LSTM’s researchers and the STAR initiative feature in a special BMJ supplement

News article 19 Jul 2021
Credit: STAR HIV Self-Testing Africa Initiative

A large team from LSTM including Professor Miriam Taegtmeyer, Professor Francis Cowan, Dr Nicola DesmondRussell Dacombe, Dr Victoria Watson, Dr Euphemia Sibanda and Dr Webster Mavhu and Collin Mangenaah – are partners on the HIV Self-Testing Africa project (STAR) which features in a special supplement in the current issue of the British Medical Journal.

HIV self-testing (HIVST) has rapidly become a standard approach to HIV diagnosis in many high burden settings in order to reach people from key population groups globally. A special issue of the British Medical Journal (BMJ) Global Health presents crucial new insights on the implementation of HIVST, drawing on lessons from the Unitaid-funded HIV Self-Testing Africa (STAR) Initiative.

The STAR initiative aims to stimulate the market for HIV self-test kits through supporting countries in Southern Africa to scale-up self-testing. LSTM developed and rigorously evaluated innovative test delivery models in Malawi and Zimbabwe that catalysed a supportive regulatory, policy and funding environment both regionally and globally.

Availability of HIV self-testing has resulted in rapid scale-up with increased testing coverage particularly among vulnerable, underserved and key populations worldwide. STAR has provided 4,500,000 HIV self-tests across Southern Africa (>2,000,000 for STAR research) and catalysed procurement of another 8,000,000 from major funders. Four manufacturers now have WHO pre-qualified HIV self-test kits available on the world market.

Entitled ‘Innovating with HIV Self-Testing in a Changing Epidemic: Results from the STAR (Self-Testing Africa) Initiative,’ this collection coordinated by the World Health Organization (WHO) in collaboration with the STAR Initiative, brings together 14 manuscripts that provide crucial insights and evidence for scaling up of evidence-based HIVST approaches worldwide.

Despite decades of progress, an estimated 16% of people living with HIV globally do not know their status. HIVST is a recommended strategy that offers users a discreet and convenient way to test, particularly those facing barriers such as stigma and discrimination as well as access barriers. To advance global HIV goals, the STAR Initiative–led by Population Services International (PSI) and the London School of Hygiene & Tropical Medicine–was launched in 2015 to support the evaluation and introduction of self-testing on a massive scale.

“This STAR special issue highlights important evidence on self-testing—that not only underscores how investments in HIV self-testing can support the first 95 in the UN global HIV goals—but has also provided a foundation from which the potential of other self-testing and self-care approaches can now be more readily realized, as a people-centred options, including sexually transmitted infections, hepatitis and potentially COVID-19,” says Dr. Rachel Baggaley, Coordinator of Testing, Prevention, Population Unit with the WHO Global HIV, Hepatitis and STI Programmes. “This evidence is timely as countries seek ways to maintain essential testing services during COVID-19 disruptions, and WHO looks forward to greater country implementation and investment in recommended self-testing approaches.”

Self-testing has shifted the paradigm for HIV testing, the first step in the care continuum. Only five years ago, use of HIVST was limited due to lack of evidence of accuracy, acceptability, feasibility, and concerns about safety. We are now witnessing large scale HIVST use around the world with increased volumes of test kits procured and distributed. As of July 2021, a total of 93 countries now report HIVST policies with implementation increasing–particularly as countries work to maintain HIV services during COVID-19 related disruptions.

“Self-testing has been a crucial innovation as we look towards achieving the global goals for HIV. Helping people know their HIV status is vital if they are to get treatment and live well with the disease,” says Unitaid Executive Director, Dr. Philippe Duneton. “Unitaid is proud to have supported the STAR project, which has generated a wealth of evidence that shows that this approach works. And we know this is true not just for HIV, but for Hepatitis C and other diseases as well.”

The special issue manuscripts include primary outcomes results from three randomized trials examining the impact of community access to self-testing on the knowledge of one’s HIV status and demand for HIV treatment. This collection also contains papers that address issues like health economics, costing, and cost-effectiveness modelling to inform efficient global scale up of HIV self-testing and optimization of HIVST distribution. In addition, the potential for HIV self-testing to increase demand for other approaches to HIV prevention is examined in two randomised trials aiming to use self-testing to increase uptake of pre-exposure prophylaxis and voluntary male medical circumcision, respectively.

“Over the last six years, researchers and implementers have developed a robust evidence-base, generated a viable market, and led to rapid scale-up of HIVST in Africa and Asia,” explains Dr. Karin Hatzold, STAR Project Director. “Self-testing has also accelerated healthcare simplification and transformation for communities and healthcare workers in these high HIV burden settings, providing an opportunity to transform health infrastructure, delivery models and community engagement.”

Scale up of HIVST is driving a movement towards demedicalization of HIV testing services and acceleration of prevention access, putting more emphasis on self-care and agency concerning one’s own health. Self-care interventions such as self-testing increases health system resilience against COVID-19 and decreases cost and complexity of services. The lessons learned from HIVST have implications for the ongoing pandemic as well as the looming epidemic of chronic disease and health system challenges more broadly. HIVST has developed alternative entry points for accessing healthcare in low- and middle incomes countries and accelerated healthcare simplification and transformation for communities and health providers in high HIV burden settings–providing an opportunity to transform infrastructure, delivery models, community engagement and demand in the context of COVID-19 and other diseases.

“Unitaid was wise to fund this groundbreaking work. The uptake of HIV self-testing has taught all of us STAR Consortium partners that self-care is a powerful tool to unlock individuals’ agency in their own health. This work has advanced equity, effectiveness and efficiency of national health systems, and taught important lessons for the future–especially in the face of challenges such as COVID-19,” says PSI President and CEO Karl Hofmann.