The path to ending Canada’s HIV epidemic begins with low-barrier access to testing, treatment and prevention, all areas of focus for I’m Ready to Know. Although Canada has made significant progress in HIV testing and treatment, we are continuing to see high rates of new HIV diagnoses that are not going down. The most recent update from the Public Health Agency of Canada (PHAC) indicated a total of 2,122 new HIV diagnoses in 2019.
Testing is a necessary step to ensuring that every person in Canada living with HIV has access to life-saving support and treatment, yet it remains a barrier for many. Approximately 13% of people living with HIV in Canada are still not diagnosed, meaning that over 8,000 individuals living with HIV are unaware of their status.
HIV self-testing has advanced in recent years and has an important place in global HIV response strategies. In 2016, the World Health Organization recommended HIV self-testing as an alternative to conventional facility-based testing, meaning testing that needs to happen with a healthcare provider in a designated setting.
HIV self-testing is fast, low-barrier, can be done in under one minute and is a highly effective screening tool.
The need for a new HIV testing paradigm in Canada
Here in Canada, the first HIV self-test was approved on Nov. 2, 2020, in part thanks to work led by REACH Nexus, making the current context a unique moment in which to seize fresh momentum and opportunity to reach people who are undiagnosed in Canada.
According to Sean B. Rourke, REACH Nexus Director and Scientist at the MAP Centre for Urban Health Solutions, Unity Health Toronto,
“Self-testing opens many doors by removing some of the barriers people face in getting tested for HIV: lack of access to a healthcare provider, travel and wait times, and concerns about confidentiality and stigma. It also promotes greater privacy, autonomy and the potential for community connections through innovative distribution programs and secondary distribution from one self-tester to another.”
A recent systematic review by PHAC concluded that efforts to improve HIV self-testing access should consider barriers and facilitators at the individual, healthcare provider and policy levels. PHAC also noted these efforts should focus on the accessibility, inclusivity, convenience and confidentiality of testing services, and that they should be adapted to the unique needs and contexts of key populations.
Acceptance of HIV self-tests in different contexts
HIV self-test studies have widely shown high levels of acceptance in different contexts and around the world. Here are some of the key studies and reviews:
A major study in the US conducted by the CDC and Emory University known as “eSTAMP” found that internet recruitment of men who have sex with men for HIV self-test distribution by mail increased testing and awareness of HIV infection among study participants and their social networks. The study identified online HIV self-testing as potentially contributing to preventing the transmission of HIV. eSTAMP showed a high proportion of infections identified in the first 3 months, and a consistently high proportion of infections identified among partners or peers who got their kits from study participants during the 12-month study. The study also showed that offering HIV self-testing online was cost-effective.
The SELPHI study conducted by Terrence Higgins Trust in the UK explored how self‐test users experienced HIV self‐testing. SELPHI also explored the implications of this for developing and scaling up interventions. SELPHI found that men were motivated to access the intervention because HIV self-testing reduced barriers related to convenience, stigma and privacy concerns. SELPHI participants expressed a high degree of acceptance and enthusiasm for self‐testing.
A systematic review of 23 studies reported high acceptance of HIV self-testing among some key populations in mostly high-income groups of people. This review also reported that HIV self-testing is one approach that can help reverse social and health inequities in access to HIV testing for people who face barriers in accessing HIV services.
Similar studies have reported near-universal acceptability (80–96%) of HIV self-testing among the general population, with similar rates for people of all genders. These studies include:
- A 2017 study on acceptance of self-testing found that around 90% of survey respondents—from a predominantly African-American neighborhood of Philadelphia, PA—agreed that they would be willing to use an HIV self-test.
- A study involving an online survey of 5,908 HIV-negative men who have sex with men (MSM) showed that 86.5% of men expressed interest in accessing HIV self-testing kits online, noting the convenience of tests and that tests could be done at home as primary reasons for their interest.
In a specific study of the INSTI HIV self-test in Kenya, investigators reported that the test was over 99% accurate compared to laboratory testing. 96.61% of participants agreed they would use the test kit again, while 97.18% would recommend its use to a sexual partner.
Getting HIV self-testing approved in Canada
These initial studies helped establish the foundation for HIV self-testing expansion across countries, including here in Canada. The REACH Nexus-led study that led to the November 2020 approval of bioLytical’s INSTI HIV Self Test, A Study to Evaluate the Accuracy, Usability and Readability of the INSTI HIV Self Test Performed by Observed Intended Users in Canada, showed high levels of HIV self-test accuracy, usability and acceptance by participants.
Our study found that the INSTI HIV Self Test had a sensitivity of 100% and specificity of 99.5%, which exceed the Health Canada required minimum performance level of 99%. It also found that study participants expressed a high level of satisfaction with the HIV self-testing experience:
- 96.7% of participants found the instructions for use easy to follow;
- 96.2% found the self-test device easy to use;
- 94.7% of participants would use the INSTI HIV Self Test again; and
- 95.5% would recommend its use to a sexual partner or friend.
Looking ahead: embracing HIV self-testing’s potential in Canada
To date, roughly 60 countries have developed national policies on HIV self-testing. Canada is not yet one of them. With HIV self-testing now available in Canada, the time is right for national leadership and coordinated strategies to implement and scale-up testing options so we can reach everyone who can benefit from access to testing, care and prevention—and end the epidemic in Canada.
Our I’m Ready research program is one such coordinated national strategy to reach the undiagnosed in Canada through HIV self-testing and by supporting connections to care and prevention.