UNITAID HIV Rapid Diagnostic Tests For Self-Testing
UNITAID HIV Rapid Diagnostic Tests For Self-Testing
UNITAID HIV Rapid Diagnostic Tests For Self-Testing
The designations employed and the presentation of the material in this publication do not imply the
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delimitation of its frontiers or boundaries.
The mention of specific companies or of certain manufacturers’ products does not imply that they are
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6 Acknowledgements
7 Abbreviations
9 Executive summary
12 Background
19 Technology landscape
37 Enabling environment
48 autotest VIH®
67 References
This landscape was assembled in partnership with Carmen Pérez Casas and Olawale
Ajose (UNITAID); Rachel Baggaley, Cheryl Johnson, Carmen Figueroa, Anita Sands,
Mercedes Pèrez Gonzalez, Irena Prat, Willy Urassa, Robyn Meurant and Boniface
Dongmo Nguimfack (World Health Organization); Petra Stankard, Karin Hatzold,
Nina Hasen, Yasmin Madan, Patrick Aylward and Shannon Rosenberg (Population
Services International).
Financial support for this work came from the UNITAID secretariat and the Bill &
Melinda Gates Foundation.
The development of this work was coordinated by Carmen Pérez Casas, Olawale
Ajose, Rachel Baggaley, Cheryl Johnson and Petra Stankard under the supervision of
Philippe Duneton (UNITAID Secretariat) and Gottfried Hirnschall (WHO Department
of HIV).
ARV antiretrovirals
CE European Conformity
mL mililitre
µL microlitre
NA Not available
PQ prequalification
UN United Nations
This report presents HIV self-testing (HIVST) as an innovative strategy with great
potential to contribute to achieving the United Nations (UN) 90–90–90 targets by
2020. It provides updates on the landscape of technologies for HIVST originally
presented in the first edition of the UNITAID/WHO Landscape on HIV self-testing
(December 2015), as well as a summary of the existing and emerging market and
projections of the demand for, and supply of, HIV rapid diagnostic tests (RDTs) for
self-testing. The information in this report is intended for manufacturers, donors,
national programmes, researchers and other global health stakeholders who are
exploring the potential role of HIVST.
The first edition of this landscape identified 52 HIV RDTs on the market, the vast
majority (48) of which used fingerstick/whole blood specimens. As of June 2016,
24 HIV RDTs for professional use were identified as eligible for procurement by
major donors, as they are either approved by WHO or the Global Fund to Fight
AIDS, Tuberculosis and Malaria (Global Fund). Between 2012 and 2014, a total
of 243 million HIV RDTs for professional use were reportedly procured by public
agencies, averaging about 81 million HIV RDTs per year. The actual volume is likely
to be much larger, as these estimates do not include HIV RDTs procured directly
from manufacturers by country governments nor HIV testing services in the private
and/or informal sector. Prices for HIV RDTs for professional use range from US$
0.50 to US$ 11.00 depending on the specimen-type, procurement volume and
buyer.
Significant innovation would be required to meet the current HIV RDT for self-
testing target product profile. Potential for innovation includes adaptation of
tests with greater seroconversion sensitivity (third and fourth generation RDTs)
and modifications of test kits to be more “user friendly”. These modifications
may include reducing the number of steps (e.g. one step), simplifying specimen
collection and transfer, achieving a faster time to results, ensuring results remain
stable for a longer period, improving the clarity of the space where the result
appears and is read to strengthen accurate result interpretation, and optimizing
packaging and instructions for use (IFU). Innovations in support tools for referral
and linkage could also improve test performance as well as ensure linkage to
further testing, prevention, treatment and care. Such modifications may not only
benefit those who self-test, but also health workers and lay providers who often
provide HIV testing services in a variety of settings where they may lack adequate
training, support and supervision and who deal with challenges such as poor
visibility, inadequate lighting and limited time and supplies.
Global demand for HIVST is largely uncertain. In high-income markets where HIV
RDTs for self-testing are approved for use, it is estimated that 1.6 million RDTS
for HIVST have been sold since 2012. Based on this information and current
data about uptake and use of HIVST in low- and middle-income countries, global
demand is estimated to be at least 4.8 million HIV RDTs by 2018. Work is currently
under way to refine this estimate using population-level data. These estimates will
focus on the African market and are planned for release in December 2016.
Despite this lack of clarity, global procurement in 2015 and the first half of 2016
significantly outpaced prior years. As of June 2016, several large buyers are
signalling increased interest in HIVST; and the President’s Emergency Fund for
AIDS Relief (PEPFAR), the Global Fund and the Bill & Melinda Gates Foundation
have all initiated procurement to support growing demand for implementation
research. Furthermore, policy development at the national level gained traction
in several countries since the first published landscape. Sixteen countries
report the existence of a policy supportive of HIVST, while another eight are
under development. WHO guidelines, a critical tool for further advancing policy
development, are also expected in late 2016.
The growing pipeline of HIV RDTs for self-testing indicates a growing market
supply, while more concrete developments in approval, policy and regulatory
pathways, as well as increased procurement indicate an increasingly healthy
environment in which the market demand for HIVST can flourish. However, risks
that may slow market development remain, such as unanswered operational
research questions, limited product innovation and unclear country-level policy
and regulatory frameworks. To maximize the potential and continue to expand this
market, country governments, donors and manufacturers can all take critical steps
to address these risks and support further market development.
To date, the global scale-up of HIV testing services has been significant. From
2010 to 2014, more than 600 million people received HIV testing services in 122
low- and middle-income countries (6). An estimated one half of PLHIV in Africa are
now aware of their HIV status (7), an increase from 2005 when only 10% of PLHIV
were aware of their status (8). These gains have been made possible through the
expanded use of rapid diagnostic tests (RDTs), implementation of routine testing in
health facilities (primarily in antenatal care and tuberculosis clinics), and expansion
of community-based HIV testing and task-sharing initiatives enabling trained lay
providers to perform HIV testing services. With the widespread availability of ART
and the widespread use of RDTs, which in a validated testing algorithm can often
provide a same-day diagnosis, HIV testing is now routinely provided with pre-test
information without the requirement for pre-test counselling (9).
HIV testing uptake and coverage for men continues to be lower than those for
women in most countries (10). Nearly 70% of adult HIV tests reported in 76 low-
and middle-income countries in 2014 were among women (10). Global reporting
suggests this is because HIV testing is integrated successfully within reproductive
health services, including antenatal care, but not consistently in other relevant
clinical settings, and that male partner testing is not widely implemented or taken
up (10,11). Thus, many men remain untested and those with HIV often continue to
be diagnosed late.
Among key populations, who are disproportionately affected by HIV and comprise
approximately 40% of the 2 million new HIV infections every year (12), testing
coverage remains low and existing reports of coverage are likely overestimates
due to limited data that are not representative. Low uptake of HIV testing services
among key populations is not only related to availability, but also depends on
acceptability and is impacted by unfriendly services, fear of stigma, discrimination
and criminalization of behaviour (12).
Source:UNITAID/Eric Gauss
In addition to scaling up HIV testing services, maintaining the quality of HIV testing
is critical. A systematic review identified several reports of poor quality HIV testing
practices, such as poor product performance, improper storage of test kits and
supplies, clerical or transcription errors, user errors in performing the test and/or
interpreting the test result, lack of training, improper use of the testing strategy and/
or algorithm, lack of supportive supervision and training, lack of standard operating
These challenges require a new focus and new approaches to reach PLHIV who
remain undiagnosed early in their infection. Many countries and programmes are
considering innovative approaches to delivering HIV testing services to adequately
reach these people and achieve national and global testing targets.
There are many models for implementing HIVST, which vary in the level of support
provided and how and where HIV self-test kits are distributed. Models include
support from health workers, distribution or sale in the community or a health facility,
as well as sale in pharmacies, kiosks, vending machines and through the Internet.
Direct or indirect assistance may also be available through a demonstration on how
to self-test via an instructional video, telephone hotlines and printed instructions
for use (IFU) or other package inserts (9). Notably, accuracy of HIV RDTs used
for self-testing can be high, particularly when using validated tests and clear and
concise IFU, as well as other support tools (e.g. demonstration on how to self-test).
According to a systematic review of 21 reports that assessed the performance of
HIV RDTs, sensitivity ranged from 65% (95% CI 33.6–87.2%) to 98.8% (95% CI
92–99.8%) and specificity ranged from 94.7% (95% CI 84.9–98.3%) to 100%
Despite good performance, it is important to note no single HIV RDT can provide
an HIV-positive diagnosis. However, a person with a nonreactive self-test result
does not need to have this result confirmed (9). It is recommended, as for all testing
services, to provide retesting messages for people with high ongoing or recent risk
exposure(s) (e.g. key populations; serodiscordant couples) (9).
There are many possible advantages to HIVST. It has been shown to be a discreet
and convenient approach that is also empowering and acceptable for diverse
populations in various contexts who may test less frequently or not otherwise test
at all (9,16–18). For those with a reactive self-test result, HIVST may lead to early
access to health services to establish an HIV diagnosis and link to prevention,
treatment and care. For those with a nonreactive test result, HIVST may support
increased uptake of prevention interventions, such as VMMC, PrEP and PEP, where
the requirement for HIV testing at the time of seeking prevention services is reported
as a barrier (19–21). For example, in Kenya, HIVST was reported to facilitate access
to PEP among health workers because accessing existing testing at their facility
was a barrier (20) and studies in Malawi, Zambia and Zimbabwe are under way to
evaluate the utility of HIVST to increase uptake of VMMC (22). HIVST may also lead
to increased frequency of testing, which is particularly relevant for individuals at high
ongoing risk for HIV and who are advised to test every three or every six months.
Several reports and models find that men who have sex with men would test more
frequently if self-testing were available (18,23) and that increased frequency would
have a public health benefit, particularly where testing coverage is low (24,25). In
addition, HIVST may ease the implementation and reduce the cost of interventions,
such as PrEP, where retesting is recommended every three months (26,27).
HIVST may also lead to cost savings and galvanize testing scale-up in settings with
low coverage and where there are health worker shortages. While the cost of an
HIV RDT for self-testing is higher compared to an HIV RDT for professional use, the
total cost of self-testing may be less than the total cost of standard facility-based
or community-based HIV testing. The potential cost savings of self-testing has also
been highlighted by a Zimbabwe-based cost-effectiveness model that states that
if HIVST were delivered for US$ 3 per test over a 20-year period, Zimbabwe would
save US$ 75 million and avert 7000 disability adjusted life-years (28). However,
since costs are highly variable across settings, further market research and cost-
effectiveness analysis is needed.
HIVST has also been shown to be safe in several studies. For example, in Malawi, a
two-year cluster randomized trial reported no suicides, self-harm or intimate partner
violence (IPV) and while a few reports of “coercion” were documented, nearly all
were among men and nearly all reported they would recommend self-testing to
others (29). Nevertheless, it is important to note violence can occur in the context of
any intervention, including existing HIV testing services, and that providing messages
to mitigate risk for potential misuse and harm and implementing monitoring and
reporting systems are key (9). To date, only one study, where 41% of participants
reported IPV 12 months prior to the intervention, has identified a case of IPV
following HIVST (30).
Box 1 highlights tools that could potentially enhance linkage to further testing,
prevention, treatment and care following HIVST.
• Package inserts can be included in HIVST kits that explain the importance of further testing,
and where and how to obtain prevention, treatment and care services.
• Telephone hotlines can be set up for people to call before or after self-testing to obtain
information, including psychosocial and technical support as well as referrals and linkage to
prevention, treatment and care and other non-medical services (i.e. legal support; redress for
violence).
• Mobile phone services, which can operate like hotlines, can also provide reminders, videos and
other messages and information to encourage linkage to prevention, treatment and care.
• Internet and computer-based programmes can support self-testers. Some approaches have
included online two-way audio or video counselling services and programmes that offer step-by-
step instructions on what to do following a reactive self-test result including descriptions of where
and how to obtain further testing, prevention, treatment and care.
HIV RDTs are serology assays that detect HIV-1/2 antibodies and/or HIV-1 p24
antigen. HIV RDTs generally provide results between 5 and 20 minutes and are
in the form of lateral flow strips or cassettes or flow through devices. When used
within a national validated testing algorithm, they can accurately provide same
day diagnosis. They are relatively easy to use, can be performed using capillary
whole blood or oral fluid specimens, contain built-in quality controls and can be
administered by trained non-laboratory personnel.
NAT is a molecular technology for detecting the presence of HIV in RNA and/or
DNA in plasma, venous and capillary whole blood or dried blood spot specimens.
Currently, there are few NAT technologies that can be used at the point of care
in resource-limited settings. Those that are available are primarily used for early
infant diagnosis.
Depending on which assays are used, HIV infection can be detected between 10
and 50 days following the initial infection (Figure 1). HIV RDTs currently in use
can be classified into three groups (second, third and fourth generation) based
on how quickly they can detect HIV following an exposure.
• NAT technologies detect HIV in RNA or DNA and have been shown to
detect HIV infection in the acute infection stage. Compared to other point-
of-care HIV tests, they have the shortest window period compared to other
testing technologies and can detect HIV beginning 10 days after an exposure.
• Fourth generation HIV RDTs can detect both HIV-1/2 antibodies and
p24 antigen. These RDTs can identify an infection beginning 14 days after an
exposure. While theoretically they may be able to detect acute HIV infection using
p24 antigen, field evaluations suggest that this does not occur in practice (32).
• Second generation HIV RDTs only detect HIV-1/2 antibodies and have
the longest window period compared to other generations as they can
typically detect HIV beginning 28 days after an exposure.
FIGURE 1
Detecting HIV-infection with various formats and generations of IVDs over the natural
history of infection
0 10 14 21 28 35 48
Eclipse period
Window period
Acute infection
4th generation
3th generation
2th generation
1st generation
Between 2012 and 2014, a total of 243 million HIV RDTs for professional use
were reportedly procured by the Global Fund, the Partnership for Supply Chain
Management Systems (SCMS), the United Nations Children’s Fund (UNICEF)
and WHO, averaging about 81 million HIV RDTs per year. In total, more than
242.2 million HIV RDTs using fingerstick/whole blood were procured, averaging
about 80.7 million annually. During the same period, nearly 750 000 HIV RDTs
using oral fluid were procured, averaging about 250 000 annually.
In 2014, the cost of HIV RDTs for professional use ranged from US$ 0.95 to
US$ 1.08 per test, using volume weighted average prices per smallest unit
per year across the Global Fund, SCMS, UNICEF and WHO (excluding any
distributor markups and assuming ex-works). However, ranges were wide: the
cost per HIV RDT for professional use procured by the Global Fund ranged from
about US$ 0.50 per test to about US$ 3.30 per fingerstick/whole blood test,
whereas the cost of HIV RDTs using oral fluid ranged from US$ 4.00 to US$
11.00. See Table 1 and Table 2 for summary of products listed by WHO or the
Global Fund.
TABLE 1
Summary table of WHO prequalified HIV RDTs for professional use (oral fluid)
a
NITAID/WHO Landscape on HIV RDTs for self-testing. First edition, November 2015: http://unitaid.org/
U
images/marketdynamics/publications/HIV_ST_Landscape_Nov_2015-_UNITAID_WHO.pdf
b
HO Prequalification of IVDs Programme list of prequalified products 16 June 2016: http://www.who.int/
W
diagnostics_laboratory/evaluations/160615_prequalified_product_list.pdf?ua=1
c
Global Fund: http://www.theglobalfund.org/documents/psm/PSM_ProductsHIV-WHO_List_en/
d
HO Prequalification of IVDs Programme list of active applications products 16 June 2016: http://www.who.
W
int/diagnostics_laboratory/160608_rapid_test_v1.pdf?ua=1
Anti-HIV 1/2
100% 10% CE marked
(Turk Lab, Turkey)
Hexagon HIV
(Human Gesellschaft für Biochemica und Diagnostica 100% 99.9% CE marked
mbHGermany)
Uni-Gold™ HIV
99.8% 99.9% WHO PQ
(Trinity Biotech Manufacturing Ltd, Ireland)
In 2014, PATH developed a target product profile for HIVST (34). The summary
below provides an overview of that profile, as well as some additional considerations
for the ideal HIV RDT for self-testing.
Test generation. At the moment, the self-testing products on, and emerging in,
the market are primarily second generation HIV RDTs. The use of second generation
HIV RDTs for self-testing has raised some concerns, as they reportedly have poorer
seroconversion sensitivity compared to third and fourth generation HIV RDTs. There
is one third generation HIV RDT for self-testing on the market currently, and another
that is emerging in the market.
Adapting tests that are highly sensitive, have high seroconversion sensitivity and
a shorter window period, including third and fourth generation RDTs and NAT
technologies that can be used at the point of care for self-testing, may be particularly
advantageous for populations that require frequent retesting and are at high risk
for HIV (e.g. high incidence). The development of third and fourth generation HIV
RDTs for self-testing is advancing, however, the development of self-operated NAT
technologies are not being developed at this stage.
In addition, possible concern about the use of second generation HIV RDTs for
self-testing should be weighed against several factors. First, NAT technologies and
fourth generation tests currently have limited availability in low- and middle-income
technologies. Where used, third and fourth generation tests may require volumes of
fingerstick/whole blood specimen, which is difficult for self-testers to collect, and
fourth generation tests may increase the risk of false-reactive results. Current NAT
technologies are optimized for specificity, not sensitivity, which may also make them
less appropriate for a “test for triage” approach with self-testing.
Reduced steps. Each step for HIV testing, from the specimen collection to
interpreting the final result, is critical for a correct result. The more steps, the greater
the risk is for user error that may then result in a greater risk of an incorrect test result.
Collecting and transferring specimen (either fingerstick/whole blood or oral fluid) has
been shown to be particularly prone to error for self-testers, resulting in test system
failures, invalid results and suboptimal performance (15). Thus, an HIV RDT for self-
testing with few steps, or ideally one single step, could substantially reduce the risk
of a number of user errors. Opportunities to develop integrated components, such as
specimen collection and transfer devices as well as integrated buffer systems may
be useful, including less painful lancets and other components that are automated to
regulate the volume of specimen collected and how the specimen is transferred.
Current RDTs that are being used for self-testing should not be read for at least 15
minutes after the sample is applied and should not be read more than 60 minutes
afterward. This requirement may be challenging for individuals who do not have
timers readily available and result in misinterpretation of results by users reading too
early or too late (15). Settings where mobile phones or other timers and clocks are
available may minimize this problem.
To address these challenges, the ideal RDT for self-testing should provide a result in
one to five minutes and have stable incubation times where results are stable. Result
windows should be clear and easy to read, particularly to prevent faint lines that can
be especially challenging to interpret. Current HIV RDTs being used for self-testing,
however, do not have these characteristics and would need to be developed.
Robustness and durability. The product design for HIV RDTs for self-
testing should consider transport, use and storage in uncontrolled settings that
require a degree of robustness and durability. Products that can withstand high
temperatures, user errors and other conditions that promote product instability may
be an advantage for self-testers and those that distribute the test kits, particularly
in resource-limited settings. Lastly, while robustness and durability are critical,
packaging is also a key consideration to maximize product acceptability. Potential
users may find bulky or heavy packaging unattractive, particularly those seeking
privacy and discretion. The inclusion of multiple tests in a single pack may be desired
in order to facilitate repeat testing or partner testing.
Cost. HIV RDTs for self-testing are intended for a single use where all components
are individually packaged. Therefore, costs are typically higher than professional use
HIV RDTs that can be sold in bulk. While the test kit costs may be higher in some
cases, for comparison purposes the cost of the testing event should be considered,
for example, health worker time, facility costs and community outreach costs.
Second generation HIV RDTs for self-testing may be slightly lower cost than
third and fourth generation RDTs, and all RDT costs will be much lower than NAT
technologies at the point of care (estimated to be as much as US$ 20 per test
for professional use). Although NAT could be potentially more accurate and able
to diagnose HIV in the acute stage, a high cost for a self-use tool can lead to low
uptake of, and access to, HIVST.
Current and emerging products require between five and seven steps and include
a reading time between 5 and 45 minutes. Significant product innovation would be
required to meet the target product profile description outlined above.
Tables 3A, 3B, 4A and 4B summarize the current pipeline. Detailed product
specifications can be found in Annex 1 and Annex 2.
TABLE 3A
Fingerstick/whole blood-based HIV RDTs for self-testing on the market
Approximate
Assay name (manufacturer) Generation Sensitivity Specificity Approval status price per test
(US$)
autotest VIH®
(AAZ Labs, France) CE marked; 25–28
2nd generation 100% 99.8%
submitted WHO PQ (to consumer)
TABLE 3B
Oral fluid-based HIV RDTs for self-testing on the market
Approximate
Assay name (manufacturer) Generation Sensitivity Specificity Approval status price per test
(US$)
Completed CE
OraQuick® In-Home HIV Test
2nd generation 100% 99.8% procedure, pending NA
(OraSure Technologies Inc., USA)
CE certificate
Approximate
Approval
Assay name (manufacturer) Generation Sensitivity Specificity price per test
status
(US$)
HemaDiagnostics Self-Test
(Hema Diagnostics NA NA NA No info NA
Systems LLC, USA)
To be named
(Chembio Diagnostics Systems 2nd generation NA NA No info NA
Inc., USA)
To be named
NA NA NA No info NA
(Alere, USA)
TABLE 4B
Pipeline oral fluid-based HIV RDTs for self-testing emerging in the market
Approximate
Approval
Assay name (manufacturer) Generation Sensitivity Specificity price per test
status
(US$)
To be named
NA NA NA No info NA
(Sedia Biosciences, USA)
HIV Self-Test
Price available
(OraSure Technologies, 2nd generation NA NA No info
upon request
Bangkok, Thailand)
Plans for future market introduction of RDTs for HIVST vary widely. The majority of
products, both oral fluid and whole blood, are intended for deployment in low- and
middle-income markets.
Currently, target markets in Africa routinely cited for both fingerstick/whole blood and
oral fluid-based HIVST include Kenya and South Africa. Interest in other African markets
is limited and inconsistent across manufacturers. Most manufacturers expect demand in
these African markets will come from the public sector (e.g. governments and international
donors) and that the private sector will comprise small volumes. Manufacturers’
interest outside of Africa is primarily in markets with concentrated epidemics and large
populations. Eastern Europe is of interest to manufacturers of both fingerstick/whole
blood and oral fluid products, particularly those already present in other European
countries or those pursuing CE-marking. The interest in this market may be particularly
important given evidence of increasing HIV incidence in Eastern Europe and the potential
for developed markets to drive innovation for low-income markets (35).
Pricing. HIV RDTs for self-testing that are currently available have a
recommended consumer price of between US$ 25 and US$ 48 in markets in
the United States and the European Union: (i) OraQuick® In-Home HIV Test
(OraSure Technologies, Bethlehem, PA, USA): US$ 40/test in the United States;
(ii) BioSURE HIV Self-Test (BioSURE Ltd, London, United Kingdom): US$ 42–48/
test in the United Kingdom; (iii) autotest VIH® (AAZ Labs, Rungis Cedex, France):
US$ 25–28/test in France; and INSTI HIV Self-Test® (bioLytical Laboratories,
British Columbia, Canada): US$36/test in European markets. In the United
Kingdom, BioSURE has also made a public sector version of its product, with a
different version of packaging, available at US$ 7.50–15 to the National Health
Service and nongovernmental organizations (NGOs). Price information for HIV
RDTs for self-testing outside these markets is limited and largely unreported. This
is because HIVST has not been widely implemented and is occurring informally
or in the context of research. HIV RDTs for self-testing used within the context of
research in low- and middle-income settings are priced at between US$ 3.15 and
US$ 16 per test. Pricing varies based on packaging requested, volumes procured,
country policies and regulation, importation taxes and fees, among other factors.
The cost of HIV RDTs for self-testing in informal markets also varies, particularly through
sale in private pharmacies and the Internet. Anecdotal reports from Kenya suggest
pricing as low as US$ 1 per test (36), while self-tests reportedly available in South Africa,
through pharmacies or online, retail for as much as US$ 10 (37). In Namibia, HIV self-
tests currently retail direct to consumers for US$ 4–12 (38). At the high end of this price
range, in both Namibia and South Africa, some products include multiple tests.
Efforts are currently under way to refine this estimate, particularly in sub-Saharan Africa
where the need and demand for HIVST is likely to be highest. A more refined model is
under development and will estimate the HIVST market size in nine African countries –
Kenya, Malawi, Mozambique, Nigeria, South Africa, Uganda, United Republic of Tanzania,
Zambia and Zimbabwe. The model will begin by examining the potential market for
all HIV testing, disaggregated by age, sex and key population group. Using data on
existing HIV testing and emerging research on HIVST uptake across various distribution
models and populations, the model will estimate the adoption of HIVST among both new
and existing users across both existing (community and facility) and new (pharmacy)
channels. Estimates will be further refined to take into account estimated testing
frequency, price and the presence of a range of factors in the enabling environment.
Estimates will be generated through 2020, and will be framed in the context of existing
HIV RDT procurement. These estimates will be formally released in 2016 and further
refinement of model assumptions will be undertaken when WHO normative guidance is
released.
Consumer demand. Efforts to estimate the size of the market for HIV RDTs
for self-testing draw heavily on the increasing body of evidence that suggests that
consumer demand for HIV self-test products can be high across a diversity of
channels.
• Nearly 1 million OraQuick® In-Home HIV Testse were sold in the United States,
primarily through over-the-counter pharmacy sales.
• Approximately 50 000 BioSURE HIV Self-Test kits were sold in the product’s
first year on the United Kingdom market between April 2015 and February
2016.f Most sales were through online retail outlets; no over-the-counter
product was available in the United Kingdom pharmacies and there was limited
distribution in the public sector. According to reports, as of February 2016,
among self-tests sold in the country, 75% were sold to men and 75% were sold
outside metropolitan areas. About 50% of users were first-time testers and 10%
ordered a test more than once (39).
• In France, AAZ Labs estimated that between 35 200 and 92 800 autotest
VIH® kits were sold between September 2015 and February 2016.g Sales of
the autotest VIH® are restricted to online retailers and pharmacies, supported
by government-led campaigns to promote HIV testing. One study of pharmacies
reporting sales of 900 kits found that 66% of purchasers were male and 42%
were first-time testers; 54% of users reported that they would not have tested if
a self-test was unavailable (40).
In developing markets where tests are not yet formally available, growing research
indicates high levels of consumer demand can be achieved through a variety of
channels. In Malawi, a study of community-based distribution of HIV self-test products
in Blantyre found a population-level uptake of 76.5% over a two-year period (29).
Uptake was highest among younger age groups, and 44% of participants were first-
time testers (29). Additionally, uptake among men was 68%, which is substantially
e
This is estimate is based on OraSure’s public reports from 2012 to present, divided by the estimated cost to distributers
(US$ 28). It also factors in publicly available procurement reports, as well as reports from contacts with past and ongoing
implementation projects.
f
Brigette Bard, BioSURE, personal communication, 29 June 2016.
g
Laure Poignant, AAZ Labs, personal communication, 27 June 2016.
Additional studies are under way to generate further evidence of consumer uptake
of HIVST, including linkage to further testing, and prevention, treatment and care
following HIVST. This includes the UNITAID/ Population Services International (PSI)
HIV Self-Testing AfRica (STAR) Project, which is evaluating several HIVST distribution
models in Malawi, Zambia and Zimbabwe, including community-based models, facility-
based distribution in public and private clinics, and distribution through peer educators
to reach key population groups (22). Studies in Australia (43), Brazil (44), China (45),
Netherlands (46), Thailand (47), the United Kingdom (39,49), the United States
(48) and Viet Nam (50) are examining HIVST distribution among key populations,
while several studies in Kenya, South Africa, Uganda and Zambia are evaluating other
community- and facility-based distribution models to reach the general population,
as well as young people and key populations (51). Several planned and forthcoming
studies are also examining how uptake of HIVST may vary for blood-based tests
versus those with oral fluid. These data will be critical to the formulation of supportive
policies and implementation guidance for HIVST.
The potential for consumer demand through the private sector in developing countries,
particularly sub-Saharan Africa is unknown although several manufacturers are
interested in entering this market. Assessments and anecdotal reports of the informal
sale of HIV RDTs in the private sector indicate that HIV RDTs for self-testing have
been available informally for more than a decade in sub-Saharan Africa. In Namibia
and South Africa, it was reported that HIV RDTs for self-testing have been available
for sale in private pharmacies as of 2001 and 2002, respectively (52). Likewise, in
Kenya and other sub-Saharan African countries, a high proportion of health workers
are already self-testing for HIV(53,54). Outside of Africa, HIV RDTs for self-testing
are also reportedly available informally in private pharmacies and through the Internet,
including in China (55), Malaysia (58), Peru (57), the Philippines (59) and the Russian
Federation (56). None of these products are known to be quality assured and sell at a
range of prices, as outlined earlier in this report.
Although most private sector markets are informal and unregulated in resource-limited
settings, they indicate the potential to capture significant latent demand for self-testing.
However, formal work to evaluate potential demand in this sector remains limited,
particularly in sub-Saharan Africa (55). A small study of pharmacy distribution of HIVST
in Kenya is under way, but further work is needed to understand private sector demand
and inform the development of market entry strategies (36).
• Global Fund currently supports one “assisted” HIVST project in Ukraine because
trained lay provider and community-based HIV testing is illegal. Since 2015, over
200 000 test kits have been procured for this project. Global Fund support for self-
testing is expected to increase after the March 2016 release of the Briefing note:
Operational research to improve implementation and uptake of HIV self-testing.
The note outlines key implementation considerations regarding HIVST to inform the
inclusion of HIVST pilot programmes in reprogramming or new applications.
This movement in the public sector market is critical to building a stable HIVST product
supply as discussions with manufacturers indicate that nearly all expect that bulk
procurement through the public sector will drive their revenue models.
Enabling environment
Approval pathways and eligibility for procurement. For many countries,
particularly low- and middle- income countries, evaluations and approvals by WHO,
the United States Agency for International Development (USAID), the United States
Centers for Disease Control and Prevention (CDC), the Global Fund and stringent
regulatory authoritiesh are utilized to guide local decisions in the absence of a national
mechanism or national regulation of in vitro diagnostics (IVDs). The procurement policies
of main international funders for HIV programmes (Global Fund, PEPFAR, UNITAID)
require IVDs to be manufactured according to the applicable International Organization
for Standardization (ISO) or equivalent standards and for the IVD to be reviewed and
approved or recommended by founding members of the GHTF and/or agencies listed
above. In addition, the Expert Review Panel for Diagnostics (ERPD), supported by
UNITAID and the Global Fund and hosted by WHO, provides expert recommendations
on the use of needed IVDs that have not yet obtained stringent approval or WHO
prequalification, leading to temporary eligibility for procurement by main donor institutions.
h
tringent regulatory authority refers to founding members of the GHTF, including the regulatory authorities from Australia,
S
Canada, the EU, Japan and the United States.
Given the potential for the emergence of diverse and complex regulatory requirements
across markets, efforts to harmonize diagnostic regulation within specific regions may
be needed. Entities such as the Pan African Harmonisation Working Party and Asian
Harmonization Working Party could play an important role in standardizing approaches
across countries in order to streamline country registration processes and decrease
market entry barriers for manufacturers.
Approval for HIV RDTs for self-testing. At the time of this publication, no HIV
RDTs for self-testing have been approved for procurement by WHO, USAID or the
CDC or recommended for temporary procurement by ERPD. WHO is currently
developing the criteria and approval pathway for HIVST. While the products in Tables
3A and 3B are available and can be procured, current pricing is prohibitive to the public
sector and other low- and middle-income buyers. The establishment of these approval
channels is intended to bring more certainty to the market and drive greater demand
and market entry – enabling costs and prices to decrease.
In high-income settings, there are examples of how HIV RDTs for self-testing were evaluated and then
licensed and registered for use. In the United States, the FDA pre-market approval of an HIV RDT for
self-testing required a three-phase clinical trial:
2a. observed evaluation of untrained users interpreting a panel of contrived test results in a
controlled setting;
2b. observed evaluation of untrained users, with high, unknown and low risk of HIV, performing the
RDT and interpreting the test results in a controlled setting;
3. established performance of the test system as a whole in the hands of untrained intended and
expected users in the actual intended use (in-home) setting as a measure of clinical utility (61).
In addition, a performance standard was established and a risk–benefit assessment was conducted to
determine the public health benefit (61).
In France and the United Kingdom, the conformity assessment conducted for the CE marking process
required the completion of both phase 2a and 2b studies in each country. For instance, the Medicines
and Healthcare Products Regulatory Agency (MHRA) guidance states no threshold for performance
and outlines that IVDs for self-testing will be evaluated in terms of usability and suitability for self-testing
population (e.g. validated IFU; labelling and packaging studies) (62).
In Australia, the Therapeutic Goods Administration (TGA) outlines guidance similar to that in France
and the United Kingdom, but specifies thresholds for sensitivity and specificity for professional use, and
states products for self-testing with a “user” sensitivity less than 90% would not be acceptable, whereas
user specificity between 90% and 95% “could be considered acceptable where evidence of significant
public health benefits can be demonstrated and where thorough risk mitigation strategies have been put
in place to minimise the risk of false negative and false positive results” (63).
All HIV RDTs with self-testing as the intended use submitted for WHO
prequalification will undergo a prequalification assessment, as per the process
described above. However, any WHO assessment that has already been
undertaken for HIV RDTs intended for professional use will be leveraged
according to a risk-based approach. The information required to support any
To facilitate the procurement of quality tests while no product has yet been
found to meet WHO prequalification requirements, the Global Fund and UNITAID
launched an ERPD for HIV RDTs for self-testing. ERPD for HIV RDTs for self-
testing will not replace WHO prequalification, but instead act as an interim
solution, while a stringent review is under way. An invitation to manufacturers
to submit an expression of interest for consideration by ERPD was issued
in February 2016 and closed in April 2016. The results of this process are
expected in July 2016. It is likely that there will be additional ERPD’s which
include HIV RDTs for self-testing in 2016/2017. Under this ERPD review, HIV
RDTs for self-testing may be procured with the Global Fund and UNITAID’s
funds for a 12-month period. Box 2 summarizes examples of regulatory approval
pathways for HIVST.
National policy. Within national HIV testing policies, several countries permit
HIVST and outline standards for approval of RDTs, how they fit within the
national HIV strategy, how RDTs for self-testing should be distributed and who
can distribute or sell them. Only three countries (France, United Kingdom and
the United States) have a policy allowing self-testing and at least one product
approved for use. Some countries have a policy allowing HIVST, but do not
yet have a product with regulatory approval for use. Additionally, several other
countries report having a policy in development and/or informal sale and use of
RDTs for self-testing (Figure 2).
Key changes since the first landscape include data reported in the Global AIDS
Response Programme Reporting (WHO, UNAIDS, UNICEF) as of 23 June 2016
and the WHO review of more than 100 national policies and regulatory frameworks
(64). In particular, the pharmaceutical council in South Africa lifted the ban on the
sale of HIV self-test kits in private sector pharmacies; however, the Department
of Health is working to develop an official policy and the standards and criteria for
HIVST. In Brazil, an HIVST national policy was released in December 2015 and it
is planned for HIV self-test kits to be in private pharmacies by the end of 2016. To
continually track the evolving policy environment for HIVST, please reference
HIVST.org for the most up-to-date information.
Australia, Malawi, Rwanda, Spain and the United Republic of Tanzania report that while there is a policy in place,
1
Although more evidence is needed to fully understand the potential public health and
market impact of HIVST, this landscape provides a review of the existing and forthcoming
technologies, as well as a strategic summary of the supply and demand for HIVST. The
available data may inform strategic planning among diverse global health stakeholders
exploring the potential role of HIVST.
Key considerations
for countries, national
programmes and regional
bodies
• To facilitate the market for low-cost and quality-assured products for HIVST, it
is important for international and national policy to be implemented. Creation of
these policies and guides, which outline necessary approval channels, processes
and location of HIVST within the national algorithm and testing strategy, will build
confidence in demand estimates, providing greater certainty to manufacturers and
catalysing market entry in settings where barriers are few and market incentives
are many. There are several country examples of existing policies and regulations,
however, WHO guidance is essential, particularly for many low- and middle-income
countries.
• While adapting existing professional use HIV RDTs for self-testing has many
benefits, it is important that countries, programmes and regional bodies work to
adapt and validate IFU, translations and other support materials to ensure they are
appropriate for their setting and context. Country governments should engage with
manufacturers to streamline processes for adaptation of IFU.
• HIV RDTs for self-testing may have a higher unit cost compared to HIV RDTs for
professional use. However, donors should consider the full cost of a testing event
and the potential cost savings and increased cost-effectiveness of self-testing.
Nevertheless given increased testing need and reduced donor budgets, it will be
critical to coordinate across donor agencies and take on collaborative efforts to
ensure the affordability of HIV RDTs for self-testing as the market evolves.
• There is significant potential for cross-over between markets for RDTs for
professional use and RDTs for self-test use. Investments in RDTs for self-testing
may catalyse optimization of existing, and development of new, HIV tests for
use by professionals, addressing the challenges facing professionals who work
in settings where conditions are poor, training and supervision are infrequent,
and resources and health worker time are limited. There may be greater market
incentives for manufacturers who can develop products that can unify the
market for decentralized HIV testing services, for example, in community-based
settings and low-level facilities and clinic settings, with the market for HIVST.
Please note that sensitivity and specificity denotes the performance in the hands
of self-testers, and not the performance in the hands of professional users.
The information was provided by manufacturers and reflects what is stated in
manufacturer IFU and what is reported by recognized regulatory authorities (e.g.
FDA; CE; TGA) or other international approval systems (e.g. WHO prequalification;
Global Fund; USAID). Sensitivity and specificity reported in the literature, but not
recognized by a regulatory authority, is not reflected.
AUTOTEST VIH®
Product specification
Approval status for professional use product CE, FDA, WHO prequalification
Company AAZ-LMB
Synthetic: gp36,gp41,gp120
Antigen type
Control line: Protein A
Wash hands and ensure they are clean and dry before testing
Do not open pouch until ready to perform test
Restrictions for use
Not intended for individuals with HIV-1 or HIV-2 who are on
ART
CE marked
Approvals for HIVST product
WHO prequalification dossier submitted in 2016
i
Steps are defined here as those beginning with the setup of the test kit and steps focused on specimen collection, specimen transfer, addition of buffer and ending
with interpretation of result.
Product specification
Synthetic : gp36,gp41,gp120
Antigen type
Control line: Protein A
Wash hands and ensure they are clean and dry before testing
Do not open pouch until ready to perform test
Restrictions for use
Not intended for individuals with HIV-1 or HIV-2 who are on
ART
Test kit has not been evaluated formally among people using
Additional details
ARV drugs for prevention (e.g. PrEP or PEP)
Product specification
FDA: 91.7%
HIVST sensitivity
CE: 100%j
FDA: 99.98%
HIVST specificity
CE: 99.8%k
FDA: 1.1%
HIVST invalid rate
CE: 1.8%
FDA
Approval status for in-home HIV test product Formal CE mark pending as product has not yet been
launched in the EU
Product specification
CE/FDA/HealthCanada/WHO prequalification
Approval status for professional use product CLIA Complexity: waived for fingerstick whole blood and
moderate for venous whole blood and plasma
j
Note this is preliminary information, as the product has not yet been officially launched in Europe.
k
Note this is preliminary information, as the product has not yet been officially launched in Europe.
Store at 15 – 30°C.
Storage requirements
The kit can be refrigerated (2-8oC) if required.
Test kit has not been evaluated formally among people using
ARV drugs for prevention (e.g. PrEP or PEP).
Additional details
Extra pipette and lancet provided in the kit, but not required
for use.
Please note all information and product characteristics described are subject to
change.
Please note that sensitivity and specificity is the performance in the hands of self-
testers, and not the performance in the hands of professional users. The information
was provided by manufacturers and reflects what is stated in manufacturer IFU and
what is reported by recognized regulatory authorities (e.g. FDA; CE; TGA) or other
international approval systems (e.g. WHO prequalification; Global Fund; USAID).
Sensitivity and specificity reported in the literature, but not recognized by a regulatory
authority, is not reflected.
Product specification
Approval status for professional use product CE; submitted dossier for WHO prequalification
1
Founding members of the GHTF include Australia, Canada, the European Union, Japan and the United States. Approval by these bodies is considered stringent
regulatory approval.
Antigen type Recombinant and synthetic peptides for HIV-1 and HIV-2
HIVST sensitivity NA
HIVST specificity NA
Wash your hands and ensure they are clean and dry before
starting the test
Restrictions of use Not suitable for blood donors or people with blood clotting or
bleeding disorders (e.g. haemophilia)
Not intended for people with HIV-1/2 using ART
Product specification
Commercial name (trademark) Aware™ HIV-1/2 OMT Oral HIV Self Test
Commercial professional use name (trademark) Aware™ HIV-1/2 OMT, Oral HIV Rapid Test
Approval status for professional use product USAID waiver list; WHO prequalification application under review
HIVST Sensitivity NA
HIVST Specificity NA
Control specimens (e.g. test kit controls) are available but sold
separately
Controls All control specimens are derived from inactivated human plasma.
None of the controls were designed to produce an invalid test result.
Test kit has not been evaluated formally among people using ARV
Additional details drugs for prevention (e.g. PrEP or PEP)
Product specification
HIVST sensitivity NA
HIVST specificity NA
Storage requirements Store at 2–27 °C– do not open foil packet until ready to use test
Do not eat, drink or chew gum for at least 15 minutes before testing
or use mouth cleaning products 30 minutes before taking the test
Restrictions for use Do not open pouch until ready to perform test
Not intended for individuals with HIV-1 or HIV-2 who are on ART
Operate at 15–37 °C
Test has a control to indicate that human specimen has been added
(i.e. band appears when human specimen is added)
Controls Control specimens (e.g. test kit controls) are available but sold
separately
Pricing (US$/per test) Pricing available from OraSure Technologies upon request
Test kit has not been evaluated formally among people using ARV
Additional details drugs for prevention (e.g. PrEP or PEP)
Product specification
n
Amount in mL not specified.
Wash hands and ensure they are clean and dry before testing
Test must be run immediately after the capillary blood has
been collected
Restrictions for use
Not intended for individuals with HIV-1 or HIV-2 who are on
ART
Test should be run in setting with 15–30 °C
HIVST pricing (US$/per test) Price to distributors and consumers not yet available
Product specification
CE/FDA/WHO prequalification
Approvals for professional use product CLIA Complexity: waived for fingerstick and venous whole
blood/moderate for serum and plasma
Synthetic: gp36,gp41,gp120
Antigen type
Control line: Protein A
HIVST Sensitivity NA
HIVST Specificity NA
Wash hands and ensure they are clean and dry before testing
Do not open pouch until ready to perform test
Restrictions for use
Not intended for individuals with HIV-1 or HIV-2 who are on
ART
None
Two private label version of the product are CE marked for
Approvals for HIVST product
self-testing in the European Union (BioSURE HIV Self-Test
and autotest VIH®)
Test kit has not been evaluated formally among people using
Additional details
ARV drugs for prevention (e.g. PrEP or PEP)
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