COVID-19 home testing – learning lessons from HIV self-testing

As the call grows for wider testing of NHS staff and those showing symptoms, what can we learn from earlier experiences with HIV testing?

Self-testing is central to the UK government’s current strategy for addressing Covid-19.   The UK Chief Medical Officer Chris Whitty has stated that an effective self-testing programme could be transformative and Prof Sharon Peacock (the director of national infection at Public Health England) described the tests as “a game changer”.

But what is the reality of using self-testing? Both Whitty and Peacock have warned that we need to be cautious about seeing self-testing as the cure to the Covid-19 crisis. The use of self-testing to tackle Covid-19 remains novel, however we can draw on what is known about self-testing more broadly to inform its roll out. HIV self-testing (HIVST) has expanded recently and can tell us about adopting self-testing as a public health solution. An important consideration is user experience. Evidence from HIVST programmes indicates that a self-testing strategy for Covid-19 must address three key problems – access, knowledge, and care pathways.

Access

Accessibility in health care covers the availability of tests and the willingness of the public to use tests. Here, there are several barriers to self-testing for governments to manage.  The cost of self-testing must be minimal – the UK government has already stated that it will regulate against ‘profiteering’ from Covid-19 and the cost of care (for the government and individuals) is a concern.  While some research suggests that HIVST presents the possibility to overcome disparities in access to and the uptake of HIV testing, the cost of self-testing can be a significant barrier and augment existing inequalities. How the public costs of a self-testing programme for Covid-19 can be met needs consideration.

HIVST evidence also suggests that the type of test is an important factor. Finger-prick antibody tests, for example, present barriers for people with blood and needle phobias; they are certainly not the same as a urine sample for a pregnancy test, as was suggested by Prime Minister Boris Johnson recently.  Given that self-testing for Covid-19 comes alongside a rising global and national death toll, the key access issue may not be a lack of willingness to test, but instead potentially over-testing and inability to meet demand.

Knowledge

User knowledge is a concern as even a straightforward test requires a degree of understanding. The ability of all users to understand how to use tests correctly and how to interpret results cannot be guaranteed. Even if self-tests are widely used for Covid-19, members of the public may still have difficulties reading results, impacting accuracy and undermining the benefits of the self-testing approach. A concern in HIVST is how comfortable the public are with using tests independently. Access to easily understandable test information and supplementary educational materials might help address these issues.

Care pathways

While an effective self-testing programme may lead to more diagnoses, it is not clear from evidence in other self-testing programmes that the diagnoses will result in seeking treatment. Research in HIVST suggests that the movement of users from ‘test to treatment’ needs to be facilitated by professionals with care pathways clearly signposted. However, the necessity of clear pathways to care is different for Covid-19. In the context of HIV, clear pathways are needed to encourage people to get treatment. For Covid-19, the issue is ensuring that treatment is sought at the appropriate time. Most people who contract Covid-19 will not need clinical care or treatment, although they will need to self-isolate and monitor their symptoms. Given anxieties around the Covid-19 pandemic there is the possibility that if people using self-testing kits are not adequately informed of care pathways, they may seek clinical care unnecessarily, overwhelming a health system already under strain. If the proposed Covid-19 self-testing programme is to be successful then establishing care pathways, and the role of educating people on what to do after self-testing requires consideration.

Conclusions

Self-testing has the potential to be an important tool to assist in resolving the Covid-19 crisis. However, the strategy is still in its early stages and questions remain over its success. As HIVST indicates, it is essential to consider the users of self-tests. As the Covid-19 crisis progresses, how accessible the tests are, whether users understand and feel comfortable using them, and the resultant care pathways are critical considerations.

Dr. Deirdre Duffy is a Senior Lecturer in the Department of Social Work and Social Care, Manchester Metropolitan University. She specialises in Sexual and Reproductive Health, gendered health activism, and evaluation research.

Dr. Natalie Hammond is a Sociologist and Senior Lecturer in the Department of Social Care and Social Work at Manchester Metropolitan University. Her research interests focus around sexual and reproductive health, technologies, gender and sex work.  

Dr. Monique Huysamen is a research associate in Sexual and Reproductive Health in the Department of Social Care and Social Work at Manchester Metropolitan University.  She is a critical qualitative researcher with interdisciplinary research interests that span psychology, social work, criminology, gender studies, and human geography.  Much of her research has focused on sex work in various global contexts.