I’m currently at the 41st Union World Conference in Berlin, Germany and this morning enjoyed an interactive session debating whether walk-in testing should be available for TB and whether self-testing for HIV should be rolled out in all settings.
Several academics and public health specialists were invited by the meeting chairs, Anthony Harries and Reuben Granich to debate this issue before members of the audience weighed in with their own views: it was a fascinating and successful format.
Helen Ayles (London School of Hygiene and Tropical Medicine and the ZAMBART Project, University of Zambia, Lusaka, Zambia, Africa) gave an overview of a trial she is currently running in Zambia named ZAMSTAR (protocol here and registration here). She drew attention to a need to integrate TB and HIV care and how we may need complex community-ld interventions to reach those in most need.
The main issues are that of those people with a persistent cough or coughing up blood (suspected TB) only 50% seek a diagnosis at a healthcare facility, and of those that do so, only 20% are correctly diagnosed, at least in the trial setting in Zambia. Walk-in tuberculosis testing was popular and uptake was high: and most participants in the audience agreed with Dr Ayles that there are few good reasons not to recommend TB testing, although it should be linked to appropriate follow-up health care advice.
The problems surrounding walk-in HIV tests are more complex . Elizabeth Corbett (also from the London School of Hygiene and Tropical Medicine) advocated for walk-in testing for HIV, commenting that over the counter HIV-testing kits will soon be available in the USA and that the widespread availability of self-testing kits should be rolled out around the world. This would improve testing rates because many people either cannot or will not travel to a health facility to take a test. She also cautioned that the availability of over the counter tests could also mean that people might buy tests over the internet, with the concomitant potential problem of trading of counterfeit tests.
The issues are not as straightforward as making tests available for TB, a curable disease: those raised by the audience included stigma of a positive HIV test, lack of counselling at the test site (in the home) and subsequent potential for depression or even suicide upon a positive result, lack of reinforcement of public health messaging if a result was negative and the potential for coercion to take tests.
The audience broadly agreed upon widening availability of self-tests for HIV, but wanted evidence of how it would work including what happened AFTER the test was used, although there was some agreement that if everyone tested, the stigma might eventually be reduced. Certainly, qualitative research might have a powerful input into assessing the potential for widespread self-testing, as would trials of such an implementation.
Rony Zachariah from MSF summed it up really well, saying that ‘there needs to be a paradigm change, to empower people not patients’.