HIV self-testing increases proportion of adults initiating antiretroviral therapy

Among adults in the African country of Malawi offered HIV self-testing, optional home initiation of care compared with standard HIV care resulted in a significant increase in the proportion of adults initiating antiretroviral therapy, according to a study in the July 23/30 issue of JAMA, a theme issue on HIV/AIDS. The issue is being released early to coincide with the International AIDS Conference.

In 2012, an estimated 35 million individuals were infected with the human immunodeficiency virus (HIV) worldwide. Antiretroviral therapy (ART) substantially reduces the risk of HIV transmission as well as greatly reducing illness and death, raising hopes that high uptake of annual HIV testing and early initiation of ART could improve HIV prevention as well as care. Achieving high coverage of HIV testing in sub-Saharan African countries is a major challenge, with low rates of HIV testing, according to background information in the article.

Self-testing for HIV infection (defined as individuals performing and interpreting their HIV test in private) is a novel approach that has seen high acceptance in Malawi and the United States, and is a process that could overcome barriers to conventional facility-based and community-based HIV testing, which lack privacy and convenience. However, no studies in high HIV prevalence settings have investigated linkage into HIV care after HIV self-testing, the authors write.

Peter MacPherson, Ph.D., of the Liverpool School of Tropical Medicine, Liverpool, U.K., and colleagues randomly assigned 16,660 adult residents of Blantyre, Malawi, who received access to home HIV self-testing, to facility-based care or optional home initiation of HIV care, for those reporting positive HIV self-test results.

During 6 months of availability, 58 percent of the adult residents took an HIV self-test kit. Participants in the home group (6.0 percent) were significantly more likely to report a positive HIV self-test result than facility group participants (3.3 percent). A significantly greater proportion of adults in the home group initiated ART (181/8,194; 2.2 percent) compared with the facility group (63/8,466; 0.7 percent).

"The main finding of this cluster randomized trial was that population-level ART initiations were significantly increased by availability of home initiation of care," the authors write.

"At a time when universal test and treat approaches to controlling the HIV epidemic are being considered, home initiation of HIV care shows high promise as a simple strategy to improve uptake of ART when HIV self-testing is carried out at home."