Presented by Dr.Francois Venter May 2017

1. Francois Venter
Wits Reproductive Health and
HIV Institute
HIV Self-Testing in the
context of South Africa
May 2017

2. Disclosures…
• Part of optimisation collaborations – grants to
improve testing, new drug regimens, linkage
to care
• Thanks: Mohammed Majam and team, WHO,
Unitaid, BMGF, PEPFAR, DoH, SAHCS

3. • On the face of it, the SA programme is doing
well!

5. Six-week and final mother-to-child
transmission rates, by country, 2015
Source: UNAIDS 2016 estimates
Six-week
transmission rate
Final
transmission rate
Mother-to-child transmission rate (%)
Angola
Chad
Ghana
Côte d’Ivoire
Cameroon
Lesotho
Malawi
United Republic of Tanzania
Zimbabwe
Burundi
Mozambique
Zambia
Namibia
Swaziland
Uganda
Botswana
South Africa
Democratic Republic of the Congo
Kenya

7. TB…
Thanks: Braamie Variava

9. ~4 YEAR LAG BETWEEN SCALE UP OF ART
AND DECLINE IN MTB INCIDENCE
Figure 1: Incidence of microbiologically-confirmed pulmonary tuberculosis (per 100,000 population)
and antiretroviral treatment coverage rates in HIV-infected individuals nationally in South Africa
nationally and provincially from 2004 to 2012
The solid black line represents the estimated trend in PTB incidence per 100,000 population over the study period and the dotted black line the
corresponding 95% confidence interval. The overlaid dotted grey line is the ART coverage per 1000 HIV positive individuals based on data from the
ASSA 2008 model.
Nanoo A, Izu A, Ismail, NA, Ihekweazu C, Abubakar I, Mametja D, Madhi SAM. 2015. Nationwide and regional decline in incidence of microbiologically-confirmed pulmonary
tuberculosis in South Africa: a time series analysis from 2004 to 2012. The Lancet Infectious Diseases, In press

10. But!!!!

11. Movement is slow!
Self testing has been
sooooo slow!!!

12. HIV and South Africa

13. South Africa: Why is it important?
(and why is it different)?
• Size of the country – 51 million people (2011),
5th largest in Africa
• Wealth – highest GDP in Africa, best
infrastructure
• Size of HIV and TB problem

14. SA snapshot
• 3.4 million 1st line ($110/year)
• Bill 2014/2015: $350 million
• Sept 2016: Test and treat – theoretically
doubling numbers

15. Source: 2016 Global AIDS Response Progress Reporting; UNAIDS 2016 estimates.
Country status
Progress toward the 90–90–90 targets, all ages, by country, 2015
For countries
not shown, both
measures are
not available or
under review.
Knowledge of status
among people living
with HIV (%)
Coverage of
antiretroviral therapy
among people living
with HIV (%)
Viral suppression
among people living
with HIV (%)
Eastern and southern Africa
Angola
Botswana
Eritrea
Kenya
Lesotho
Madagascar
Malawi
Mozambique
Namibia
Rwanda
South Africa
South Sudan
Swaziland
Uganda
United Republic of Tanzania
Zambia
Zimbabwe
Middle East and North Africa
Algeria
Djibouti
Egypt
Iran (Islamic Republic of)
Lebanon
Morocco
Somalia
Legend
90% and higher
45–89%
44% or lower
Measures not available
L
81% or higher
41–80%
40% or lower
Measures not available
L
73% and higher
37–72%
36% or lower
Measures not available
Mauritius
Tunisia
Yemen
Sudan

16. Incidence still remains stubbornly high…

17. And does not correlate well with ART…
Source: Leigh Johnson, Spotlight, 2016

18. Several things happened in 2017….
• 90-90-90 success stories (Botswana, Havlir,
Sweden)
• But failure to link to care in some RCTs –
Swaziland, KZN
• And no impact on new incidence (KZN)

19. Some ideas why: missing men?
• First and second 90: probably there for women;
not men – and that’s a huge problem

20. RHIVA collaboration with MiET Africa and DoE with
funding from the Royal Netherlands Embassy
Age Group
HIV Prevalence (Oct/Nov 2010)
% (95% Confidence Interval)
Male Female
14 1.0 (0.0 – 3.0) 2.2 (0.3 – 4.0)
15-16 1.4 (0.4 – 2.4) 3.6 (2.2 – 5.0)
17-18 1.2 (0.2 – 2.2) 7.9 (5.0 - 11.0)
19-20 1.1 (0.0 – 2.7) 16.0 (9.2 – 22.0)
CAPRISA: HIV prevalence in school boys and girls
in a rural South African district (grades 9 and 10)

21. Or is it something else?

22. Testing in SA
• May 2017: “32% and 42% of women and men
respectively indicated that they have never
been tested for HIV”
2016 South African Demographic and Health Survey

23. • Men under-tested
• Youth under-testing
• And people testing too late! May explain why
impact on new infections limited
• Key populations probably under-tested

24. Then came self testing….
• Magic bullet?

25. History of self-testing in SA…
• Long history of pregnancy tests; more recently, PSA, malaria,
STDs, recreational drugs
• Pharmacy Council: pharmacists can’t sell HIV self tests
• HIV self tests sold ‘under the counter’
• 2007: Pick and Pay, SAMA ‘’ unethical”
• 2007 onwards: advocacy on ST – WHO leading policy
environment, increasing local engagement
• 2013 onwards: products evaluated locally – some eye-opening
results
• SAHCS 2016: guidelines process

26. So slow….
• Ethics – everyone is the first to have thought
of problems
• Regulatory – international, local (and SAPHRA)
• Manufacturers – small, unclear on process
• Retailers – not following process
• Policy – international, local (private and
public) vs Pharmacy Council vs SAMA
• Donor interest

27. Now we are in a place to think about how
ST can augment the HIV response….