</h2>
<p>Learning by doing or through experience is called “<a href="https://theconversation.com/why-learning-from-experience-is-the-educational-wave-of-the-future-92399">experiential learning</a>”. It offers a great way to understand how people experience a situation. <a href="https://www.sciencedirect.com/science/article/pii/S0260691718304842">Our research</a> presents an overview of nurses’ experiences when we asked them to test themselves for HIV.</p>
<p>Our students revealed that they worried about their past sexual encounters and the test made them recall all of these encounters. And, despite their knowledge of health, some questioned non-risky behaviour – such as sharing cups with roommates. They then considered how their patients may feel when taking the tests. If they were concerned about “sharing cups”, then their patients might have similar worries. This suggested a need to consider what questions their patients may have.</p>
<p>All 30 participants of the study said they had experienced emotional fluctuations, worrying about the possibility of a positive test result. A few wanted to be alone when they were viewing the results of the test, they were nervous about waiting and some worried that they hadn’t done the test properly. All participants said they underestimated the significance of asking their patients to take such an “easy” test. </p>
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<img alt="" src="https://images.theconversation.com/files/248115/original/file-20181130-194950-gwcd0o.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/248115/original/file-20181130-194950-gwcd0o.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=375&fit=crop&dpr=1 600w, https://images.theconversation.com/files/248115/original/file-20181130-194950-gwcd0o.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=375&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/248115/original/file-20181130-194950-gwcd0o.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=375&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/248115/original/file-20181130-194950-gwcd0o.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=471&fit=crop&dpr=1 754w, https://images.theconversation.com/files/248115/original/file-20181130-194950-gwcd0o.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=471&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/248115/original/file-20181130-194950-gwcd0o.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=471&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Not as easy as it looks.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/488256589?src=Lcaczd-NznsTITFtPUCvmw-1-0&size=medium_jpg">divasoft/Shutterstock</a></span>
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<p>It motivated the nurses to learn more about HIV and HIV testing. Taking the test gave them insights into their patients’ experiences – they felt they understood why people may be reluctant to take the test. Taking part in the study meant they felt better able to give advice to their patients. This is important because, as patients, we trust those who have insight into our experiences. People who have experienced similar feelings will be more compassionate and understanding. </p>
<p>Nowadays, self-test kits are available in pharmacies and online, but the test is not all that is needed. People must be prepared for the result and, if they are HIV positive, they must be able to access treatment and support. This could be improved if it was guided by people who have been taken the test themselves. Nurses and other healthcare workers play an important role in process, and experiential learning is key to offering a more informed and humane test.</p><img src="https://counter.theconversation.com/content/107740/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Taking the HIV self-test gave nurses valuable insights into what their patients go through.Amanda Lee, Associate Dean (International) Faculty of Health Sciences, University of HullMark Hayter, Professor of Nursing and Health Research/ Associate Dean Research, University of HullLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1073682018-11-28T12:57:36Z2018-11-28T12:57:36ZOvercoming the real – and perceived – barriers to HIV testing<figure><img src="https://images.theconversation.com/files/246891/original/file-20181122-182059-1aqwx1s.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The WHO recommends testing for HIV every 6 to 12 months.</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>There was a time when HIV was untreatable, heavily stigmatised, and the benefits of testing weren’t as clear as they are now. But that was 25 years ago. </p>
<p>HIV testing remains the crucial entry point for all HIV services, including both prevention and treatment. </p>
<p>When someone tests and learns that they are HIV positive, there is an opportunity to access life-saving treatment, ensure their own well-being and that of their intimate partners. When someone tests and learns they are HIV negative, there is an opportunity to evaluate their risk and assess which HIV prevention options are the best fit for them.</p>
<p>UNAIDS <a href="http://www.unaids.org/sites/default/files/media_asset/Global_AIDS_update_2017_en.pdf#page=100">estimates</a> that 76% of people living with HIV in eastern and southern Africa know their status. While an HIV-positive diagnosis can still provoke fear among some, <a href="http://www.hsrc.ac.za/uploads/pageContent/9234/SABSSMV_Impact_Assessment_Summary_ZA_ADS_cleared_PDFA4.pdf">85% of people with HIV</a> in South Africa know their status. </p>
<p>The goal is that by 2020, 90% of people with HIV should know <a href="https://www.spotlightnsp.co.za/2018/07/18/new-estimates-of-sas-progress-toward-90-90-90/">their status</a>. Increasing the uptake of testing is an essential first step in this quest, which is part of a package of goals aimed at ending the epidemic.</p>
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<p>Many people still struggle to overcome real and perceived barriers to testing. These include access to testing and the stigma related to testing. However many of the hurdles still in place might not be as big as once thought.</p>
<h2>What’s standing in the way of 90%</h2>
<p><strong>Access:</strong> HIV testing is free in South Africa in all public clinics and health facilities, but for many people just getting to the clinic can seem like a major barrier. Whether this is because of long walking distances, the need to take time off work, or simply not prioritising or having the time to build testing into their health care routine.</p>
<p>One solution lies in the advent – and increasing availability – of <a href="https://sajhivmed.org.za/index.php/hivmed/article/view/775/1030">HIV self-testing</a> kits. Now getting an HIV test can be as simple as going to the pharmacy and following the instructions.</p>
<p><strong>Being judged:</strong> A common concern is around confidentiality and being judged. This is especially evident among young people who are at risk of HIV infection, but may feel as if they would be judged for being sexually active. It’s estimated that <a href="https://www.gov.za/sites/default/files/nsp%20hiv%20tb%20sti_a.pdf">2000</a> adolescent girls and young women in South Africa are infected every week. </p>
<p>This problem needs to be tackled by helping young people access testing. This can be done by providing <a href="http://opensaldru.uct.ac.za/bitstream/handle/11090/813/201604_SaldruPolicyBrief_02.pdf?sequence=1">youth friendly services</a> where health care professionals are friendly, non-judgemental and supportive. Testing must be normalised and seen as an appropriate, responsible and acceptable thing to do. Many clinics already undergo training and accreditation for the provision of adolescent and youth friendly services. But it’s not universal.</p>
<p><strong>Stigma:</strong> Aside from stigma around HIV, many <a href="http://www.unaids.org/en/topic/key-populations">high-risk groups</a> (such as sex workers, men who have sex with men, and injecting drug users) still face enormous barriers to accessing traditional services due to stigmatisation, discrimination and even criminalisation. This is especially true in sub-Saharan Africa where <a href="https://www.iasociety.org/The-latest/News/ArticleID/209/Condemning-Tanzania%E2%80%99s-anti-gay-initiatives">anti-LGBTI laws</a> are rife and few protective mechanisms exist.</p>
<p>The way this can be solved is by ensuring that testing campaigns and environments encourage everyone to test. More work must be done to combat bad laws and policies, stigma and discrimination. The fight should be against the virus, and not the people it targets.</p>
<p><strong>Low risk perception:</strong> The World Health Organisation and the South African government recommend testing every six to 12 months. But most people only test when they feel they have been at risk. Risk perception is highly subjective and sometimes incorrect. In a South African context, where the prevalence of HIV is so high – <a href="http://www.hsrc.ac.za/uploads/pageContent/9234/SABSSMV_Impact_Assessment_Summary_ZA_ADS_cleared_PDFA4.pdf">20.6%</a> of adults aged 15 to 49 years have HIV – everyone is at risk and should get tested every year.</p>
<p>To encourage people to test more frequently, campaigns should continue to focus on the fact that HIV doesn’t discriminate. HIV testing also increases the opportunity to screen for multiple conditions, such as tuberculosis and other sexually transmitted infections, at the same time. This integration of HIV testing services with other health services is seen as a way of reducing stigma, increasing access, and is a move towards achieving universal health care.</p><img src="https://counter.theconversation.com/content/107368/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Linda-Gail Bekker receives funding from various research agencies both local and international. She is the immediate past president of the International AIDS Society. </span></em></p>Knowing your HIV status is key to accessing life-saving treatment or evaluating the best prevention options.Linda-Gail Bekker, Professor of medicine and deputy director of the Desmond Tutu HIV Centre at the Institute of Infectious Disease and Molecular Medicine, University of Cape TownLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1076222018-11-28T12:57:30Z2018-11-28T12:57:30ZSelf-testing: a potentially powerful tool for fighting HIV<figure><img src="https://images.theconversation.com/files/247721/original/file-20181128-32208-fqhl7g.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The theme for World Aids Day is "know your status". </span> <span class="attribution"><span class="source">EPA</span></span></figcaption></figure><p>In recent years, more emphasis has been placed on testing for HIV. The idea behind this drive is that if people know their status, they’ll be able to seek treatment and support. One approach that’s become fairly common is self-testing, or <a href="http://apps.who.int/iris/bitstream/handle/10665/251655/9789241549868-eng.pdf;jsessionid=4368C00514D95782E3718B5D1599966D?sequence=1">self-screening</a>.</p>
<p>This is when a person collects their own specimen (blood or oral fluid), performs a rapid diagnostic test and interprets the result themselves. This type of test can also be done by a health provider or peer educator. The blood is obtained by pricking one’s finger; the oral fluid is swabbed from the inside of your cheek.</p>
<p>The rapid diagnostic test detects HIV antibodies in the blood or oral fluid. If the result is positive, people are encouraged to go and get their blood tested by a professional for confirmation.</p>
<p>Self-screening for HIV has been touted as a disruptive innovation: one that can help to close the HIV testing gap by reaching key and under-tested populations who won’t necessarily want to visit a doctor or clinic for testing. These under-tested populations include sex workers, men who have sex with men and young women aged between 15 and 24.</p>
<p>Research shows that HIV self-screening yields <a href="https://www.ncbi.nlm.nih.gov/pubmed/28530049">highly accurate results</a> even when carried out by untrained lay people. Two years ago the World Health Organisation published <a href="http://apps.who.int/iris/bitstream/handle/10665/251655/9789241549868-eng.pdf;jsessionid=4368C00514D95782E3718B5D1599966D?sequence=1">guidelines</a> recommending that self-screening be included in countries’ existing testing services. So far, 59 countries have implemented HIV self-screening policies and 53 others developing these policies. </p>
<p>Access to HIV testing is an important factor in reaching the United Nations’ “90-90-90” goal: by the year 2020, 90% of people with HIV must know their status, 90% of people with HIV must be on antiretroviral treatment, and 90% of people on treatment must be virally suppressed.</p>
<p>It’s estimated that <a href="http://www.who.int/hiv/topics/self-testing/en/">only 75%</a> of people around the world know their HIV status. This figure is higher in South Africa where an estimated <a href="http://www.hsrc.ac.za/uploads/pageContent/9234/SABSSMV_Impact_Assessment_Summary_ZA_ADS_cleared_PDFA4.pdf">85% of people</a> with HIV know their status. </p>
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<p>To help South Africa reach this first “90”, my colleagues and I at the <a href="http://www.wrhi.ac.za/">University of the Witwatersrand, Wits Reproductive Health and HIV Institute</a> are collaborating with a number of organisations to scale up HIV self-screening among under tested populations. These include men, who have lower testing rates than the general population, young people, sex workers and their networks (clients, partners and peers).</p>
<h2>Self-screening</h2>
<p>From November 2017 to September 2018, we distributed HIV self-screening kits to primary recipients (clients directly receiving the kit) and secondary recipients (people related to primary recipients, for example their sexual partners). These were distributed in four of the country’s nine provinces. </p>
<p>The kits were handed out in a number of different places including existing HIV testing mobile services, and selected spaces in communities such as shopping centres. HIV self-screening kits were also distributed in workplaces, taxi ranks, and at health facilities for partners of pregnant women and people living with HIV. Participants in our <a href="http://www.wrhi.ac.za/uploads/files/Wits_RHI_Annual_Review_2017.pdf">sex worker programmes</a> were also given self-screening kits to share with their networks. </p>
<p>As part of the initiative, follow-ups were done telephonically with a randomly selected and representative sample of people who received kits in communities, workplaces and taxi ranks. We also followed up with everybody who received self-screening kits at health facilities and through our sex worker programmes.<br>
The aim is to encourage people to use the HIV self-screening kits and interpreting the results themselves. If the results are positive, the person must have the results confirmed by a health professional. If the results are still positive, the person should start HIV treatment immediately. </p>
<p>By the end of September 2018, we had distributed 505 836 kits. A majority – 62% – went to men; 12% were received by people who had never tested for HIV before; and 45% of the recipients had not tested in the last year. The WHO recommends testing for HIV every six to 12 months. </p>
<p>In less than a year we were able to reach the target populations. Our project is ongoing and forms part of a Unitaid-funded <a href="http://hivstar.lshtm.ac.uk/news/">HIV self-testing Africa initiative</a>, which is evaluating HIV self-screening around the continent.</p>
<p>Our findings, is informing the implementation of HIV self-testing in South Africa, and other countries. The findings will also be published in open access journals early next year. </p>
<p><em>Mohammed Majam, technical head of HIV Self-Testing at the Wits Reproductive Health and HIV Institute contributed to this article.</em></p><img src="https://counter.theconversation.com/content/107622/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Joel Msafiri Francis received funding from HIV Research Trust, UK, THRiVE consortium, Global Fund Round 8 (HIV-Initiative), HIV Implementation Science fellowship, NIH grant through Harvard School of Public Health, Global Health Department.</span></em></p>Access to HIV testing is an important factor in reaching UN goals that 90% of people with HIV must know their status by 2020.Joel Msafiri Francis, Epidemiologist, Wits Reproductive Health and HIV Institute, University of the WitwatersrandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1003432018-07-24T14:20:04Z2018-07-24T14:20:04ZMen aren’t being tested for HIV. How health services can plug the gap<figure><img src="https://images.theconversation.com/files/229044/original/file-20180724-194131-to6c93.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A community health worker conducting a HIV test in a mobile clinic in a remote part of KwaZulu-Natal. </span> <span class="attribution"><span class="source">Greg Lomas / Médecins Sans Frontières</span></span></figcaption></figure><p>Men make up slightly less than half of the adults living with HIV across the world. Yet they account for nearly 60% of the AIDS related deaths. </p>
<p>This is one of the observations from the <a href="https://www.thelancet.com/commissions/global-health-HIV">The Lancet Commission on HIV</a>, which looked at the global response to the pandemic. According to the <a href="https://www.thelancet.com/commissions/global-health-HIV">report</a>, the key driver of this gender difference in health outcomes between men and women is that men use health care services less than women. </p>
<p>This isn’t a new observation: for more than 10 years antiretroviral therapy (ART) programmes in sub-Saharan Africa have been reporting that a <a href="https://www.ncbi.nlm.nih.gov/pubmed/17459154">disproportionately higher</a> number of women are on treatment compared to men. </p>
<p>There’s a simple reason for this, which my work in the last decade highlights: men’s health is generally overlooked in HIV care. My studies show that women remain the focus of HIV testing and ART programmes, while men are disadvantaged in access to these. </p>
<p>In a <a href="http://journals.sfu.ca/jias/index.php/jias/article/view/21902/html">recent analysis</a> of long-term mortality in five large antiretroviral programmes in South Africa, I found that that over the last 12 years the proportion of men starting ART remained the same: between 2004 and 2006 only 31% of those enrolling in treatment programmes were men; by 2015, the figure was unchanged. </p>
<p>What this shows is that there needs to be a real mind shift towards men’s health issues. This, in turn, should lead to health care being provided in ways that encourage men to be tested so that they can get treatment earlier than is often currently the case. For example, <a href="https://www.ncbi.nlm.nih.gov/pubmed/25062091">research</a> shows that providing mobile clinics, or testing people at home, can make a difference.</p>
<p>So what are the obstacles to increasing men’s access to ART?</p>
<h2>Opportunities to access</h2>
<p>The largest obstacle is access to HIV testing. Most testing is done through health facilities, often with a strong focus on testing pregnant women. </p>
<p>The average woman will have a number of encounters with the health system in her lifetime. As a young girl, she will probably go to the local clinic for family planning. When she is pregnant she will go for antenatal care. When her child is small she will go to the local clinic for vaccinations. As mothers are generally still the main caregivers, she will take her child to the clinic when the child is ill. And if she has an elderly relative, there’s a chance she will accompany them to the clinic. </p>
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<img alt="" src="https://images.theconversation.com/files/229062/original/file-20180724-194143-1cazopv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/229062/original/file-20180724-194143-1cazopv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/229062/original/file-20180724-194143-1cazopv.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/229062/original/file-20180724-194143-1cazopv.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/229062/original/file-20180724-194143-1cazopv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/229062/original/file-20180724-194143-1cazopv.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/229062/original/file-20180724-194143-1cazopv.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Community caregiver Nonhlanhla Ngema passes a long queue of patients at Eshowe Gateway Clinic to collect ARVs as part of a Medecins Sans Frontieres (MSF) to keep people on treatment.</span>
<span class="attribution"><span class="source">Greg Lomas / Médecins Sans Frontières</span></span>
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<p>This means that there are several opportunities to be offered an HIV test and to start treatment. And if she starts treatment at a young age, she is likely to be healthy and have good survival prospects. So the health system seems to be doing well at engaging young women in HIV services. </p>
<p>In contrast there has been very little concerted effort from health services to go out and find the men. </p>
<p>The pattern of men’s engagement with the health system is totally different. There is no easy entry point into the health system for healthy young men. Primary health care clinics offer few services targeting men. This is generally limited to treating TB and sexually transmitted infections.</p>
<p>The fact that men are falling outside the net of health care systems is well illustrated in data on people knowing their HIV status. In 2012 nearly a third (31.9%) of men didn’t know their status compared with only 19% in the case of women. The greater proportion of men not knowing their status was particularly worrying given that the percentage of all adults with HIV who didn’t know their status <a href="https://www.ncbi.nlm.nih.gov/pubmed/26091299">dropped dramatically between 2000 and 2012</a> – from over 80% in the early 2000s to 23.7%. </p>
<p>This has important implications for men as well as their sexual partners. People with HIV who are undiagnosed are likely to have high viral loads. This means they have a <a href="https://www.ncbi.nlm.nih.gov/pubmed/22313960">high risk</a> of sickness and death, and also that they are more likely to transmit HIV. </p>
<h2>Reaching men</h2>
<p>So how do we reach more men earlier?</p>
<p>Finding ways of testing men as early as possible will mean changes in the way our health system delivers services. </p>
<p>Preliminary findings show that there is higher testing uptake among men in services that fall outside the traditional facilities. For example, research shows that <a href="https://www.ncbi.nlm.nih.gov/pubmed/25062091">providing mobile clinics</a>, testing people at home, self-testing and offering male-only or <a href="https://onlinelibrary.wiley.com/doi/full/10.1111/tmi.12593">male-friendly services</a> can increase men’s uptake of HIV testing. </p>
<p>These and other strategies need to be tried in different settings, and where successful, rolled out across the sub-continent.</p>
<p>The good news is that a change in mindset seems to be happening. After years when it seemed that they were blind to the mounting evidence, international agencies and big donors are starting to discuss the absence of men from HIV programmes. At the end of 2017, UNAIDS produced a report on this blind spot in the response to HIV.</p>
<p>The World Health Organisation has recently established a working group on engaging men into HIV care. And most recently, at the 2018 International AIDS Conference, PEPFAR, the US President’s Emergency Plan for AIDS Relief, launched a global coalition <a href="https://www.pepfar.gov/press/releases/284176.htm">to increase testing and access for men</a>. </p>
<p>Given the huge influence that international agencies and donors have on the priorities of national programmes in sub-Saharan Africa, these are long overdue but extremely welcome new initiatives which could substantially increase access to testing and ART for men.</p><img src="https://counter.theconversation.com/content/100343/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Dr Morna Cornell receives salary funding from the National Institutes for Health, USA, under award number U01AI069924.</span></em></p>Women and children remain the focus of HIV while men are disadvantaged in accessing testing and treatment in Africa.Dr Morna Cornell, Senior Researcher, University of Cape TownLicensed as Creative Commons – attribution, no derivatives.