Even with increased HIV services and sensitisation programmes globally, stigma and discrimination suffered by people living with HIV/AIDS remains a huge barrier to testing. Geneva-based global health agency, Unitaid is finding new ways to address this gap, including through innovative mass media campaigns.
MTV Shuga, the popular soap opera that has helped lift the lid on sexual health issues among young people in Africa, returned to the screens in February with new storylines tackling the daily realities of HIV, whilst also encouraging self-testing.
In the latest season of the Francophone franchise “Shuga Babi” - Eslie, one of the protagonists, takes a home test for HIV and records the experience live on her vlog.
“Several months ago, I slept with someone not using protection and I immediately got tested,” she tells her online viewers. “It came back negative. After three months I wanted to get tested again.”
Matéo, the man she slept with, watches the video on his phone as Eslie proceeds to take the OraSure test. Twenty minutes later, she holds up the test, which is negative. She sighs, he smiles.
Supported and funded by Unitaid, a hosted partnership of the World health Organization, and produced by the MTV Staying Alive Foundation, the show’s latest storylines are part of a wider campaign efforts to encourage more self-testing for HIV in Africa.
Why it’s important
Despite increased HIV services and sensitisation programmes on the continent, evidence points towards a lack of testing due to the stigma and discrimination suffered by people living with HIV/AIDS. Only an estimated 70 per cent of people living with HIV know their status, according to Unitaid, who since 2006 has been working with over 40 partner organisations to address this gap.
“Many who may be positive live far from clinics and are additionally hesitant to check their status because of the stigma attached to HIV,” said Heather Ingold, programme manager at Unitaid.
Together with French NGO Solthis, Unitaid is providing around 500,000 kits across three countries in West Africa: the Ivory Coast, Mali and Senegal, with over 130,000 distributed so far.
Over 2.3 million kits have been distributed through the HIV self-testing Africa Initiative (Star), led by a consortium led by Population Services International (PSI) and funded by Unitaid, in countries across Eastern and Southern Africa.
By raising awareness and preventing the spread of disease that once stole 2.4 million lives annually, Unitaid and their partners believe self testing is a starting point for reaching undiagnosed people living with HIV.
Taking matters into one’s own hands: From STAR to ATLAS
HIV self-testing was first proposed in the 1980s, however, it remained largely unexplored and unavailable to low-to middle income countries until 2015 when the Star initiative launched a five-year project to expand their reach into new markets.
At the time, no WHO pre-qualified test kits were available for procurement, and only two countries had self-testing national policies in place. Now, 88 countries have adopted policies with a further 31 countries developing kits.
Updating the HIV testing guidelines in 2016 to include self-testing led to the first WHO prequalified test in 2017. The screening kits, which give users more privacy than going to a clinic and require only an oral sample, have led to an increase in both the number of people getting tested and the frequency of testing.
Star, together with other Unitaid-funded projects including the ATLAS collaboration with Solthis, have been at the forefront of promoting self-test kits on the African continent.
The first HIV Self-test (HIVST) product available was OraQuick and needed some getting used to, says Ingold, lead for the self testing programmes at Unitaid.
“People had to remember not to eat for 15 minutes and originally there was some misunderstanding around this, so for example if you do not have a clock, in some countries you would put on a radio show instead because you know the duration of the show,” she told Geneva Solutions.
The first phase, which ran for two years spanned across Malawi, Zambia and Zimbabwe, and more than 750,000 self tests were distributed. By November 2018, 2.3 million kits were distributed in Eastern and Southern Africa, raising HIV testing by up to 28 per cent amongst people who had never previously been tested.
With such promising results in 2017 the scale up began, adding Lesotho, Eswatini and South Africa to the pack.
Like the STAR initiative, the ATLAS project seeks to distribute test kits but this time in the West African countries, Côte d’Ivoire, Senegal and Mali. In this region, the 70 per cent figure dwindles to just 42 per cent of people living with HIV who know their status.
Hoping to bridge this gap, the ATLAS project serves communities that are more prone to being infected by HIV but are stigmatised and discriminated against. The project is implemented by Solthis and their network of 27 community-led and institutional partners, who have access to key populations at risk of contracting the virus, including men who have sex with men (MSM), female sex workers (FSW) and people who use drugs (PwUD).
Clémence Doumenc-Aïdara and Juliette Bastin responsible for the ATLAS project told Geneva Solutions that a ‘silent’ epidemic has continued, particularly among these key populations.
“Access to testing remains the most important goal to be achieved in order to also improve therapeutic management and viral load suppression,” added Bastin.
Due to punitive measures placed on the activities of MSM, SW and PwUD, these groups are often too afraid to go to health facilities. Beyond the criminalisation of these key populations, those who may be at risk but are not part of these groups are hesitant to get tested out of the fear of being attributed to these groups, a catch-22 leading to further stigmatisation and discrimination.
Self-testing is therefore a great mitigating factor to such a conundrum by accessing those who otherwise may be left behind. In turn, HIVST sustains high testing rates which could push back against the epidemic.
By performing the test in a private setting where discretion is guaranteed, this can be an “empowering tool” urged Bastin.
Self testing is a quick process where the person provides either an oral fluid or blood. Using the OraQuick kit, Doumenc-Aïdara explained that by placing the pad in a tube with the liquid, the individual waits for 20 minutes and then interprets the results. “Two lines mean the test is reactive, the person is certainly HIV positive and a confirmatory test is required; one line means you are HIV negative,” she added.
Lights, camera, action!
Bringing in their own secret star weapon, the ATLAS team in collaboration with the MTV Staying Alive Foundation, launched the first francophone Shuga multimedia campaign that was , “too cool” and “compelling a case” for Unitaid to pass up, says Ingold.
With its gripping storylines, Shuga intertwines important information on sexual health & rights that resonates with its target audience of 15-24 year olds.
“MTV has a 360 approach which isn’t just a show. There was a lot of information, social media interactions with whoever was watching the show and peer education guides. In addition to this there is also the radio and graphic novels that the young people seem to really love,” she explains.
Unitaid has already been collaborating with the Staying Alive Foundation both in South Africa and Côte d'Ivoire on self testing kits and the pre-exposure prophylaxis (PrEP), the medication people at risk of HIV take to prevent getting the virus from sex or injecting drugs.
Leveraging the use of free television channels on the continent as well as the rapid spread of social media outlets such as YouTube, the Foundation aims to raise awareness on the dangers of risky sexual behaviour, which could lead to HIV/AIDS.
Since its inception the award winning television series has been hugely received, airing across 87 broadcasters worldwide, reaching an unprecedented 719 million-plus households both inside and outside of Africa.
Launched for the first time in Kenya in 2009, the show touches upon not just HIV but broad topics including gender-based violence, women empowerment, sexual and reproductive and health rights, and self-testing.
On World Aids Day in 1998 when the Foundation began its social consciousness journey, Sara Piot deputy executive director explained they were on the lookout for issues that affected the target age bracket. “At the time AIDS was the biggest killer of young people globally,”thus a documentary was broadcasted to commemorate the occasion.
Till 2009 however, “there were virtually no messages on HIV” and thus Shuga became an “edutainment” to fill this gap.
The show’s success and its educational reach has been largely based on the fact that the producers take into account the cultural and social context, through well-planned storylines. In South Africa, for example where homosexuality is protected in the constitution, the subject is addressed more directly than in other countries.
“In South Africa we in the first season we, we had a character who was gay. Reggie. This storyline was about a journey of self-discovery and coming out.” In the same vein a “Pan-African” version was created where Reggie was still gay but the focus on his sexuality shifted.
In the case of Nigeria, storylines featuring the nightclubs of Lagos are different to those catering for more conservative viewers in Kano in the North of Nigeria. “so we have characters that resonate with Northern characters, whilst getting out our message on HIV and sexual and reproductive rights generally,” said Piot.
MTV’s Shuga babi, recently launched season two in Côte d’Ivoire, offering onlookers the tools to deal with the realities of HIV and sex generally, with partners at Unitaid and MTV recognising the lack of HIV investment in Francophone Africa compared to the Anglophone regions.
Different approach to HIV in West Africa
With low numbers in testing in the West African region compared to the Southern parts of the continent, pushing self-testing is even more vital.
In South Africa “pretty much everybody knows of somebody who either lives with HIV or has died due to AIDS, so we did not have to do that much on messaging” said Piot. “From our formative research in the West African case we found that myths around HIV still persist today, for example, some people believed you could contract HIV through kissing,” she added.
Fighting HIV on all fronts is not an easy task, but research has found that the multimedia and community-led campaigns are working. Research conducted by Johns Hopkins University in 2009 in Kenya for example, indicated that more than 80 per cent of viewers had changed their perceptions and practices after watching Shuga.
Similarly in 2017, the World Bank found that the show played an important role in the fight against HIV and Gender-Based Violence (GBV) generally. The study conducted in Nigeria found that young people who watched Shuga were twice as likely to get tested, Chlamydia infections dropped by 58 per cent among women and that the use of this type of mass media promotes positive behaviour change.
As Babi just launched the self-testing kits in its episodes, it is difficult to evaluate its uptake, but based on lessons from South Africa, the response is expected to be positive. Unitaid is forecasting an increase of at least 10 per cent in HIV self-testing among viewers of the TV show.
Covid-19, a force to be reckoned with
The work to distribute HIVST has not been smooth sailing after the pandemic disrupted healthcare systems and slowed efforts. According to Ingold, overall testing was down across the board, but it was not all doom and gloom as some countries responded quickly to find new ways of distributing kits.
“In South Africa, with stronger health systems they were able to quickly shift and distribute self-tests through pharmacies. They did more mailing of products or sending an Uber, using dynamic and responsive forms of delivery to avoid Covid infections. In addition, in South Africa when they were first going around to deliver the Covid tests, they also distributed HIV tests.”
In the three West African Nations, ATLAS saw the continuous demand and distribution of kits despite the pandemic.
“HIVST represented an opportunity to maintain testing access during Covid19. Peer educators showed resilience and adapted by relocating from public to private areas, reducing group sizes, moving night activities to the daytime, increasing the use of social networks, integrating hygiene measures, and promoting assisted HIVST as an alternative to conventional rapid testing,” said Doumenc-Aïdara”
Self-testing helped maintain social distancing and lockdown measures as individuals could test in the comfort of their own homes.
The 90-90-90 target becomes 95
In 2014, the UN set its “90-90-90 target” for 2020, where 90 per cent of all people living with HIV know their status, 90 per cent of people tested positive have access to antiretroviral treatment, and 90 per cent on treatment will have viral suppression.
Now shifting the focus to 95-95-95, setting a pathway to end the HIV epidemic by 2030 Ingold says as we approach the end of the tunnel eradicating the disease becomes harder.
In countries like South Africa, where 92 per cent of people know they are living with HIV, it will become even difficult to find those who do not know they are infected, whilst shifting to epidemic concentrated areas like West Africa, Ingold says testing needs to be more targeted.
“These are marginalised populations, the key populations, including young people, don't want to access services and health facilities, because they're either not youth friendly or transgender friendly. They are not friendly for gay people, or sex workers. Although we have come a long way, we still have a long way to go to access the hardest to reach.”
To target these groups Doumenc-Aïdara believes the global targets should be integrated into national testing strategies.
Embedding the programmes into national health programmes
As the ATLAS project comes to an end, Unitaid, Solthis and the MTV Staying Alive foundation have developed strategies to ensure the projects are sustainable beyond their life cycle.
“In each of the three countries, with WHO providing technical support, we assisted the health authorities in defining the national strategy for self-testing and the practical guide for self-testing, which describes in concrete terms the strategies and delivery channels chosen by the country offering training sessions for awareness-raising, monitoring and evaluation, and quality assurance of inputs. Providing handover materials to Senegal, Mali and Côte d'Ivoire,” said the ATLAS representatives.
Mali and Senegal already secured funds for a HIVST national scale, and have began integrating nationwide programmes in collaboration with national authorities and civil society organisations.
For the STAR, Ingold explained that ending phase one and phase two of the project meant that governments of Eswatini, Lesotho, Malawi, South Africa, Zambia and Zimbabwe transitioned smoothly by integrating national monitoring and testing systems.
The Staying Alive are also in this for the long run, working closely with governments to tackle the disease head on. “The minister of Health in South Africa and Vice president of Côte d’Ivoire, for example have been very supportive of the HIV projects in their respective countries,” said Piot.
Comparing the HIVST journey to when it first began to now where there are 88 countries with self-testing policies in place is a positive step towards achieving a HIV free world.
*Name changed for anonymity.
Images provided by Solthis / B DEmeocq.