Expanding the toolbox of HIV self‐testing at home: the importance of user choice and feedback

To maximise its health benefits, self‐testing for infectious diseases must be reliable, accessible, and affordable

Human immunodeficiency virus (HIV) testing is a key prevention strategy; a positive test result can lead to life‐saving antiretroviral therapy, while a negative result opens access to effective prevention measures, such as pre‐exposure prophylaxis. Home‐based testing of blood or oral secretions for HIV antibody has been available in some countries for many years. In Australia, however, only self‐testing of blood is available (since November 2018),1 and its uptake by people regularly tested for HIV has been surprisingly low (about 1%).2 With the recent widespread use of antigen tests for severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2),3 home‐based testing is now quite familiar in Australia, providing an opportunity to improve the acceptability of its use for detecting other infections, including HIV.

In this issue of the MJA, Lee and colleagues describe a randomised crossover trial that examined the usability and acceptability of blood‐ and oral fluid‐based HIV self‐test kits among gay, bisexual, and other men who have sex with men.4 The authors recruited 170 adult men who attended two large sexual health clinics in Melbourne and Sydney during 2019, and randomised participants to receiving the blood test followed by the oral fluid test, or vice versa. Both written and video explanations of the test procedures were provided. A clinic nurse observed and evaluated the test process, but they could not directly assist participants. Although both tests were easy to use, more participants preferred the oral fluid test (58%) than the blood‐based test (41%). Interestingly, some participants who preferred the blood test perceived it as being more accurate, but the reasons for this view were not further explored.4

Self‐testing reduces barriers to testing and allows people to decide when and where they are tested.5,6 Self‐testing for HIV is recommended by the World Health Organization as safe and effective,7 and a recent systematic review and meta‐analysis found that it increased testing frequency, particularly among cisgender men who have sex with men.8 For diagnosing established HIV infection, the specificity and sensitivity of both the oral fluid and the blood self‐test kits are high. However, oral fluid testing is less reliable for detecting recent HIV infection, as the antibody concentration is lower in oral secretions than in blood. The window period following infection during which test results are negative is 55 days for the oral fluid test and 18–22 days for a home‐based blood test.9

In the study by Lee and colleagues, completion rates for both tests were very high and the number of invalid test results extremely low. However, the authors recruited only men who could speak and read English, and three‐quarters of participants had tertiary qualifications.4 Although the overall number of new HIV infections in Australia has fallen among men who have sex with men, it has not declined among Asian‐born men who have sex with men.10 Further, people born in countries with high HIV infection rates remain at increased risk of infection, even after migrating to Australia.10 The useability and acceptability of blood‐ and oral fluid‐based home testing therefore needs to be assessed in men born overseas who have sex with men and people born in countries where HIV is endemic, as well as in other community groups, including female sex workers and Aboriginal and Torres Strait Islander Australians.

The coronavirus disease 2019 (COVID‐19) pandemic has driven major changes in the way infectious diseases are diagnosed and managed in Australia. Public awareness of and familiarity with self‐testing have increased, including with respect to test access, using self‐test kits at home, and reporting test results via online portals. More than 45 COVID‐19 self‐test kits have been approved by the Therapeutic Goods Administration (TGA), including ten that allow testing of saliva rather than a nasal swab sample, providing users with choice.3 Moreover, the rise in telehealth care during the pandemic offers opportunities to rapidly refer people with self‐test results to appropriate health care.11

These changes will be of direct relevance when considering self‐testing beyond HIV and COVID‐19. In October 2021, the TGA approved self‐testing for a range of infectious diseases, including chlamydia, gonorrhoea, syphilis, hepatitis B and C, and influenza.12 This change is an important landmark in the way infectious diseases will be diagnosed in Australia, although substantial work is required to ensure that self‐testing is reliable, accessible, and affordable. Just as important, we need to raise awareness of home‐based testing to ensure its widespread and equitable uptake by people in the groups at greatest risk. The study by Lee and colleagues illustrates the acceptability and feasibility of self‐testing for HIV, and highlights the importance of providing people with a choice of self‐testing approaches to maximise the health benefits of home‐based testing.4