Self-testing: legal, ethical, implications
The study of Oraquick, HIV self test kits, in Blantyre has had quite remarkable results. The uptake was very good; it linked more people to treatment and care, and reached people who would not normally get tested. Fantastic! Often, I get emails asking where Oraquick can be purchased or when the national rollout will be. However, on reading a report about HIV instant result self-testing in Scotland—addressing key questions and recommending good practice—raised in me a lot of questions about the what, how, when, where of a national rollout in Malawi.
There are number of legal, ethical, gender, human rights and public health policy implications of scaling up HIV self-testing. Few countries have laws that allow the sale and distribution of HIV self-test kits. The USA approved a law in 2012 for the sale of over the counter HIV self test kits. A UK law is coming into effect this month.
In Africa, Kenya led the way and Malawi is currently piloting HIV test kits. Other countries such as India have outrightly refused to allow the sale and distribution of HIV self-test kits. Currently, there is no global guidance on the issue, the first international symposium on HIV self-test kits was only held last year.
Policy makers and health professionals have various arguments for and against self- testing. Arguments against include potential for inaccurate results; difficulty ensuring referral to treatment, care and support; potential unethical use of HIV self testing for example coerced testing by a partner or employer; and self-testing as justification for unprotected sex.
On the other hand, self-testing could dramatically increase the number of people who know their HIV status; increase confidentiality and convenience; remove stigma around HIV, and facilitate repeat testing and early diagnosis.
How will kits be distributed? Will it be through non-restricted open access where they are publicly available at clinics, pharmacies and supermarkets? Semi-restricted access where health workers distribute the kits or clinically restricted access where professionals provide kits to specific groups for example sex workers or discordant couples.
The advantage of semi and restricted access are that they enable a worker to provide pre-and post-test information, support as well as referrals.
Will the kits be free, subsidised at a fixed price or sold for profit on the market? In the USA, Oraquick self test kits are sold for $40 in pharmacies. A high cost will be prohibitive for increased uptake of self test kits.
A national policy on HIV self-testing would need to consider all these legal, ethical and public health implications. Clear instructions on how to use, perform and interpret results cannot be emphasised enough.
Equally important are systems to guard against potential unethical actions, linkages to further testing to confirm test results, as well as support, care and treatment. Self-test kits can improve the rates of early diagnosis and ensure that people can access treatment and care as early as possible.
I would love to hear responses from the researchers involved in this study.
