Why is a HIV self-test screening strategy needed?
We were funded by Grand Challenges Canada, in 2011, through its Inaugural Stars in Global Health Awards program, to create an innovative, synergistic HIV self testing strategy for South Africa—the country with the highest HIV burden in the world.
Conventional health facility based HIV testing is plagued with poor rates of testing and has been around for the past 15+ years. Further, about 40-60% of individuals tested in facilities are lost to follow up. Nobody knows the exact data from countries, because such data are hard to collect. But a WHO report states that only 40% people worldwide know their HIV serostatus (which translates to about 60% being unaware).
Anecdotally, fewer men than women (30-40% vs 60-80%) seek an HIV test. Men need to get tested and they dont wish to show up in health care facilities because of shame, social visibility, stigma and discrimination. Adolescents desire testing but are afraid. Women desire convenient options.
With Universal access to HIV treatment, we need to bring people into care. We need to expand screening options. Provide a strategy that works for people—therein comes the role of an HIV self testing strategy.
Many countries are nervous about introducing and approving self tests, and rightly so. Simply selling self tests in the stores without clear instructions to test wont cut it. Companies are only interested in selling their products—more thought is given to the product—but less to the human / the individual who will use the product and get a life changing diagnosis.
Some of these individuals may live in many tough circumstances.
Hence the need for a self- testing strategy— engages potential individuals who may consider getting a test hence the need for an app! Or internet software.
HIV is often association with stigma and discrimination. Why do you think this is the case?
HIV/AIDS Exceptionalism—has plagued us for a long time.
A diagnosis of HIV was a death sentence until treatments arrived in the US in the late 90s. As for the rest of the world, Universal Access to ART become a reality in mid 2000s.
HIV is a disease associated with practising risky behaviors- hence, subject to stigma. Affects the marginalized poor populations even more than the rich—hence, discrimination.
Shame, fear of social visibility, fear of lack of privacy and confidentiality regarding a positive status, prevents people from coming forward and getting tested. Societal factors such as stricter laws, criminalization, homophobia, gender inequity, vulnerability, impede our prevention efforts on a daily basis—including developed countries.
But, in 2013, with great treatment options are available everywhere, a diagnosis of HIV must not be stigmatized, it has no room for negativity...we must educate everyone on these possibilities.
Treatments are very effective (once a day pill dosing regimens)—and if HIV is treated and monitored well, it is controlled well, as is the case in the developed world.But we need to get there in developing countries and emerging economies, that bear the brunt of the disease burden...
Treating HIV has consequences to partners, to future children, and reduces transmission in the community—because the risk of transmission is very low—if HIV is treated. The disease can be controlled to a point that it could be called a functional cure. If many more people get treated, the infection can be controlled at a community level, country level...treatment reduces the virus to controllable levels.
Please can you outline the innovative self-test screening strategy for HIV your team recently developed?
We synergized an oral HIV test (Oraquick) with internet and mobile phones to develop an internet based confidential self testing strategy that captured a clinic visit online- we also created a similar paper application those who preferred them. We successfully evaluated it in a sample of health care workers at the University of Cape Town, South Africa.
Details about our strategy can be found in the paper recently published (OPEN ACCESS PUBLICATION IN PLOS ONE http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0079772 )
After evaluating it, we converted it to a smartphone Application: HIVSmart!.
Prior to creating it, we reviewed global evidence on oral HIV rapid tests and published it in Lancet ID, and proved that oral self tests are accurate enough for self testing. We also reviewed evidence on self testing strategies and published it in PLos Med and proved that self testing strategies acceptable, preferred and useful for partner self testing but evidence on linkages was limited. We created self test paper applications and evaluated them in a study in Montreal and then we moved to develop an internet strategy for South Africa.
We thank our primary collaborator Prof Keertan Dheda, who with his dedicated team of researchers, nurses, counsellors and scientists helped us prove our unconventional solution. Without his support, this project would not have been possible.
How does this strategy make use of mobile phones?
Counsellors were available on Mobile phones to assist self testers at any time during self testing process. Through mobile phones, links to clinics and information were also confidentially communicated.
Patients preferred the strategy to clinic based testing because it was personalized, private and confidential. Besides, non invasive oral nature of self testing also made it easy to self test.
Our self screening strategy has the potential to impact HIV screening and linkages to care—the strategy can be adapted, modified and tailored to any country and language—When introduced with the right partners, it will help many learn their status and the afraid get linked to care.
Mhealth has emerged as a new field and is very trending in HIV—It has been proved to be effective in clinical trials in reaching people—from medication reminders, to appointment reminders, to messaging for health, to tracking test results, to now, self testing, All we did is harnessed its power for self testing. We have synergized it in our work and proved in a clinical study that it could work in South Africa.
Many individuals may not live in optimal environments, but they certainly have a phone! The power of the phone is phenomenal for health—( and business/economy/education) ..And they could be optimized for service delivery everywhere from rural to urban areas!
What platforms is the app available for and which languages is it available in?
Right now, it is only available for an Android device and in English. We are working to expand it into many other languages and other platforms for global portability. We also have other options for people who don’t have smartphones—we developed solutions to every pocket.
Your team recently received the international 2013 Accelerating Science Award Program (ASAP) for the HIVSmart self-screening strategy and app. What impact do you hope this will have?
We are grateful to PLOS, GOOGLE, and WELLCOME Trust for the open access innovation award. I shared the cash award with my trainees - Roni, Caroline and Sush. It was given at the World Bank last month.
The award gave us global visibility.
I have believed in the open access movement—for a long time. Scientific knowledge shared globally through the Internet has the power to transform economy, science, technology and arts—and create more jobs, with innovation, and collaboration..
For me, the innovation was inspired by open access literature and developed and shared in open access journals, and the award is a culmination of my beliefs. I volunteer my team to a lot of open access journals and for the open access movement at large.
What excites you most about the strategy you have developed?
Its global impact and its global portability.
As a medical doctor, a scientist and innovator, i believe that right brain approach to problem solving works well for implementation research.
We thank Grand Challenges for supporting our project.
Grand Challenges Canada encourages scientists to think out-of-the-box and supports ideas that are bold and unconventional. These integrated innovative solutions have the potential to impact global health in a big way.
What are your plans for the future?
With the support of Grand Challenges Canada and with the collaboration of Professor Keertan Dheda at the University of Cape Town, we are looking to generate stronger evidence in at risk populations in South Africa.
At our lab, we are aiming to expand our innovations pipeline for co-infections. We have been recently funded by Grand Challenges Canada for another project on co-infections.
Where can readers find more information?
Our website www.nitikapantpai.com
More information can also be found on YouTube
About Dr. Nitika Pant Pai
- Stars in Global Health Award from Grand Challenges Canada, year 2011, and 2013
- Inaugural Chanchlani Global Health Research Award for HIV from McMaster University 2012
- Maude Abbott Award for research excellence from McGill University 2013
- ASAP award for Open access innovations from PLOS GOOGLE and Wellcome Trust 2013
- CIHR New Investigator Award recipient for Research 2010
- NIH Fogarty Fellow 2001-2006
- CIHR CTN fellow 2006 -2009
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