The WHO backs HIV self-testing to boost PrEP access

The World Health Organization (WHO) has updated its HIV testing guidance, including how to use self-testing kits to help more people access PrEP. Here’s all you need to know. 

What are the guidelines about? 

The WHO first released these HIV testing guidelines in 2015. This new version has been updated to reflect the latest evidence and best practices. The WHO has also published case studies from Eswatini, Mozambique, Thailand, Nepal, Brazil and Spain to show how health practitioners are using self-testing to boost PrEP access, and the difference this is making to people’s lives. 

Why is this important? 

Only HIV-negative people can use PrEP to prevent HIV. If someone with HIV uses PrEP it can mean their HIV becomes resistant to treatment. That’s why people need to test before they begin PrEP. They also need to test regularly while taking PrEP in case their adherence has not been high enough and they have contracted HIV. But having to go to a clinic for an HIV test and to get medication stops some people from using PrEP, particularly people who avoid health facilities due to stigma. Self-testing could be part of the solution. 

What do the guidelines say? 

The WHO now recommends HIV self-testing for beginning, restarting and continuing PrEP. This is recommended for PrEP pills or the PrEP vaginal ring (and PEP). Further research is needed to understand the role of self-testing with injectable PrEP.  

People using PrEP should test for HIV every two to three months, depending on the type of PrEP they are using. 

In Eswatini, community outreach workers are providing self-testing kits to people at increased risk of HIV. Anyone with a HIV-negative self-test result is immediately offered PrEP. If they accept, they are given a one-month supply of PrEP pills and followed up in a month. At this point they are given another self-testing kit. If they are still negative, they are given a three-month PrEP supply. If they self-test after three months and are still HIV negative, they are given six-monthly PrEP supplies from then on. This is enabling people to start using PrEP and keep taking it without ever having visited a clinic. 

Sandra, a 29-year-old from Eswatini who the WHO interviewed, described the programme as “a perfect arrangement”. She added: “We were given a [self-test] kit and directed to test in private... Initially I wasn’t sure how to self-test, but after the provider explained how to use the oral and blood-based [fingerprick] kits, I felt confident and took two tests kits for my partners so they could test themselves.” 

In Mozambique, healthcare facilities and mobile community clinics are offering self-testing kits to encourage people to use PrEP. They are finding it is particularly useful for reaching people who are mobile or internally displaced. People are given oral PrEP refills every six months, and they can choose between self-testing and clinic-based testing. 

The updated guidelines also recommend self-testing kits for syphilis and dual HIV/syphilis. And they include new recommendations on how to expand ‘network’ testing services to reach the partners and social contacts of people with HIV or a sexually transmitted infection. 

What does this mean for HIV services? 

The guidelines and case studies clearly show that self-testing kits can be useful for encouraging people to use PrEP. 

The guidelines outline how to use self-testing as part of a strategic mix of tailored testing options for different groups of people. These groups include adolescents (ages 10‒19), young people (ages 15‒24), people at increased risk of HIV, pregnant women, couples and partners.  

Distributing HIV self-testing kits online (via websites or social media), alongside telehealth consultations and counselling, can be particularly effective for reaching people who may not want to go to clinics or local collection spots. 

There is a need to provide self-testers with clear guidance on how often to test and how to interpret their results. People also need to know where to go for confirmatory testing and HIV treatment if they get a positive screening test. This should be given alongside information about the benefits of HIV treatment, including the message of U=U. People who get a negative result should be given information about the different HIV prevention options available, and the option they select should be given to them immediately if possible, or through a referral. It is also important to talk to people about the possibility of their partner/s self-testing, including the benefits and possible risks of partner testing.