Mark Bloch elucidated several advantages of rapid self-testing which includes

1.      Privacy

2.      Convenience

3.      Short time interval to obtain result

4.      Less anxiety period prior to knowing test result

5.      Easy to use in remote communities with little or no access to health care

Results of the NSW study demonstrated a high uptake and usability of people performing a  rapid self-testing and also correctly following all the steps.

 Clinicians are still concerned about commencing treatment based on results of this self-tests which is also self-reported by patient.

 Example, after a patient self-tests, how will a clinician have documented evidence of test result in patients chart prior to commencement of therapy or even referrals to a specialist

In addition, after a positive self-testing and a patient fails to present for treatment, how can one ensure follow ups.

The Atomo device would undoubtedly improve access to HIV testing but much work has to be done regarding guidelines to clarify concerns as above to make it universally acceptable

Anna McNulty presented about the New South Wales initiative of posted self collected HIV dried blood spot testing. This is of interest to me as I work in a sexual health clinic in a regional setting and I'm aware of how isolated some people are who could benefit from a HIV test.  In my setting I'm aware of isolated MSM who are not out in the local community and/or don't want to be seen at a sexual health clinic or are unable to travel to a local sexual health clinic. Some feel unable to discuss this with their GP or may not even have access to a GP.

 Background to this project:

• HIV New South Wales strategy identifies GBM and CALD  as priority populations for testing
• 11% of people with HIV in New South Wales are undiagnosed
• GBN are interested in self testing however currently not available
• Those from CALD communities are more likely to be diagnosed late 

 How it works: 

•  Dried blood spot test (DBS) test ordered via website
•  Person uses small lancet to prick finger and apply blood to small circles on blotting paper, 5 drops preferred
•  Sample is returned in the reply paid envelope to SVH lab
•  Negative results SMS via Sexual Health Infolink (SHIL)
•  Positive results via phone 

 Promotion: 

•  Promoted through social media and local initiatives
• Translated into 10 languages 

Results:

• November 2016 to end of September 2017 there were 505 registrations
• 77% MSM, 32% had partners from Asia or Africa, 26%  were from Asia or Africa, 14% CALD MSM, 11% CALD heterosexual, 4%had ever injected drugs or  5% Aboriginal. Note people could be for more than one group
• 58% kit return rate
• 54% have never tested or tested greater than two years ago
• Median kit return time was 18 days
• Reactive results: 1 confirmed and the person linked to care, another recent reactive result
• There were 39 repeat testers

Feedback from users of the test  in a post test survey:

• Test participants  were very supportive of HIV testing done this way and we're very happy they had the opportunity to test.  Feedback included: They  could test  in private, the test was was quick, free, convenient, no need to go to GP,  allows me to test ahead, it is less embarrassing, easy to do

Conclusions: 

•  Successful implementation however slowper uptake than anticipated
• Difficult to reach heterosexual CALD
•  Expected 1% HIV positivity
• Marketing is the key to uptake

Future:

• Phase 2 site specific projects including addition of hepatitis C RNA testing and Aboriginal and PWID added as populations to be targeted
• SOPV
• NSPs
• D&A services 

The talk was presented by Dr Jeffrey D Klausner, Professor of Medicine, Department of Infectious Disease, University of California, Los Angeles, USA

Outline

·         What is self – testing?

·         How is self – testing Adopted?

·         What is the fidelity of self – testing?

·         Where can self – testing can be disseminated?

Self – Testing for HIV Infection

Only US FDA approved in Home HIV testing kit which used similar technique of Western Blot

Used by over a million consumers and same device used by health care professionals recently

The technique is simple oral swabs, no blood, and results will be in 20 minutes

24 bilingual customer phone support and details product website offering information, referrals to care, product usage instructions and more

Higher consumer satisfaction

Self – testing adoption

Influenced by user’s perception of costs, benefits, personal need and convenience.

Users greatly prefer painless oral testing over finger stick or venepuncture

Additional benefits include increased confidentially, privacy and reduced social stigmatization

Self – testing Fidelity

Original studies by manufacturer < 2 % failure

-          Limited by use of select population (MSM)

-          US adult vs trained providers ( Sensitivity 92.9% vs 99.3 % )

Singapore, error rate 0.6 %

Atlanta, 9 % error rate

China (non – Oraquick) 10 % difficulty swabbing, 17.5 % difficulty reading results

In NYC young MSM and transgender women reported concerns of anxiety, test correct use and instructions

Self – testing Dissemination – Los Angeles

-          Vending machines

-          Vouchers

-          US Priority mail

-          Online

Vending Machines in sex clubs which are located at private areas with self – contained unit that can be monitored remotely as well as posted instruction how to use the kit

Initial Concerns for Vending Machines

·         Cost of HIV home test kits

·         Emptying the vending machine

·         Conflict with existing testing programs

·         Home test kit window period

·         Result anxiety

Results summary over 7 weeks, in 2014

-          1176 hours and 312 tests for Vending machines versus 64 hours with 58 tests for traditional testers with clinicians

Providing Vouchers for the free test kit that can available at Pharmacy is also very positive outcome 

Social Medical Promotion commenced since 2014 through Periodic advertisements

In General, among three choices; vouchers, vending machine, priority mail to home 

Approximately 2/3 used Mail services and 1/3 of other consumers accessed through free vouchers, 67 % and 30 % respectively. Only 3 % used vending machine to get the self – testing kit  

Linkage to care for community

HIV Self- test added as a reported element in HIV Surveillance and also follow up management goes through by receiving the positive test kit photos taken by consumers

STD Self – Testing

·         Self -collection urine send via mail for STD testing

·         Self – referral syphilis lab testing

·         Commercial home – based collection and shipping

·         True home – based collection and self – testing.. .. not yet but coming soon.

Among all, using Mail for screening is the most cost effective method

Summary

·         HIV self – testing is desirable, safe and effective – WHO recommended

·         Need more evidence on outcomes, impact and cost effectiveness

·         STD home – specimen collection and self – referral options

·         True STD home – based self – testing …. Coming soon and waiting approval from FDA

This talk was presented by Udesha Chandrasena, Policy Officer, Scarlet Alliance, Australian Sex Workers Association, Australia

Udesha spoke about the results from a study conducted by the Scarlet Alliance, involving an online survey that was distributed to sex workers including members of the Scarlet Alliance. The survey looked at potential implications of HIVST 

Sex workers in Australia have low rates of HIV infection despite laws that stigmatise and discriminate against them. This is largely due to the success of peer eduction, outreach services, and safer sex information practices.

Benefits of HIVST may include providing testing options that are private and confidential and that take place outside of a clinical setting 

The risks of such testing , however, may include a higher rate of false reactive results due to sex workers being a low prevalence population 

In addition, there is no opportunity for pre and post test counselling 

In the event of a reactive result this may be considered evidence of HIV infection as per the National Policy on HIV testing, which could have consequences for the sex workers due to current laws and policies that are in place 

It is important to ensure that if HIVST was carried out, sex workers are supported and that information is available regarding what to do in the case of forced or coerced testing. Privacy rights also need to be protected

In addition, clear information regarding the risks of false reactive test results and the need for confirmatory testing needs to be in place

The sex workers who completed the survey generally welcomed HIVST, however they were concerned about the legal implications and other possible drawbacks as mentioned above

Australia has led the way in many HIV activities so why are we so behind when it comes to self-testing? Marginalised groups have been a focus of this conference, and rightly so. We know that self testing will be a part of the response to closing this gap in hard to reach groups but so far, no home test has been approved in Australia and access is currently limited to research.

Sarah Bell from the University of Queensland presented data on a peer led pilot to increase access to high risk men in rural and remote communities. They had a high uptake by infrequent/never testers with self-perceived risk and convenience being the main reason for participation. 93% didn’t want the optional pre-test counselling and most participants stated they were willing to pay for a test given the option to. 

ASHM President Dr Mark Block reminded us that HIV testing doubles when self tests are available and reported that the ATOMO test, currently under TGA review, is an accurate test with high usability. 

Dr Anna McNulty presented findings from the NSW Health dried blood spot self-sampling initiative targeting hard to reach groups.  Resources have been translated in 10 languages and the project has been promoted by multicultural health. Privacy was the most commonly stated reason for participating.