Why aren’t all countries self-testing for COVID-19?

There has been a huge demand for COVID-19 self-testing in the Philippines amid a rise in cases from the start of January. The government has yet to approve a self-administered rapid test, but that has not stopped people from purchasing rapid test kits online.

Lara, a private employee based in Metro Manila who experienced COVID-19-like symptoms in early January, bought a box of saliva-based COVID-19 rapid tests to test herself and her family members. She had just had her COVID-19 booster shot and suffered chills for two nights, which could have been due to the side effects of the vaccine. But she wanted to be sure it’s not COVID-19. Lara — who requested not to use her full name for privacy reasons — got a negative result. 

Cases of COVID-19 have shot up in the Philippines after the Christmas holidays, but have since gone down. The number of newly registered cases on Wednesday stood at 22,958, down from the 32,246 cases registered a week earlier.

Reverse transcription polymerase chain reaction, or RT-PCR, tests remain the gold standard for COVID-19 testing in the country, but taking rapid tests at home has become an attractive option for many amid the spread of the omicron variant. Those who’ve taken rapid tests at home said results come out in as little as 15 minutes, and serve as a cheaper option to RT-PCR and rapid tests taken in public and private laboratory facilities.

The kit Lara bought online contained 25 tests, and costs $136 including shipping. That’s close to $6 per test. The government price cap for RT-PCR tests in private laboratories is at 2,940 Philippine pesos ($57.16) for GeneXpert based PCR tests, and 3,360 Philippine pesos for plate-based PCR tests. The price cap is lower in public laboratories, and some local government units offer free tests, although some citizens report having to wait for days and weeks to get tested amid a rise in requests.

Self-testing for COVID-19 is not new. In the United Kingdom, the government has been providing rapid tests for free to citizens since early last year. In Malaysia, self-testing is part of the government’s national testing strategy for COVID-19, and some kits are now priced as low as $1.

In the United States, the government this week launched a website where people can order at-home rapid tests for free. People can also purchase at-home test kits in stores or online, and reimburse the cost of up to eight self-test kits per month with their health insurance providers.

But self-testing is not yet the norm in all countries. In the Philippines, manufacturers have only recently filed for the registration of self-administered rapid test kits, and 11 are currently undergoing review. In Somalia, rapid tests are only carried out by trained professionals.

Dr. Mamunur Rahman Malik, World Health Organization country representative for Somalia, told Devex via email that there are a number of reasons why self-administered rapid test kits have not yet been introduced in the country. One is that there are not enough rapid test kits available in the country — they are not available in pharmacies — and most of the available kits have been reserved by health agencies for testing in places where there are no basic functioning laboratories.

Another reason is due to the country’s health system capacities.

“In a country where the health system is so fragile and 70% of its people live below the poverty line and educational level is below sub-optimal and wide[spread] and pervasive health inequality exists, how can one be so sure that people will safely collect the swabs and interpret the test result accurately?” he wrote.

In a press briefing on Thursday, however, Dr. John Nkengasong, director of Africa Centres for Disease Control and Prevention, said that he believes decentralized testing and self-testing should be the “way to go” in 2022 so people can know their status and isolate themselves.

“That is the only way to continue to arm the community to be in control of this pandemic,” he said.

Testing, a right

There are a few drawbacks to self-testing. In the U.S., there have been reports of people testing negative using self-testing kits, but test positive via RT-PCR tests. An analysis made by the American Society for Microbiology in December also found countries such as the U.K. and Germany that provided free rapid tests to their populations didn’t particularly do well in limiting community spread of COVID-19 during the last fall season.

But several experts see benefits in self-testing. FIND, which co-leads the diagnostic pillar for the Access to COVID-19 Tools-Accelerator and does independent evaluations of COVID-19 diagnostic tests, said it sees “huge potential” in self-testing as a complementary tool to the range of diagnostic tests currently available, even if evidence of its impact “is still emerging.”

“We’ve seen in other global health diseases such as HIV and HCV [hepatitis C virus] that self-testing has enabled communities who otherwise struggle to access health services to access testing; and we have seen in HICs [high-income countries] that self-testing has become a key part of the pandemic response,” Emma Hannay, FIND’s chief access officer, told Devex via email.

She added that self-testing can help solve some access barriers to testing such as geographic distance and cost. But while there’s growing interest in self-testing kits among several low- and middle-income countries grappling with omicron, there’s a lack of low-cost, quality-assured self-testing kits on the market, “which is why this is a focus for FIND,” she said.

Harley Feldbaum, head of strategy and policy at The Global Fund to Fight AIDS, Tuberculosis and Malaria, said in a press briefing Thursday that cheaper self-testing kits are increasingly becoming available and easier to use, but their use “has really lagged” particularly in low-income countries.

Self-testing can also help reduce the burden on health workers and systems and ensure available public testing capacity is accessible for those who may be exclusively dependent on government systems, and are in need of early intervention, according to Dr. Chandrakant Lahariya, a physician-epidemiologist, and public policy and health systems specialist.

Fifa Rahman, a civil society representative at ACT-A, told Devex that it will be a useful tool for individuals at high risk of developing severe COVID-19 to access early treatment, such as the new COVID-19 antiviral drugs molnupiravir and paxlovid. Both treatment courses are recommended to be taken within five days of symptom onset. It can also be useful in places where there’s internal displacement of people and there’s a need to get faster test results so as not to lose people when following up. But fundamentally, she said, it’s a human right.

“There are a lot of technical people and clinical people and epidemiologists who view self-testing as only valuable if linked to surveillance or if linked to public health action. But … the act of testing itself is a public health action, and someone has the right to information about their own health,” she said.

Rahman said she’s currently pushing for both self-testing and more professional-use rapid tests for COVID-19 within ACT-A as they are currently “insufficiently used at this stage.”

Lara said immediately knowing whether she had the virus or not has given her some peace of mind.

“The thought of yourself getting tested, regardless if it’s RT-PCR or antigen, is somehow giving peace of mind to people, including myself,” she said.

Things to consider

But there are several things countries need to consider when adopting self-testing in their strategies such as having robust communication strategies and guidance on how to take the tests, when to take them, who should take them, and what to do afterward, experts said.

Additionally, having quality-assured test kits that have high sensitivity to pick up the infection is important, and tests that are easy to use by the general public, said Adeeba Kamarulzaman, president of the International AIDS Society and professor of infectious diseases at the faculty of medicine at the University of Malaya.

“You also don't want to get into a situation where the worried well are using up lots of tests, testing themselves for no good reason. So having some kind of guidance and policy when to test — who and when — would be helpful,” she said.

In Malaysia, where self-testing kits are now widely used, the government has put out a guideline stating when individuals should test and who should be testing themselves. Those participating in events or activities where they will be meeting with people from different households, such as religious gatherings, conferences, and social events are encouraged to test themselves prior.

Individuals should also report their test results, even if it’s negative or invalid, to the MySejahtera, a mobile application developed by the government to aid in COVID-19 contact tracing efforts. The government also lays out examples of who should be testing, how frequently, and the type of test to take.

Countries should also assess the level of transmission and immunity at a given time, look at its resources, and assess how best to utilize rapid tests efficiently, said Dr. Lahariya, who also co-authored the book “Till We Win: India’s Fight Against The COVID-19 Pandemic.”

While he doesn’t see much use for self-administered tests in the long run for the majority of the population — except for high-risk individuals who might require early intervention for COVID-19 — he believes self-test kits should be widely available for anybody who wishes to get a hold of them and should be used to supplement RT-PCR testing capacity in a given setting when more testing is needed to ensure testing systems function without delay.

“And of course, availability of multiple kits will help in reducing the cost … and making those kits affordable. The key point to remember is that … every setting has to continuously review their policy and approach to testing. There cannot be one approach for all the time,” he said.

Sara Jerving contributed reporting.

Update, Jan. 24, 2022: This story has been updated to attribute comments from FIND to its chief access officer, Emma Hannay.