Scaling up HIV self-testing in China and Africa.

HIV self-testing has yet to scale up, with one exception – China. Approximately one-third of men who have sex with men (MSM) report HIV self-testing in China, with many of these self-tests representing the first time that the men ever tested [1]. HIV self-testing scale-up may be related to unmet demand, self-testing partnerships and local entrepreneurship. First, the centralised, facility-based HIV testing system in China has yet to meet the diverse needs of key populations, such as MSM. The wide range of self-testing models gives greater agency to key populations about where, when and with whom they test. Second, China has forged self-testing partnerships between city-level public health agencies and key population community-based organisations (CBOs) [2]. Public health agencies provide funding, technical support, confirmatory testing, linkage to care assistance, and quality assurance; CBOs help stimulate demand for HIV self-testing. Third, entrepreneurs in China have developed new HIV self-testing service delivery models [3]. For example, a social enterprise model could sell HIV self-test kits and then use the revenue to support social causes like MSM health services [3]. This has led to a thriving online self-test kit market in China [4]. The expansion of HIV self-test services has driven down prices in China. Self-tests cost as little as US$1 per kit, including counselling and post-test referral. This is a remarkable win for public health. It should be noted that self-testing services in China have variable quality assurance, underscoring the need for evaluation.

China's strategies for scaling up HIV self-testing may be useful for African countries that are now expanding self-testing. Key population CBOs in China and many African nations are thwarted by harsh local environments that challenge service delivery with CBOs. However, these partnerships are critical as government and CBOs each bring valuable contributions to HIV self-testing programmes. In addition, entrepreneurship is an essential component of expanding self-testing because market dynamics, supply chain issues, and consumer pricing are all fundamentally about the business of self-testing. Creating a viable market for self-testing will require a broader set of players than conventional campaigns. Given the overall momentum for China–Africa co-operation and specific interest in China–Africa HIV collaboration, further implementation research [5] on HIV self-testing is warranted. The WHO now recommends HIV self-testing as an additional testing strategy, helping to make the policy argument in favour of HIV self-testing. The experience of China scaling up HIV self-testing may be helpful for low- and middle-income countries moving in the same direction.