In the early 1990s Sub-Saharan Africa had more AIDS cases than anywhere else in the world. Over 8 million of the estimated 13 million HIV-positive adults worldwide were in Sub-Saharan Africa, where transmission occurred primarily through heterosexual sex.1
During the same period, an estimated 25% of patients attending STD (sexually transmitted disease) clinics in South Africa had HIV infections. In 1993, Tanzania had southern Africa's highest incidence of reported HIV cases (37,719), followed by Zambia (29,734), Malawi (29,194), and Zimbabwe (25,332). During this period, it was estimated that 1 out of every 4 adults in Uganda was HIV-positive. The WHO projected 10-15 million children worldwide would lose one or both parents to AIDS by the year 2000.2
AIDS had become so widespread in the region that many felt a sense of hopelessness. Given the high level of poverty in Africa, the cost of treatment and management was unaffordable for most of the population. An extreme example was a Ugandan grandmother who lost 6 children to AIDS and cared for her 25 grandchildren. The consequences were far reaching. There was the cost of funerals, there were orphans, lack of caretakers or overwhelmed caretakers, loss of productive workers, and drains on health services.
Moreover, skepticism persisted about the extent of the epidemic. Some argued that many deaths were due to other opportunistic diseases such as pneumonia and tuberculous – which occur more frequently in AIDS patients who have weakened immune systems.
The ability to provide counselling and on-the-spot HIV testing transformed the HIV epidemic across Africa.
In 1990, the AIDS Information Center (AIC) was established in Kampala, Uganda in response to increasing interest from members of the general public who wished to know their HIV status. HIV serologic testing was performed at a central laboratory and results were reported back to the AIC after 2 weeks. Approximately 25% of clients failed to learn their HIV status due to late arrival of results or loss to follow up. Unfortunately, a high percentage of people lost to follow up turned out to be HIV positive and often continued infecting others unknowingly in their communities.
To address these issues, AIC carried out an evaluation of rapid HIV assays against a standard criterion to identify a testing algorithm that could be used as an on-site confirmatory test. An algorithm was identified that produced minimal indeterminate results, was 100% sensitive and specific, and could be integrated with minimal disruption into existing counseling procedures. By 1996, all clients left the AIC knowing their HIV status in less than 2 hours. The results of this evaluation demonstrated that "same day" results could be provided without compromising the quality of counseling or the accuracy of the HIV testing.
In Uganda, the introduction of rapid on-site HIV testing with same-day results resulted in a 27% increase the number of patients who learned their HIV status and received counseling. It took less than five minutes to perform a single test, and results were returned to patients in less than an hour. Patients expressed a preference for same-day HIV results due to less time and expense associated with a single visit.
The ability to provide counselling and on-the-spot HIV testing transformed the HIV epidemic across Africa. Uganda was a trailblazer in the introduction of rapid HIV testing, and was one of the first countries in Africa to start Voluntary Counselling and Testing (VCT). As result of scaling up VCT services, Uganda reversed its HIV prevalence from 30% in 1990 to 6.5% in 2003. This remarkable success was achieved through promotion of an ABC strategy (abstinence, be faithful, condom use), effective treatment of opportunistic infections, prevention of mother-to-child transmission of HIV (PMTCT) and use of antiretroviral therapy (ART).3
Today, POCT has the potential to improve the management of a variety of diseases and conditions, especially in resource-limited settings where healthcare infrastructure is weak, and access to quality and timely medical care is a challenge. POCT is used to test for many infectious diseases including HIV, malaria, TB, hepatitis and syphilis, as well as for non-communicable diseases such as diabetes. Access to these technologies has improved health outcomes for millions of Africans and has provided a huge economic benefit to both healthcare systems and individual patients.
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