Blog

By Ojoma Akor

Self-testing for HIV is fast becoming a game changer in the fight against HIV/AIDS in Nigeria, especially with the backdrop of the country’s huge disease burden, widespread stigma and the drive to get more people to know their status. About 1.9 million people are living with HIV in Nigeria, according to the Nigeria HIV/AIDS Indicator and Impact Survey (NAIIS). Despite this, experts say the lack of knowledge of one’s HIV status leads to over 51,000 AIDS related deaths annually in the country. Many people are hesitant to know their HIV status because of the challenges of visiting laboratories for testing services. These challenges include loss of privacy, stigmatisation, discrimination, missed work opportunities, lack of convenience and financial barriers.

Experts say these further underscores the need for HIV Self-Testing (HIVST). They say it opens the door for many more people to know their HIV status and find out how to get treatment and access prevention services. Findings reveal that HIVST has provided people with a discreet, convenient and empowering way to know their HIV status. According to the World Health Organization (WHO), HIVST is a process in which a person collects his or her own specimen (oral fluid or blood) using a simple rapid test, performs the test as per given instructions and interprets the result privately or with someone they trust. However, the result needs to be confirmed by further testing at a facility.

THE RISE OF HIVST IN NIGERIA

WHO first recommended HIVST in 2016 as an alternative to traditional HIV Testing Services (HTS) given its potential to expand HIV testing access to the hard-to-reach population – mostly young people who are at risk or with an undiagnosed HIV infection who may not receive testing from conventional services. A WHO progress report revealed that lack of HIV diagnosis is a major obstacle impeding its recommendation that every person living with HIV be offered antiretroviral therapy. WHO, thereafter, issued new guidelines to broaden HIVST amid concerns that up to 18 million people living with the virus, majority of them unaware, were unable to access treatment.

The guidelines allow for rapid testing lasting up to 20 minutes, using oral fluid, blood or finger prick “in a private and convenient setting” before a confirmatory test at a clinic. The Director-General of the National Agency for the Control of AIDS (NACA), Dr Gambo Aliyu, said HIV testing was the Achilles heel in Nigeria’s achievement of the UNAIDS 90- 90-90 target. Dr Aliyu said that in the bid to improve the identification of those living with HIV, Partner Notification Services and Index Case Testing were employed in addition to the traditional testing approaches. However, he said the approaches had been limited due to reliance on provider initiation, noting that in 2017, in line with WHO’s recommendation, Nigeria adopted HIVST as a screening method which provided an opportunity to reach underserved populations. He said, “Since then, the government and its partners have been working hard to create an enabling environment, support service delivery and gather evidence towards a gradual scale-up.” More recently, the Federal Ministry of Health incorporated HIVST into the revised National HIV and AIDS Strategic Framework 2019–2021 as a priority policy and pragmatic approach to HIV response in Nigeria. To fast-track HIVST in Nigeria, therefore, the Federal Government has approved various self-test kits.

Experts say HIV Rapid Diagnostic Tests (RDTs) used by self-testers can perform as accurately as when used by a trained tester provided the HIVST products meet quality, safety and performance standards. Some of the RDTs that have been approved by the ministry are OraQuick and Wondfo HIV 1 and 2. For instance, the National AIDS and STDs Control Programme (NASCP) said OraQuick which was introduced into the country in 2020 has the ability to identify and detect HIV antibodies with a 98.4 per cent specificity and sensitivity. Dr Godwin Emmanuel of NASCP explained that OraQuick, which was certified by WHO, the United States Food and Drug Administration and the National Agency for Food and Drug Administration and Control (NAFDAC) is being used in over 50 countries. He said, “As part of measures to promote HIVST, OraQuick was evaluated by the Federal Ministry of Health across the six geopolitical zones in Nigeria. This is in line with national guidelines to assess the efficacy of the test kits for use in Nigeria. “The evaluation showed 98.4 percent specificity and sensitivity to detect HIV antibodies I and II among Nigerians. “This, therefore, affirms greater confidentiality and privacy from individuals who will purchase the easy- to-use, pocket – friendly diagnostic kit from a designated outlet.”

Also, the results of the evaluation which was conducted at the Public Health In Vitro Diagnostic Laboratory, Lagos, showed that Wondfo HIV 1 and 2 have sensitivity of 99.5 per cent and specificity of 99.4 percent. A research titled: “Acceptability and strategies for enhancing uptake of human immunodeficiency virus self-testing in Nigeria”, conducted by Victor Abiola Adepoju and others revealed that HIVST acceptability is high from an intention-to-use perspective. They say targeted strategies are required to improve the acceptability of HIVST, especially among males, sexually active individuals and first-time testers.

HOW TO CARRY OUT HIVST

The NACA DG, Dr Aliyu, said one only needs saliva to do HIVST in the comfort of his/her home, noting that when people test positive, they can visit a health facility for confirmatory test. He said this testing method is pain-free, effective, accurate and safe. He explained that “The test is performed by swabbing the outer gums of the mouth; the swab is then dipped into a buffer tube. All these are provided in the kit and within 20 minutes the results will be ready.” Nasir Saadat, an HIV counsellor and caregiver who has been counselling and demonstrating how to use the HIVST kit for some years, said using the kit correctly and accurately is critical to getting a valid result. She said, “Anyone using the kit must first read the leaflet of the manufacturer to understand how to use it because failure to do so may lead to an invalid and inaccurate result.”

She said the beauty of this testing approach is that it is easy to use, confidential and does not require a blood sample. She noted that the kit users should not eat 30 minutes before the test to “make sure food particles are not included in the specimen.” Tobi Ademola-Kay, the HIV Testing Officer for the JHPIEGO/STAR project in Lagos, said care must be taken by anyone doing the test to ensure they do not have a big sore in the mouth at the time of doing the test as “it can lead to a wrong result.” The expert disclosed that HIVST service delivery and HIVST kits are available via many channels: government hospitals, private hospitals, pharmacies, patent medicine stores, Mobile HTS centres, voluntary counselling and testing centres, one-stop shops and community distributors.

HOW HIVST HELPS BREAK STIGMA

The NACA boss, Dr Aliyu, who noted that stigma still hampers testing and treatment for HIV, said a major challenge facing HIV interventions is that a lot of Nigerians do not know their HIV status and are in fact reluctant to go for testing mostly because of the fear of stigmatization. “Some people have the virus in them and are reluctant to go to facilities and do the test, and some who come out and do the test and discover they have HIV; they don’t want to come forward for treatment all because of stigma and discrimination,” he said.

The National Coordinator of the Network of People Living with HIV/AIDS in Nigeria (NEPWHAN), Abdulkadir Ibrahim, said stigma against people living with HIV is still a major challenge in Nigeria. Mr. Abdulkadir said this is discouraging many people from knowing their HIV status and also commencing treatment. The National Secretary of NEPWHAN, Clifford Emmanuel, said some of the inequality issues faced by people living with HIV/AIDS in the country are stigma and discrimination with respect to marriage, workplace, and health facilities, among others. Rachael Goldstein, Director of HIV and TB Office, USAID, said HIVST is important in the county’s HIV response because it could empower individuals who might otherwise be disempowered either due to stigma or access to facilities. Narrating her experience with HIVST, Joy Linus (not her real name), 19, said sometime last year she was worried about her status following an exposure while in school and she decided to use the HIVST kit. She said, “I repeated the test after some time and still tested negative. I am happy because I did the test in my room. I did not need to be going to the health facility the two times except if I wanted to confirm if I had tested positive.” Hassan (50) who noted that he did not know his HIV status for several years because of the fear of stigma, said, “I didn’t know there was a self-test for HIV until an NGO came to my area and shared kits for us. It helped me to know my status without meeting familiar faces at my community hospital.”

IMPACT OF HIVST ON NIGERIA’S RESPONSE, HEALTH SYSTEM

An investigation by this author revealed that HIVST has several benefits and has had significant impact on Nigeria’s healthcare system. Health experts said it has helped address barriers such as confidentiality of results, accessibility to healthcare facilities, time management and attitude of clinical staff. Dr Godwin Emmanuel of NASCP agreed that the HIVST has been identified as one that would contribute to the attainment of the UNAIDS 95-95-95 goal. This implies that 95 percent of people living with HIV should know their status, 95 percent of people who know their status should access treatment, and 95 percent of people on treatment should achieve suppressed viral loads. The Project Director of Catholic Relief Services (CRS), Dr Chizoba Mbanefo, said the HIVST programme of her organization’s Faster Project showed that self-testing helped accelerate progress in pediatric HIV diagnosis in Nigeria. She said HIVST is one of the innovative strategies and approaches required to increase the uptake of HIV testing services, especially for a population with low access and high risk of HIV. She advocates for the adoption of the HIVST kit as an effective strategy for scaling up HIV testing, especially for children and adolescents. Mr. Harry Omoakhia, the Brand Manager, Oraquick HIVST kit, said that his organization has been undertaking the moderation of the kit for the past few years and this has yielded good results for people who have used it. He noted that out of the 100,000 kits his organization had distributed, 99 per cent who collected had used it, stressing that the ability to reach a wide audience is one of the advantages of the kit. The Senior Programmes and Evaluation Officer, Nigeria Business Coalition Against AIDS (NiBUCAA), Damilola Araoye, said the organization’s “Reaching the private sector with the HIV self-testing project” encouraged more individuals to know their HIV status. Due to the stigma attached to positive HIV status in some workplaces, Araoye emphasized that employees are not mandated to disclose their status after using the HIVST kit. A health worker in a Primary Healthcare Centre (PHC) in Abuja, who craved anonymity, said self-testing for HIV has reduced the number of people who relied on the inadequate health facilities in the country for HIV tests.

Speaking while flagging off HIV testing services in Abaji Area Council of the FCT, Dr Aliyu, NACA DG said people did not need to go to a hospital before they know their status as they could simply buy HIVST kits and do the test. They can go for confirmatory test if the self-test is positive. Meanwhile, findings show that NACA, in collaboration with stakeholders, has recorded achievements in HIVST. They include awareness creation and advocacy; provision of HIVST kits; training of pharmacists, Traditional Birth Attendants (TBAs), Community Pharmacists and Patent and Proprietary Medicine Vendors (PPMVs) per state to reach Orphans and Vulnerable Children (OVC), high-risk adolescents and children whose parents are not enrolled in facilities using HIVST in several states; acceptability of HIVST and linkage to treatment among men who have sex with men.

CHALLENGES, WAY OUT

Despite the fact that there is a high acceptability for HIVST, there are challenges. For instance, research on young people’s preferences for HIVST services in Nigeria by Chisom Obiezu-Umeh and others revealed that there is limited knowledge of the preferences and potential factors that may influence the uptake of HIVST. Some stakeholders said there is need to increase awareness about HIVST, and also make it readily available for people to get them at the delivery channels. Ademola-Kay noted that despite its many benefits, HIVST in the country is fraught with some behavioural and affordability challenges.

She said these are associated with “non- or late disclosure of results, poor knowledge and awareness among the general populace and relatively high cost of HIVST kits in the private sector space due to monopoly of the products.” She, therefore, advised the Federal Government to, in collaboration with other health sector partners, take proactive steps to ensure that the challenges are addressed. Ademola-Kay further said that effective counselling is being promoted across the system to facilitate the collection of client’s phone numbers and addresses with their permission to ensure appropriate follow-up after the kit was collected. To address challenges on the administrative side, the expert said that the government is working to ease registration and approval processes for more HIVST products to increase choice and drive down costs.