The places we live have become home to other parts of our life from before COVID-19. Over the past year, they have become places of work as well as wellness. Telehealth and in-home services have taken off as a result of COVID-19 restrictions within public accommodations, including HIV and sexually transmitted infection (STI) clinics. The pandemic has stymied HIV and STI testing efforts, with some clinics shutting down altogether.
But some community organizations have invested in HIV and STI home-test kits to bolster their prevention efforts at this time. As of July 2019, 77 countries worldwide had adopted HIV self-testing policies, and many others are developing them.
European countries, in particular, have launched many different model home-test programs that capture regional realities during the COVID-19 pandemic. A 2016 report from the European Centre for Disease Prevention and Control found that 11 European Union member states had already introduced HIV home-testing plans since 2010. The desire to expand HIV and STI prevention to the home had picked up prior to the pandemic, but the pandemic’s challenges for prevention at large may be the final kick inspiring countries to make this commonplace across the continent.
Prepared for the Worst Before the Worst Is in Sight
I first met Momchil Baev, Ph.D., M.P.H., the sexual health and HIV program manager at Single Step Foundation, as the organization was piloting an HIV home-testing program in Bulgaria. Eventually called #endHIVbg, the program became the first national-level home test platform in Eastern Europe.
“With our self-testing initiative, we filled a gap in the prevention efforts,” Baev noted when discussing the overall aim of the pilot program, which launched in September 2018. “Most importantly, we provided for the MSM [men who have sex with men] group something they long awaited—the comfort to test at home without having to see a doctor, a nurse, or to visit a clinic,” Baev continued.
The decision for Baev and team to put HIV tests directly into the hands of community members came from the skyrocketing rates of HIV among cisgender men who did not identify as gay, bisexual, or queer. “Since 2013, on average, 80% of the newly diagnosed were [cisgender] men,” Baev told me in our recent email exchange, noting that only half of those now living with HIV reported having sex with other cisgender men.
Hypothesizing that stigma was keeping cisgender men as well as transgender people from accessing testing in clinical settings, the program decided to promote home test kits using social media and the dating app, Grindr. After screening over 1,500 people, the team sent out 900 free home test kits in all 28 districts of the country. In less than two months, they were left without any remaining tests.
Of all participants in the survey taken before deciding whether or not to order a test kit, 58% had either never tested for HIV or had most recently tested for HIV more than a year before. Home tests increased the overall national rate of HIV testing dramatically while also removing barriers that living in rural areas often imposes—68% of those who did not know their HIV status before taking the test were located farthest from city centers in small towns.
Besides being an accessible option for those outside of Sofia and other Bulgarian city centers, home testing was widely accepted in this program; over 70% of survey respondents preferred a home test over health centers or even mobile labs.
The program started up again last August when the Ministry of Health’s free and confidential testing all but vanished as the pandemic beleaguered the country. “It became impossible to test for HIV anonymously and free of charge anywhere in the country,” Baev explained. He expects the program to continue running throughout the second year of the COVID-19 pandemic, at least until the end of 2021.
The World Health Organization recently lauded Single Step’s ongoing HIV home-testing program as a model, urging other European countries to start or scale up programs of their own.
Scaling Up Home Testing as On-Site Services Vanish
Community-led organizations in other areas of Europe have taken on piloting HIV and STI home testing programs amid the COVID-19 pandemic. Adam Shanley, MPOWER Programme manager at HIV Ireland, had already planned to launch an HIV home-test program prior to the pandemic. With almost 2,000 miles between Dublin and Sofia, Baev and Shanley shared similar reasons for supporting home testing. Shanley initially came to HIV work after having a negative experience with a hospital health care provider. After talking openly about his sex life, the physician reacted in a way that “left [Shanley] feeling judged and shame for the sex [he] enjoys.”
Shanley started the MPOWER Programme at HIV Ireland for community members to lead more affirming efforts for their health and wellbeing. Home testing was one way to begin to alleviate the stigma, judgement, and fear so many gay, bi, queer, and trans (GBTQ) people had experienced in traditional clinic settings.
As the realities of COVID-19 became clearer in Ireland, Gay Men’s Health Service, Ireland’s only health center for GBTQ people, closed its doors in March 2020. It remains closed over one year later, leaving nearly 12,000 people who use sexual health services without traditional on-site care. According to reports from VICE World News, chronic understaffing, underfunding, and an abstinence-only attitude from governmental leadership has left community members with the choice of paying high prices out-of-pocket for sexual health screenings or going without.
As a result, HIV Ireland pushed forward and made their HIV home-test kits available at the very end of 2020 to fill the gap on-site testing left behind. Expecting to pilot the service for the following 12 months, the kits barely lasted a week. Seventy-five percent of available kits were ordered in the first 24 hours of the program’s launch. Those remaining flew out the doors by the end of the first week.
This interest in testing at home was not unique to Ireland. According to AIDES board member Cédric Daniel, their organization saw a 57% decline in mobile clinic or on-site testing over 2020 throughout France. “We couldn’t go into the streets like we are used to,” Daniel offered. At the same time, AIDES saw a 71% increase in home-test kit orders. “[Home testing] allowed us to [reach] people we aren’t used to seeing in our regular testing,” Daniel noted. One in ten of those who ordered a home test kit had never tested before for HIV. Daniel expects AIDES to continue pushing for home testing throughout and after the pandemic: “This is a new tool to take care of your health and that of your partners, family, and friends.”
In Switzerland, Checkpoint Zürich became one of the few STI testing providers in the country as the pandemic shuttered other testing sites or diverted their resources to COVID-19, according to Ben Hampel, M.D., Checkpoint’s head physician and medical codirector, in an interview.
Notably, Checkpoint’s home testing program, Checkpoint@Home, offers testing to monitor kidney function and other values for active pre-exposure prophylaxis (PrEP) clients in addition to a range of STI home tests. Hampel and other researchers found that 95% of a sample of Checkpoint@Home’s PrEP users would want to have these routine screenings done at home in the future.
While programs in Bulgaria, Ireland, France, and Switzerland have provided some level of screening, they do so within a challenging set of circumstances. One impact across these programs remains—that sexual health workers were the front line for COVID-19 testing and overall response, taking away critical personnel from STI prevention efforts. A reduction in the supply of collection swabs also proved a difficult workaround for STI testing in particular. While these home-test kit programs saw and met the high demand in the gap left by clinic closures, COVID-19 all but stopped mass HIV and STI prevention efforts across the continent.
Can One Pandemic End Another?
However, 56 Dean Street, a London-based sexual health clinic, proposed lockdown restrictions as a chance for a larger-scale intervention. The organization launched “Test Now, Stop HIV” with the goal of “breaking the HIV chain of transmission” as the U.K. government imposed strict lockdown orders. In June 2020, both houses of Parliament prohibited people from being indoors with those who don’t live in the same household. This amendment to COVID-19 public health legislation implied that people living apart could not have sex, prompting a cheeky call for more scenic hook-up opportunities. Following more recent lockdowns in 2021, updated reporting from the BBC now states that you can have sex with people in your social bubble, not just those in your household.
“I would love to say there was a big master plan,” laughed Alan McOwan, M.B.B.S., 56 Dean Street’s lead clinician, in a recent phone interview. Prior to lockdown restrictions, McOwan noticed two critical indicators that proved lockdown might be the best opportunity to identify new HIV infections. “We saw a plummet in people seeking PEP [post-exposure prophylaxis] services—down by 80%—and treatment for gonorrhea and chlamydia,” McOwan pointed out, noting these as indicators of having sex that could also potentially transmit HIV.
McOwan recorded a YouTube video encouraging people to test now, while they aren’t having as much sex as usual. He describes “breaking the chain” of HIV transmission—by identifying people early in seroconversion and starting them on treatment—as a way to end the HIV epidemic altogether. The story was picked up internationally, and European community organizations in Spain, France, and Belgium reached out to adapt “Test Now, Stop HIV” locally.
However, a recent article in the journal Culture, Health & Sexuality examined how the clinic messaged quarantine and opportunities to test at home through “Test Now, Stop HIV.” “At best, the campaign’s silence risked ignoring lived experiences during lockdown, including sustained sexual practices and the continued need for effective treatment and prevention,” the authors noted. “At worst, the campaign exacerbated government inaction, constructing ‘testing’ as a mode of community building without providing policy or institutional oversight for supporting populations at risk for both HIV and COVID-19.”
This “idealisation of quarantine,” as researchers described it, “reinforced hygienist fantasies of abstinence and quarantine” while excluding “the politics of care for the newly diagnosed and other people who may continue to live with HIV'' after the campaign’s proposed break in the HIV transmission chain. It’s an endemic pattern that many HIV activists are familiar with—crisis efforts focus on protecting HIV-negative people instead of supporting and bolstering services for people living with HIV. At a time when it was still unknown whether people living with HIV—including those with undetectable viral loads—were at heightened risk for complications or death related to COVID-19, it could be a difficult pill to swallow.
“Testing at home is not for everyone, just like testing during lockdown isn’t everyone,” McOwan clarified.
Will Nutland, D.P.H., co-founder of PrEPster, spelled out some of those concerns in a recent email interview.
“For the chain of transmission to be broken, there would have had to have been a massive uptick in testing during lockdown,” he offered, clarifying that people who never or infrequently test would have to be reached as much as regular testers. Both McOwan and Nutland described some of the reasons why someone may not have tested during lockdown, including if they were:
- Already struggling with isolation and exacerbated mental health issues.
- Concerned about getting to a clinic for treatment and support.
- Not able to have support from loved ones.
- In a new housing situation and not wanting to receive a kit at their current address.
The Culture, Health & Sexuality article also critiqued the abstinent tone of the campaign, which McOwan countered. At the same time they were running “Test Now, Stop HIV,” the clinic launched another campaign called, “We’re Still Here for You, London,” which promoted the clinic’s PrEP, PEP, and emergency contraceptive services during the initial stages of lockdown.
Checkpoint Zürich’s cohort studies showed that most people had reduced their number of sex partners at the start of the pandemic, but “hardly anyone was abstinent during the pandemic,” Hampel offered. Hampel’s team saw that by summer and fall 2020, the sex lives of most people in their studies looked like their sex lives before COVID-19. Additionally, Nutland’s research found that some key communities in the U.K. were not seeing STI and HIV risk lessen during lockdown, especially sex workers, people living alone, and people using drugs.
PrEPster has compiled an extensive list of emerging COVID-19 guidance to take care of sexual health at home, including resources for safer hooking up and how to access HIV treatment and PrEP while under lockdown restrictions.
As restrictions ease up further in the U.K., McOwan says the focus of 56 Dean Street has moved to promoting PrEP 2-1-1, or intermittent PrEP, as people ease back into their sex lives. “We want [clients] to get their appointments now, so that when their opportunity comes to have sex again, they are ready,” McOwan said.
From messaging to lab capacity, to providing wraparound support whether people are having sex in lockdown or not, these are among the critical considerations organizations must ponder when deciding what—if any—home testing strategies to offer in the future.
“Home testing is on a continuum of services,” Nutland reminds me, when asked about the future of on-site services. “[Home testing is] not ‘instead of’ or a ‘replacement’ for clinically based services. Many of us will jump in between depending on our service needs—and if we have symptoms.”
Even outside of a pandemic, testing for STIs at home can be the safest option for people with high security needs—such as undocumented people, survivors of violence, and young people—as well as immunocompromised people like elders and disabled and chronically ill people, including some people living with HIV.
The COVID-19 pandemic continues to divert resources, personnel, and funding away from in-clinic and home-testing programs alike throughout Europe. As the pandemic waxes and wanes, HIV community organizations and providers will be left with plenty of lessons learned and ideas for improvements to expand testing options in the future.
Author disclosures: While employed at Grindr, I was part of a team that provided funding to Single Step Foundation for their 2018 HIV home testing pilot and was an author of the resulting report from the pilot program mentioned in this piece. I have also been a paid contractor for The Love Tank, Inc., which is the parent company of PrEPster.