Technology: The Next Step Up in HIV Testing Innovation
As Principal Investigators on large PEPFAR and other donor-funded public health programs, we know the difficulty of finding new HIV-positive patients in environments with ever-shrinking new positive yields. This has been done with pressure to be more cost-effective across wider areas, while maintaining the same quality. This conundrum has become more evident as we approach epidemic control, given the various preventive and treatment strategies available. However, metaphorically, this also means an increasing search for the last remaining needles in a vast haystack — i.e. identifying undiagnosed HIV-positive people in the population.
The “Iron Triangle” of healthcare is the application of the universal business principle describing the difficult trade-offs that are required when trying to achieve “quality, access, and cost control.” The reality is that you cannot have all three – one, will always need to be a lesser priority to achieve the other two.
We firmly believe in the crucial role of innovations and digital health to achieve global HIV testing objectives.
Testing matters and is important, as 70% of clinical decisions are based on a lab result. In the case of HIV testing there are two important testing objectives:
● If HIV positive - start lifelong treatment as soon as possible
● If HIV negative and at increased risk - discuss HIV Pre Exposure Prophylaxis (PrEP)
Given the downward trend in budgets for HIV testing in donor-funded programs, it requires us to focus on access and quality with innovations, to reach program objectives.
Access: Where and how we focus our testing resources must be strategic and guided by accurate data, innovation, and frequent implementation updates. Previous examples of such efforts include targeted testing strategies, such as index testing, facility based high volume self-test screening approaches, and a focus on testing scale in mapped hotspots. There is also now emphasis on wider access through non-traditional testing entry points for more difficult to reach populations, such as workplace-based strategies to improve access to men, who do not access clinic-based services as frequently as women. Commercial sex workers and other high-risk populations need bespoke strategies outside of traditional clinics, such as community-based screening, pharmacies, self-testing, and a variety of allied health services.
The “differentiated care model” is popular, and one which offers testing within 4 settings: health facilities, non-health facilities, community, and self-testing. HIV self-testing volumes have grown recently and can be effective as a cross-cutting strategy in myriad contexts.
Quality: The quality of HIV testing remains a critical focal point. Unfortunately, quality of HIV testing is often not prioritized sufficiently, despite global initiatives such as the “Rapid Test Continuous Quality Improvement (RTCQI).” Applying digital health applications to RTCQI allows for precision interventions, knowing where testing quality is poor, and how to intervene. Our combined experience has demonstrated significant improvement in HIV rapid test quality through our digital health platform and online learning management system. Some key quality-related questions we have addressed systematically include:
Are the tests stored, handled, and distributed properly?
Is there appropriate infrastructure to perform the tests?
Are testers trained and certified?
Do providers know how to use the tests correctly?
Are providers correctly interpreting the results?
Are testers using “internal quality assurance” and external quality assurance” samples to ensure correct results are given out?
Are these results linked to data systems and care pathways to inform prompt decision making?
These are not new questions and have been common considerations within the HIV- and global health communities.
Precision tools can assist us to achieve the most impact, given more limited funding. Fortunately, we now have access to digital tools and online learning curricula to support testers more and improve test administration and interpretation, as well as link test data to national data systems. These tools have demonstrated their worth, improving quality outcomes and demonstrating objective quality control testing data for both providers and self-testers. Furthermore, the use of such tools has shown to increase uptake, engage first-time testers and hard-to-reach populations, and successfully link participants to treatment.
These digital tools also pinpoint with accuracy for donors and implementers what the challenges are for every facility, and how to address them.
Given the “Iron Triangle” conundrum, we need to consider how best to take this forward. The challenge lies in the consistent and widespread user acceptance and uptake of such tools. Achieving improved adoption by testers of devices that read the test result and upload patient data automatically would increase the volume and timely integration of the data entering health systems and make this data more readily available for better program decision support and further innovation. One possible strategy would be to pair the use of digital tools with attractive, case-appropriate incentivization to promote uptake and use of both the test or self test modality and the digital companion tool. Although incentivization has not been widely tested with the use of a digital companion tool, there are studies that have found positive results of using incentives for HIV testing and TB adherence, amongst others.
HIV has, to an extent, led the way with self testing. Jamil et al [2021], for instance, updated a 2017 systematic review examining the effects of HIV self-testing compared to standard HIV testing services, which informed the 2016 WHO recommendation on HIV self-testing. The original review included 5 Randomized Control Trials [RCTs], whilst Jamil and colleagues added a further 14. This study, as with others, demonstrates the viability and impact of self-testing solutions — showing that self-testing is safe and effective not just for HIV but for a range of illnesses .
We have achieved so much using testing innovations over the years. However, an ongoing challenge we all face after many years of scaled HIV testing is how to hone and innovate our testing strategies further, and keeping our teams engaged and energy levels.
As we progress towards HIV epidemic control and widespread viral suppression, testing remains a key pillar of our programs. We need to constantly support, re-invent, and vigorously implement both the successfully tried and tested modalities and search for new approaches to deliver care. New ideas will maximize cost effective HIV case finding in an increasingly challenging and low-yield environment while maintaining strong quality standards.
Digital health tools and resultant precision public health interventions present an important opportunity to do this. Could digital health tools be the key to our next phase of identifying HIV positive persons and other priority illnesses? Could digital health tools be how we empower individuals at scale to better manage and control their own health? We certainly hope so.
