Making HIV Testing a Private Affair

Posted mai 18, 2017

By Kristen Little, HIV/TB Research Advisor, PSI

How do we do a better job reaching those most affected by the HIV epidemic? PSI’s answer: bring HIV services closer to consumers. A key piece of this strategy is PSI’s new project leveraging the private sector to increase access to and uptake of HIV self-testing (HIVST) among populations at high risk of HIV infection in Kenya, including adolescents.

Launched in March 2017, the two-year $2 million-dollar grant from the Children’s Investment Fund Foundation (CIFF) is being implemented by PSI in partnership with in-country independent network member, Population Services Kenya. The project aims to demonstrate the potential of Kenya’s private sector to generate informed consumer demand for HIVST.

While HIV testing has traditionally been driven by the public sector, in many countries private providers represent a major and growing – if not preferred – source of health services. Engaging with and strengthening the private sector (e.g., private clinics, pharmacies, drug vendors) is essential to ensure greater access to innovations like HIVST.

Lucy Maikweki, PS Kenya’s director for HIV/TB, agrees: “The environment in Kenya is ripe for the roll-out of private sector HIVST. Implementation guidelines have been launched by the Ministry of Health to support HIVST scale-up, and there is a big focus on reducing stigma and discrimination, especially among youth, and increasing testing and treatment coverage.” HIV self-testing transcends many of the common barriers to HIV testing, such as fear of stigma and discrimination, lack of privacy, lack of time, and distance and cost of transportation to the nearest health facilities. To this end, the project will particularly target groups that have been historically hard to reach with conventional testing approaches, including adolescents, young women and adult men.

More than 80,000 HIV self-test kits will be distributed over the life of the project through 120 private sector pharmacies and small franchised health clinics in Nairobi and Mombasa counties. The kits will allow individuals to test themselves, at the time and location of their choosing, using an oral fluid- or blood-based rapid diagnostic test.

OraSure Technologies’ OraQuick HIV Self-Test and bioLytical Laboratories’ INSTI HIV Self Test – both registered with the Kenyan Pharmaceuticals and Poisons Board and the Kenyan Medical Laboratory Technicians and Technologists Board – were selected for the research to be conducted by this project. The first uses a simple oral fluid swab and provides results in 20 minutes, while the second is a blood-based test that gives results in under a minute.

This project will generate important insights into consumer preferences, willingness to pay for self-tests, demand creation approaches, and test operation and linkage support strategies for private sector HIVST. It will also explore subsidy levels and targeting required to generate demand among youth and adolescents, building upon the leadership of the National AIDS and STI Control Program (NASCOP) and the recent launch of national guidelines for HIV self-testing.

While HIV self-tests are available in several sub-Saharan African countries, this project is one of the first efforts to use private sector distribution of HIVST to reach public health goals. “There is a growing body of evidence on the acceptability and feasibility of HIV self-testing,” said Petra Stankard, PSI’s senior technical advisor for HIV/TB. “But most of the investment in HIVST so far has been largely public-sector focused. CIFF’s investment in private sector HIVST distribution is strategic, and promises to generate important and timely evidence for the field.”

Project findings will inform national guidelines and contribute to efforts by the Ministry of Health to ensure broad access to HIVST in Kenya. “We have an opportunity to meaningfully contribute to achieving the first of the 90-90-90 targets in Kenya,” concluded Joyce Wanderi, PS Kenya’s chief operating officer, referring to the UNAIDS goal of having 90% of people living with HIV knowing their status by 2020. “Private sector HIVST can help us to reach people that our other testing approaches haven’t.”

Banner photo: © Population Services International / Banner Photo by: Eric Gauss

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By: Fana Abay, Marketing and Communications Director, PSI Ethiopia

In rural Ethiopia, women and girls often face significant barriers in accessing healthcare facilities, which can be located hours away. Moreover, there is a prevailing stigma surrounding the use of contraception, with concerns about potential infertility or the perception of promiscuity. To address these challenges, the Smart Start initiative has emerged, linking financial well-being with family planning through clear and relatable messaging that addresses the immediate needs of young couples—planning for the lives and families they envision. Smart Start takes a community-based approach, utilizing a network of dedicated Navigators who engage with women in their localities. These Navigators provide counseling and refer interested clients to Health Extension Workers or healthcare providers within Marie Stopes International-operated clinics for comprehensive contraceptive counseling and services.

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In 2022, 328 thousand malaria cases were recorded by CHWs); 6.5 thousand severe malaria cases were referred to health centers, according to the national health information system.

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In IM-supported areas of Mali, 36% of CHWs in the first round were competent in performing the RDT, which rose to 53% in the second. 24% of CHWs in the first round compared to 38% in the second were competent in the treatment of fever cases and pre-referral counseling. Between both rounds, availability of ACT increased from 80 percent to 90 percent.

Supportive supervision with interviews and observations at sites improved the basic competencies of CHWs between the first and second rounds, and additional rounds will help to understand the longer-term programmatic benefits.

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By: Dr Karin Hatzold, Associate Director HIV/TB/Hepatitis

Building upon the success and insights gained from our work with HIV self-testing (HIVST), PSI is actively applying this approach to better integrate self-care, more broadly, in the health system beginning with Hepatitis C and COVID-19. Self-testing has emerged as a powerful tool to increase access to integrated, differentiated, and decentralized health services, accelerating prevention, care, and treatment for various diseases, while also increasing health system resilience against COVID-19.

Here’s how we got there.

Seven years ago, the landscape of HIV self-testing lacked global guidelines, and only the U.S., the UK and France had policies in place that allowed for HIV self-testing. High disease burdened countries in low-and-middle-income-countries (LMICs) lacked evidence and guidance for HIVST despite major gaps in HIV diagnosis.

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“The men we spoke to [while I was traveling to South Africa for a PrEP project with Maverick Collective by PSI] were not only decidedly open to the idea of taking a daily pill…many were willing to spread the word and encourage friends to get on PrEP too. We were able to uncover and support this new way forward because we had flexible funding to focus on truly understanding the community and the root barriers to PrEP adoption. This is the philanthropic funding model we need to effectively fight the HIV epidemic, and it’s beneficial for all sorts of social challenges.”

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The shortage of skilled health workers is widely acknowledged as a significant barrier to achieving Universal Health Coverage. To address this challenge, PSI supported ministries of health to develop a digital ecosystem that brings together stewardship, learning, and performance management (SLPM). The ecosystem enhances training, data-driven decision-making, and the efficiency of healthcare delivery.

Here’s what it looks like in practice.

In July 2020, PSI Angola, alongside the Angolan digital innovation company Appy People, launched Kassai, an eLearning platform that targets public sector health workers in Angola. Through funding from USAID and the President’s Malaria Initiatve (PMI), Kassai features 16 courses in malaria, family planning, and maternal and child health – with plans to expand learning topic areas through funding from ExxonMobil Foundation and private sector companies. A partnership with UNITEL, the largest telecommunication provider in Angola, provides all public health providers in Angola free internet access to use Kassai.

Kassai’s analytics system to follow learners’ success rate and to adjust the course content to learners’ performance and needs. Kassai analytics are integrated with DHIS2 – the Health Management Information System (HMIS) of Angolan MOH, to be able to link learners’ knowledge and performance with the health outcomes in the health facilities. The analytics track learners’ performance by course and gives visibility by health provider, health facility, municipality, and province. Each course has pre-and post-evaluation tests to track progress of learning, too.

By the end of 2022, there were 6,600 unique users on the Kassai platform and 31,000 course enrollments. PSI Angola’s partnership with UNITEL, the largest telecommunication provider in Angola, allows for free internet access to learn on the Kassai for all public health providers in Angola. Building on its success for malaria training, Kassai now also provides courses in family planning, COVID-19, and maternal and child health. This reduces training silos and provides cross-cutting benefits beyond a single disease.

Implementing the SLPM digital ecosystem brings numerous benefits to health systems. It allows for more strategic and efficient workforce training and performance management, enabling ministries of health to track changes in health workers’ knowledge, quality of care, service utilization, and health outcomes in real time. The ecosystem also supports better stewardship of mixed health systems by facilitating engagement with the private sector, aligning training programs and standards of care, and integrating private sector data into national HMIS. Furthermore, it enables the integration of community health workers into the broader health system, maximizing their impact and contribution to improving health outcomes and strengthening primary healthcare.

Making HIV Testing a Private Affair

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The Consumer as CEO

Digitalizing contraceptive counseling to reach rural women and girls in Ethiopia

Building community health worker capacity to deliver malaria care

Taking a market-based approach to scale sanitation in Ethiopia

Promoting self-managed care like Self-testing and Self-Sampling

Using peer coaches to counter HIV stigma in South Africa

simplifying consumers’ journey to care in Vietnam

Engaging the private sector for disease surveillance in Myanmar

Training health workers in Angola

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