Opportunities and challenges for HIV self-testing in China

Comment

Each hour of 2017, about 220 HIV self-test kits (110 packages) were sold by a single online pharmaceutical store in China. In addition, eight community-based-organizations (CBO) in seven Chinese provinces are working with local centers for disease control prevention (CDC) in developing self-testing scale up pilot programs among men who have sex with men (MSM) (Figure 1).¹ For example, in Zhuhai – a small city with more than 12,000 MSM, 782 self-testing kits were distributed by a local CBO in the first three months of 2018 (93.3% of the testing results were reported back). In addition, there was a high HIV self-testing (HIVST) demand and HIVST uptake rate among Chinese MSM. For example, around 29% of Chinese MSM already initiated HIVST², and about half (49%, 593/1219) of MSM in a trial performed HIVST between August 2016 and July 2017.³

Figure 1,

A HIV self-testing poster developed from a designation contest in China, 2016.

The rapid expanding of HIVST among MSM has captured the attention of the Chinese government. The State Council of China issued the “Thirteenth Five-Year Plan (2017–2022)” for HIV prevention and control in 2017 and indicated that China will “explore strategies to promote HIV self-testing through selling HIVST kits in pharmacies and online.” Meanwhile, the Center for AIDS control of China CDC is planning to pilot HIVST programs in 20 Chinese cities, and the Chinese STD and AIDS Association is collaborating with six CBOs to develop different HIVST strategies. However, the Chinese government is also met with a few challenges in HIVST expansion among MSM, a population with high HIV prevalence and low testing rate in China.⁴

First, China still lacks authority approval on HIV self-test kits. Presently, the Chinese State Food and Drug Administration (CSFDA) has not approved any testing kits for self-testing, leading to lack of quality assurance. There is uncertainty about the accuracy of self-testing kits, especially those sold online in China. Take the kits sold on Taobao (A Chinese online shopping website) for example, the majority of kits sold online were blood-based rapid testing kits for clinical use instead of self-testing, without monitoring from the CSFDA.² Recently, the National Center for AIDs Control of China CDC conducted an online survey among 54,785 people who purchased of HIVST kits online. Overall, 150 (0·27%) people who self-tested as HIV positive attended the survey and send their blood samples to a lab for confirmation testing. Of those, 97 people were confirmed to be positive, with an accuracy rate of 64·7% (97/150).⁵ While evidence shows self-testers can accurately do HIV rapid diagnostic tests ⁶, it is recommended that Chinese government should approve some quality assured rapid testing kits for HIVST and prioritizes quality assurance policies for the use of these kits.

Second, China still lacks a national guideline to promote HIV self-testing. Although China CDC and China STD and AIDS Association started to focus on improving HIVST, and have piloted HIVST in multiple cities, a national plan and guideline remains absent regarding the development of policies and strategies for HIVST promotion, HIVST kits delivery, and linkage to care service. This leaves local authorities and CBOs unguided in spreading HIVST, which may further halt the enthusiasms of stakeholders in initiating HIVST programs in other parts of China.

Third, the sustainability of the current HIVST programs remains a concern. The current HIVST pilot programs are usually initiated by local CBOs, with funding support from local CDCs. The sustainability of these programs is jeopardized by the low capacity of the local CBOs, the limited funding, and the absence of a national HIVST guide. Developing a plan to maintain the sustainability of HIVST programs should be listed as one of the top AIDS control priorities of China, and empowerment of local CBOs by improving their capacity would be essential.

In addition to the challenges mentioned above, China also faces several common challenges met by other countries, which include but not limited to missing linkage (even China already piloted online-to-offline linkage-to-care models), safety, coerced testing, and legality. ^1,7,8

HIV/AIDS control in China already faces many challenges, and now HIVST related challenges are added to the list. However, HIVST offers an outstanding opportunity to further expanding the HIV testing coverage, identifying people living with HIV but unaware of the infection, and linking more cases to care. The provision of approved quality-reliable testing kits, national HIVST guide, and increasing support to local CBOs would be critical for achieving the first goal of the “90-90-90”. These measures should be in place soon to maximize the benefits of HIVST.