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Commentary: Here’s one positive from Covid-19 — it could give a boost to HIV self-testing in Singapore

The Covid-19 pandemic has changed our lives in ways too numerous to count. But not every effect has been a bad one.

Self-testing offers people options to learn their status before or after a possible exposure, after large events or while travelling, says the author.

Self-testing offers people options to learn their status before or after a possible exposure, after large events or while travelling, says the author.

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The Covid-19 pandemic has changed our lives in ways too numerous to count. But not every effect has been a bad one.

Massive disruptions to healthcare services aside, beneficial emerging trends have been accelerated: Greater access to telehealth, a better understanding of respiratory etiquette and hand hygiene as well as awareness of the importance of staying home when sick all have obvious advantages to public health.

Another positive outcome of the pandemic may also be new confidence among the public to be active participants in managing their own health.

Self-testing for Covid-19 has arguably helped to usher in a new era of at-home diagnostics among a public that has become more accustomed to checking their health status with convenience and privacy.

Singapore took a further step in supporting self-testing technology by approving the introduction of at-home tests for the human immunodeficiency virus (HIV) from Aug 1.

These tests have been made available for sale through two clinics in a pilot programme that brings the technology to the public for the first time.

They are available at the Department of Sexually Transmitted Infections Control Clinic and Action for Aids’ anonymous test site for between S$20 and S$32.

The Ministry of Health advises those who test positive in a home test to receive a confirmatory test from a healthcare provider and be referred for treatment.

Even though the Government’s move isn’t explicitly related to the pandemic, the fact that the community has become used to using at-home tests to know their infection status means this pilot programme is likely to gain more traction than before the Covid-19 pandemic.

SIMPLE AND SCALABLE

Before Covid-19, a small number of people were in the habit of routinely performing diagnostic tests at home. Those with diabetes, for example, have monitored their own glucose levels for years.

But people wanting to learn their HIV status in Singapore have until recently had to do so by visiting a testing site — usually a clinic.

Now, however, self-testing has become a routine part of our lives as we regularly use Covid-19 tests. This in itself is a radical transformation given that it has happened very quickly and at a massive scale. 

Manufacturers have had to adapt quickly. Abbott, which was among the first to bring a Covid-19 self-test to market at scale, has said it can make 100 million such tests a month.

The company has stated a goal of reaching every third person on the planet by 2030, with access and affordability baked into design R&D of key products. This also implies scalability in case of future outbreaks of concern.

Self-testing offers people options to learn their status before or after a possible exposure, after large events or while travelling.

It has become so mainstream that many people likely have a few tests in the medicine cabinet at home as part of day-to-day supplies.

This habit has had a beneficial side effect: It has helped people acclimate to a world in which self-diagnosis for some medical conditions, without requiring a visit to the doctor, is more the norm.

And it has exposed us to best practices in diagnostic testing more generally.

From a public-health perspective, cultural acceptance and awareness of at-home testing for diseases has great potential to stop future epidemics before they spread widely.

But whether the test is a Covid-19 test, an HIV test or another at-home diagnostic tool, discussion and interpretation of the results with a healthcare provider is imperative.

This is especially true when it comes to specific nuances like testing too early or late in an infection for a standard test to get a good reading or if the individual has multiple comorbidities or is immunocompromised.

A NET INCREASE IN TESTING

Although Singapore’s HIV self-testing programme is in its infancy, data from a comparable market, Hong Kong, suggests the introduction of self-tests will likely lead to an increased level of overall testing.

One crucial benefit of at-home testing during the pandemic is that it can help mitigate the problem of people avoiding healthcare settings because they fear Covid-19 infection or because opening hours have been affected by restrictions.

Public-health experts around the world have warned of a rise in undiagnosed disease, stemming from a drop in health screening.

In Hong Kong, self-testing for HIV has grown as clinic-based testing declined during the pandemic.

Data from Aids Concern, an HIV non-governmental organisation in Hong Kong, shows that attendance at the organisation’s testing centre fell by 50 per cent in 2020, compared to a year earlier, amid sporadic facility closures and avoidance of clinical settings in the first year of the pandemic.

However, bucking the trend, HIV self-testing has grown rapidly over the course of the pandemic, with the organisation selling 250 test kits a month in 2020, up from an average of 30 test kits a month in 2019.

Now that Aids Concern’s testing service is at full operation again, people are returning to test there in similar numbers to before the pandemic.

However, the number of self-tests being accessed has also remained higher, suggesting an overall net increase in overall testing.

While it is too early in Singapore’s pilot programme for sales data to become available, Hong Kong’s sales have remained on a par with the level in 2020.

We are still collecting the most recent figures from self-test providers in Hong Kong, but we have seen that the number of people diagnosed with HIV via self-testing has risen since 2020.

In Singapore and Hong Kong, where HIV numbers had been declining since before the pandemic, some experts have speculated that restrictions to combat Covid-19 may have contributed to a decline in higher-risk behaviour, contributing to lower HIV infection numbers in 2021.

The new availability of self-test kits can only help to increase identification of new HIV cases more quickly.

A MATTER OF ACCESS

In addition to offering greater privacy, at-home tests are now often much easier to access than tests conducted through a clinic.

Covid-19 rapid antigen tests have become a staple in drugstores and convenience stores throughout the region. Singaporeans can even get them from vending machines.

This kind of large-scale access to at-home diagnostic tools brings with it benefits that will last beyond Covid-19.

Without having to face the inconvenience and possible stigma or embarrassment of going to a clinic or laboratory, people who fear they may have been exposed to HIV or other sexually transmitted diseases can obtain a test discreetly and administer it privately—having become more accustomed to doing this for Covid-19.

The pandemic has seen researchers, governments and companies undertake an effort on a global scale rarely seen before, making huge advances in technology and logistics in an astonishingly short time.

We hope the progress we’ve made can allow us to react faster and more effectively to current and future pandemics.

In the meantime, our embrace of at-home testing for Covid-19, HIV and many other diseases will come with the distinct public-health benefit of a populace more willing and able to using self-diagnostic tests, giving people the power to protect their health and help outbreaks before they spread.

Of course, the convenience of such home tests for infectious diseases like HIV needs to be balanced with a reporting mechanism that works on the principle of trust and the intent to cut the chain of transmission.

There are worries in some quarters that positive cases may not report and instead go “underground.”

But even if that were to sporadically happen, one can’t take away the fact that knowledge of one’s HIV status with a self-test is better than a potentially infected individual not getting an HIV lab test out of fear of stigma.

As the Hong Kong HIV testing experience is showing us, the best healthcare solution is the one that reaches the people who need it most.

 

ABOUT THE AUTHORS:

Dr Asok Kurup is an infectious disease physician at Mount Elizabeth Hospital, Singapore and Mr Andrew Chidgey is chief executive officer of Aids Concern in Hong Kong.

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