Measuring linkage to HIV treatment services following HIV self‐testing in low‐income settings

Abstract

Globally, HIV testing services (HTS) have been scaled up resulting in 79% of all people with HIV aware of their status in 2018 [1]. However, 8.1 million people remain undiagnosed [1], many of whom are hard to reach through traditional HTS approaches. In 2016, the World Health Organization (WHO) strongly recommended HIV self-testing (HIVST) as an HTS approach, followed by an update in 2019 [2, 3]. Since 2016, the number of countries with supportive HIVST policies has grown rapidly to 77 with 38 countries implementing HIVST as of July 2019 [1]. HIVST has proved effective in reaching people with undiagnosed HIV and those at high ongoing risk [4-6], however, many countries are yet to implement or scale up HIVST. As with any HTS, HIVST needs to provide a pathway to appropriate HIV treatment, care and prevention services. Because no single test, including HIVST, can provide an HIV-positive diagnosis, all individuals with reactive HIVST results must receive further testing by a trained provider before initiating antiretroviral therapy (ART) [5]. Measuring linkage to ART is important to demonstrate programme effectiveness and impact, however, monitoring linkage after HIVST can be challenging because of its private nature. We highlight key challenges in measuring linkage to treatment and care following HIVST and suggest pragmatic approaches to addressing these in low-income settings that routinely offer HIVST. Evidence from randomized trials shows that the proportion of people linked to ART following HIVST is comparable to that of standard facility-based HTS [5]. However, outside a research or trial environment, it may be unclear whether routine programmatic HIVST implementation results in similar successes. The challenges to accurately measuring linkage following HIVST include: (i) not knowing the number of HIVST kits used out of the number distributed, particularly when distributed in the community or via secondary distribution to partners and/or social contacts; (ii) clients on ART using HIVST to “check” their HIV status without disclosing their HIV-positive status and/or ART use to the provider (kit distributor); (iii) clients using HIVST as a prompt for “re-engaging” in care or “restarting” ART without disclosing their HIV-positive status and/or ART use to the provider (kit distributor) [7]; (iv) clients with reactive HIVST results who are lost to follow-up; and (v) use of paper-based and unlinked clinic records, such as clinic registers or logbooks and the lack of case-based surveillance in many low-income settings, leading to duplicate or missing information, an issue affecting HTS monitoring broadly. No single method would give an accurate measure of linkage following HIVST due to the limitations of each of them. However, using data and information from diverse sources, such as survey and programme data, can increase confidence in linkage estimates and minimize missing information. WHO is developing guidance for countries to monitor and evaluate HIVST, including linkage. HIVST is an important testing approach for meeting the global goals of diagnosing 95% of all people with HIV by 2025. Effective linkage to appropriate services following HIVST is important. Given the privacy of HIVST, which allows autonomy, fosters empowerment and reaches people who may not otherwise test, a resource-intensive approach to monitor linkage is neither feasible nor desirable as programmes scale up HIVST. The need to collect in-depth linkage data should not delay the wider availability of HIVST. Programmes, donors and implementers should consider pragmatic and innovative ways to measure linkage. The authors declare no conflicts of interest. MSJ, CJ, ATC and PM conceived the idea. ATC wrote the first draft of manuscript. MSJ, PM, EC, EC, LC, HI, EBA, MdE, MDC, MM, TS, VW, RB and CJ reviewed, provided input and approved the final draft of manuscript. WHO HIV Self-testing Technical Working Group members who are not co-authors: Amy Medley, Anita Sands, Asha Hedge, Christine Kisia, Elena Vovc, Elkin Bermudez, Emmanuelle Bomo, Ena Oru, Euphemia Sibanda, Florence Anam, Francesca Merico, Fritz Fonkeng, Germina Mphoso, Giovanni Ravasi, Jean Njab, Jennifer Cohn, Karen Champenois, Karin Hatzold, Kimberly Green, Kristina Grabbe, Lelia Coppens, Maeve de Mello, Mark Lanigan, Morganne Ahmar, Muhammad Safdar Pasha, Naoko Ishikawa, Nayé Bah, Olga Denisiuk, Patricia Garcia, Peris Urassa, Philippe Girault, Simbarashe Mabaya, Sofia Furqan, Thato Chidarikire, Valdilea Veloso, Van Thi Thuy Nguyen and Wanjiru Mukoma. Bill and Melinda Gates Foundation OPP1177903 and Unitaid (PO# 10140–0-600 and PO# 8477–0-600). PM is funded by the Wellcome Trust (206575/Z/17/Z). EC is funded under a Wellcome Trust Senior Research Fellowship in Clinical Science (grant number: WT091769) and by Unitaid-STAR Initiative (NCT02718274). The authors alone are responsible for the views expressed in this article and they do not necessarily represent the views, decisions or policies of the institutions with which they are affiliated including the World Health Organization, the U.S. President's Emergency Plan for AIDS Relief, the U.S. Agency for International Development and the U.S. Government. The corresponding author had final responsibility for the decision to submit for publication.