According to the Joint United Nations Programme on HIV and AIDS (UNAIDS) 2018 Global HIV & AIDS statistics, an estimated 36.9 million people globally were living with HIV in 2017, of which 75% knew their status. Of this 75%, 79% were accessing anti-retroviral therapy and among this group, 81% were virally suppressed. These figures show that there has been considerable progress made in achieving the UNAIDS global plan known as the 90-90-90 Plan to end the AIDS epidemic by 2030. The 90-90-90 Plan proposed that by 2020, 90% of all people living with HIV should know their status, 90% of people living with the diagnosis should receive anti-retroviral therapy and 90% of people receiving such therapy should have viral suppression. According to the UNAIDS statistics, of the 7.2 million people living with HIV in South Africa in 2017, 6.4 million were aware of their status. 

From the 2018 “Know your status” campaign it appears that there are still many barriers to HIV testing, intricately linked to the stigma and discrimination surrounding traditional HIV testing services. It is crucial to address these HIV testing gaps, as testing is the key to unlocking further treatment and achieving the UNAIDS 90-90-90 targets. The World Health Organisation (WHO) in 2016 recommended that HIV self-testing be considered as an additional approach to HIV testing services and that “voluntary assisted partner notification services” should be offered to people living with HIV. According to guidelines published by the WHO in 2016, HIV self-testing is defined as “a process whereby an individual collects his or her own specimen (oral fluid or blood) and then performs a test and interprets the result, often in a private setting, either alone or with someone he or she trusts”. 

If an HIV self-test yields a positive result, a further confirmatory test by a trained professional is needed, as it is not a definitive test. However, HIV self-testing, according to the WHO, might, due to its nature, assist those highest at risk – especially men, adolescents and female sex workers – to access further care. The WHO’s HIV self-testing guidelines highlight that men specifically appear to be “lagging behind” in this regard, as nearly 70% of adult HIV tests “in lower to middle income countries” in 2014 appear to have been taken by women. This seems to be linked to the fact that HIV testing is integrated with reproductive healthcare services, which include antenatal care.

South Africa has followed the WHO’s recommendation and has included HIV self-testing in the South African National HIV Testing Services Policy (2016).The sale of HIV self-testing kits by pharmacies has also been made possible since February 2016, after the South African Pharmacy Council lifted a ban. Furthermore, in February 2018, the National Department of Health published specific guidelines for HIV self-testing (referred to as self-screening in the guidelines). The 2018 HIV self-testing guidelines provide a uniform framework on HIV self-testing as an additional HIV testing method, emphasising the WHO’s “5C’s”, namely consent, confidentiality, counselling, correct results and connection. 

The 2018 HIV self-testing guidelines stipulate that the age of consent for the use of HIV-self tests is based on age of consent of children for HIV testing, as per the Children’s Act of 2005. The guidelines do, however, recommend that in this instance the “direct assisted HIV screening method” be used, which provides that a trained health worker would provide direct support to the child on using the kit and interpreting the results.  The guidelines also reiterate that HIV self-testing must be voluntary and all HIV self-testing kits will have pre and post-test information for the user. Counselling will also accordingly be offered to those who go for a further confirmatory test after receiving a positive result. The guidelines also provide for distribution methods of such HIV self-tests and it highlights that it can be introduced in workplace programmes, such as the mining industry, which can specifically reach men high at risk. 

The fight to end the AIDS epidemic can only be won by implementing innovative approaches to address the gaps in prevention, treatment and care. One such modern innovation is the formal regulation of HIV self-testing, which could potentially break social barriers in accessing treatment and care. It will be critically important for the Department of Health to create awareness around HIV self-testing and to ensure that such information reaches specifically those at highest risk. This in itself might require innovation and the utilisation of various communication tools. On World AIDS Day, we acknowledge that the battle is long not over but that with innovation, strategic partnership and the political will, we stand a good fighting chance.  

By Ms Christine Botha: Acting Director, Centre for Constitutional Rights
30 November 2018