HIV self-testing has become a cornerstone strategy for reaching people who face barriers to conventional clinic-based services. In Cameroon, both same-sex practices and sex work are criminalised, and the resulting stigma and fear of disclosure deter many men who have sex with men and female sex workers from visiting health facilities for testing. Self-testing sidesteps that obstacle: participants collect a small blood sample themselves, apply it to a rapid diagnostic strip, and read the result privately. Crucially, the test functions as a triage tool rather than a definitive diagnosis, meaning any reactive result must be confirmed through standard laboratory algorithms before treatment can begin.

The study enrolled 789 participants through 17 community-based organisations, ten serving men who have sex with men and seven serving female sex workers, in the two largest cities. All participants were aged 21 or older and were recruited through voluntary sampling. After counselling, each person performed an unassisted self-test and completed a structured questionnaire covering demographic characteristics, sexual behaviour, and medical history. The researchers then used modified Poisson regression, a statistical approach suited to common outcomes in cross-sectional data, to calculate adjusted prevalence ratios that quantify how each factor relates to the probability of a reactive test while controlling for other variables.

The headline finding is sobering: 23.3 percent of all participants had a reactive self-test, with a 95 percent confidence interval of 20.5 to 26.4 percent. The proportions were nearly identical across the two populations, at 23.2 percent among female sex workers and 23.4 percent among men who have sex with men, suggesting that both groups carry a comparably heavy and previously underappreciated burden of presumed infection. Because reactive self-tests require confirmatory testing, these figures represent an upper signal of infection prevalence rather than confirmed diagnoses, but the sheer scale of reactivity underscores how much undiagnosed infection may be circulating within networks that clinics rarely reach.

Perhaps the most dramatic signal in the data is geographic. Reactivity was more than three times higher in Yaoundé, the capital, than in Douala, the country’s economic hub, at 38.3 percent versus 12.2 percent. After statistical adjustment, living in Douala was associated with a 78 percent lower probability of reactivity among female sex workers and a 69 percent lower probability among men who have sex with men. This concentration in a single city is epidemiologically significant because it implies that tailored interventions, from intensified testing campaigns to partner services and pre-exposure prophylaxis roll-out, could achieve disproportionate impact if prioritised in Yaoundé rather than spread evenly across both metropolises.

Education emerged as a powerful and consistent protective correlate, particularly among women. Relative to female sex workers with no formal schooling, those with primary education had a 72 percent lower adjusted probability of a reactive test, those with secondary education a 66 percent lower probability, and those with higher education a 56 percent lower probability. A similar gradient appeared among men who have sex with men, where secondary education was associated with a 63 percent reduction. The pattern likely reflects the ways literacy and schooling shape access to health information, negotiating power in commercial sex, economic alternatives, and familiarity with preventive technologies, though the cross-sectional design cannot disentangle the underlying mechanisms.

Behavioural and clinical history markers also carried important signals. Among female sex workers, a history of symptoms suggestive of sexually transmitted infections nearly tripled the adjusted probability of reactivity, tripling the odds relative to women without such a history. This finding aligns with well-established virology: genital ulceration and inflammation amplify both acquisition and transmission of HIV by recruiting activated CD4-bearing target cells to mucosal surfaces and disrupting epithelial barriers. It also suggests that syndromic STI screening, when integrated with self-testing programmes, could serve as an efficient triage layer identifying women at highest risk.

Among men who have sex with men, each additional sexual partner over the preceding six months was associated with a modest but statistically reliable 3 percent increase in the probability of reactivity, a dose-response relationship consistent with cumulative exposure risk. Interestingly, alcohol consumption was associated with a 35 percent lower adjusted probability of reactivity in this group. The authors caution that such counterintuitive associations in cross-sectional data may reflect residual confounding or complex social patterns rather than any protective biological effect of alcohol itself.

The methodological strength of the study lies in its scale, its reliance on trained community-based organisations to recruit criminalised populations that formal health systems typically miss, and its use of regression techniques appropriate for high-prevalence outcomes. The ethical scaffolding was equally careful: the protocol received approval from Cameroon’s National Ethics Committee for Human Health Research and administrative authorisation from the Ministry of Health, and every participant provided written informed consent, with data handled confidentially given the acute legal risks these populations face.

The implications for public health strategy are direct. The authors conclude that reactive self-tests were frequent among both populations, with a marked concentration in Yaoundé and among unschooled female sex workers, and they argue that geographically prioritised, differentiated prevention, combined with STI screening and robust linkage to confirmatory testing, would meaningfully reduce this burden. As Cameroon and its regional neighbours work toward UNAIDS testing and treatment targets, the study demonstrates that self-testing is not merely a convenience but a surveillance instrument, capable of mapping where infection concentrates and guiding resources to the people and places that need them most.

Subject of Research: Factors associated with reactive HIV self-test results among female sex workers and men who have sex with men in Cameroon

Article Title: Factors associated with a reactive HIV blood self-test result among female sex workers and men who have sex with men in Yaoundé and Douala, Cameroon: a cross-sectional study

Article References: Ndié, J., Noah, J.-P. Y. A., Ndongo, F. A., Dongmo, R. K., Yongwa, O., Tchikangni, G., Palisson, T. A. N., Ketchaji, A., Yepndo, C. D., Ndindjock, C. B., IV, Tabala, F. N., Bonyohe, M., Moulioum, F., Nzaddi, A. R. D., Monteh, C. T., Mboussam, P. H., Nguemkam, G., Seukam, B., Anaba, E. D. M., … Bissek, A. C. Z.-K. (2026). Factors associated with a reactive HIV blood self-test result among female sex workers and men who have sex with men in Yaoundé and Douala, Cameroon: a cross-sectional study. BMC Infectious Diseases. https://doi.org/10.1186/s12879-026-14598-4

Image Credits: AI Generated

DOI: 10.1186/s12879-026-14598-4

Keywords: HIV self-testing, HIV, Cameroon, men who have sex with men, female sex workers, key populations, prevalence, Yaoundé, Douala, sexually transmitted infections, public health, cross-sectional study

The scale of the original problem is worth recalling. In 2015, a survey-based analysis across 16 countries in sub-Saharan Africa estimated that nearly half of people living with HIV in those countries did not know their status. Extrapolated across the region, that implied roughly 11 million people standing entirely outside the treatment cascade, unaware they needed antiretroviral therapy and capable of onward transmission at rates far higher than people whose infection was suppressed by medication. Self-testing, the authors contend, was precisely the technology positioned to reach this population, because it removed many of the barriers that keep people away from clinics: stigma, distance, waiting times, fear of being seen entering an HIV service, and the loss of a day’s income.

The epidemiological logic behind self-testing is straightforward. Antiretroviral therapy dramatically reduces infectiousness, and people who know their status can start treatment and achieve viral suppression. Every undiagnosed infection therefore represents both a personal health risk and a transmission risk to others. The UNAIDS 95-95-95 framework, which targets 95 percent of people living with HIV knowing their status, 95 percent of those diagnosed on treatment, and 95 percent of those on treatment virally suppressed, depends on the first 95 more than any other, because no one can be treated if they have not been found. Yet in 2025, an estimated 2.6 million people in sub-Saharan Africa and 4.9 million worldwide still did not know their HIV status.

The authors quantify the shortfall in procurement terms. The need for HIV self-testing in low- and middle-income countries was estimated at 177 million self-tests in 2020, rising to 192 million by 2025. Confirmed procurement over that same period reached only 21 million kits in total, an average of 5.3 million per year. That is roughly 3 percent of the estimated annual need. In other words, for every hundred self-tests that modeling suggested the region required, fewer than three were purchased. The gap between need and supply was not marginal; it was nearly total.

Why did a cheap, simple, WHO-endorsed technology fail to reach the market at scale? The analysis identifies four interlocking structural failures. The first is what the authors call research capture. Instead of population-scale deployment, the field invested heavily in demonstration projects, small studies designed to show that self-testing could work. Such studies accumulated evidence of feasibility and acceptability year after year, but they substituted for, rather than preceded, real distribution. A technology that had already been endorsed by WHO did not need another pilot; it needed procurement, supply chains, and delivery systems. The demonstration-project cycle, the authors argue, consumed a decade that should have been spent scaling.

The second failure is a paradox embedded in early implementation. Many programs introduced self-testing in supervised or provider-assisted forms, in which a health worker remained present while the client performed the test. This arrangement, intended to reassure regulators and funders, effectively reconstituted the very clinic barriers self-testing was designed to bypass. If a person must still travel to a facility, wait for a provider, and test under observation, the private, convenient, stigma-free experience that defines self-testing disappears. Supervised delivery, the authors suggest, blunted the technology’s core advantage during the years when scale was most urgently needed.

The third failure concerns procurement conservatism. Donors and national programs were slow to commit volume, and without predictable demand, manufacturers had little incentive to invest in production capacity or price reduction. Procurement behaves like a market signal: guaranteed volumes attract suppliers, drive competition, and lower unit costs, while hesitant, fragmented purchasing keeps prices high and supply chains thin. By buying cautiously, the global health system suppressed the very market development that would have made self-testing cheap and abundant. The result was a self-reinforcing loop of low demand, high prices, and continued hesitation.

The fourth failure is one of accountability. The authors found no publicly accessible, Africa-level series of HIV self-testing commodity volumes, which means the scale of the missed opportunity cannot even be measured from published data. Without transparent reporting of how many kits are bought and distributed, no one can hold programs, donors, or manufacturers to account, and no one can detect shortfalls in time to correct them. The absence of a simple volume series, the authors argue, is itself a policy failure, because what is not measured cannot be managed, and what cannot be measured cannot be missed publicly.

The consequences of the delay, while not formally modeled in the analysis, are likely to be severe. Each year that millions of people remained undiagnosed translated into untreated infection, avoidable illness and death, and onward transmission. The authors characterize the burden as potentially millions of illnesses, deaths, and transmissions that could have been avoided had self-testing been deployed at the scale the need estimates demanded. They are careful to note that this counterfactual has not been quantified with formal modeling, but the arithmetic of the treatment cascade makes the direction of the effect unambiguous: people outside the cascade are sicker and more infectious than people within it.

The paper closes with four concrete prescriptions. First, mandatory public reporting of HIV self-testing commodity volumes, so that procurement and distribution become visible and auditable. Second, a dedicated Africa-specific distribution target of at least 50 million kits per year, embedded within the UNAIDS 95-95-95 framework, to convert the first 95 from an aspiration into a supply commitment. Third, community-based distribution as the default delivery model for the general population, moving self-tests out of clinics and into the places where undiagnosed people actually live, work, and socialize. Fourth, explicit self-testing volume commitments written into the 2026 to 2030 memoranda of understanding and work plans of the Global Health Sector Strategies on HIV, so that the next decade begins with binding obligations rather than another round of pilots. Whether the global response absorbs these lessons, the authors suggest, will determine whether the remaining millions finally learn their status, or whether the diagnostic gap closes as slowly and as late as it opened.

Subject of Research: HIV self-testing scale-up and the global undiagnosed HIV gap in sub-Saharan Africa

Article Title: HIV self-testing and the global diagnostic gap: Addressing a decade of missed opportunity

Article References: Granich, R., Gupta, S., Munyangaju, I., & Ruffner, M. (2026). HIV self-testing and the global diagnostic gap: Addressing a decade of missed opportunity. PLOS Medicine, 23(9), e1005241. https://doi.org/10.1371/journal.pmed.1005241

Image Credits: AI Generated

DOI: 10.1371/journal.pmed.1005241

Keywords: HIV self-testing, HIV diagnosis, sub-Saharan Africa, UNAIDS 95-95-95, procurement, global health, PLOS Medicine, undiagnosed HIV, community-based distribution, World Health Organization, antiretroviral therapy, diagnostic gap

The research team, led by Gloria Aidoo-Frimpong of the University at Buffalo in collaboration with Ghanaian colleagues from institutions including Ensign Global University and hospitals in Osiem and Offinso, brought together ten adolescent girls and young women and five community interest-holders for an intensive co-creation workshop. The methodological architecture of the study reflected a deliberate commitment to participatory design. Rather than extracting survey responses and departing, the investigators audio-recorded group discussions, captured facilitator field notes, and employed the Nominal Group Technique, a structured consensus method in which participants independently generate and rank ideas before the group deliberates. This ranking procedure allowed the researchers to quantify which barriers participants considered most pressing, while the open discussions and intervention prototypes revealed the texture and reasoning behind those priorities. Transcripts were then subjected to thematic analysis with iterative coding and consensus refinement, a process in which coders repeatedly revisited the data until the interpretive categories stabilized.

What emerged from the analysis was a four-tier map of obstacles operating at distinct but interlocking levels. The first and arguably most pervasive domain involved cultural and religious norms that moralized female sexuality. Participants described how conversations about HIV prevention were frequently framed as evidence of inappropriate behavior, so that a young woman seeking an HIV test or requesting PrEP risked being read as sexually active, and therefore as transgressing expectations of feminine propriety. This moral framing transformed a straightforward health behavior into a social gamble. The second domain concerned knowledge that was real but not actionable. Many participants had heard of HIV self-testing and PrEP, yet they lacked procedural clarity about how the tests worked, how PrEP should be taken, and what to do with a result, leaving them uncertain at precisely the moments when confidence mattered most.

The third barrier domain was emotional and relational. Fear and stigma did not operate only through overt discrimination; they worked through anticipatory distress, the dread of what might happen if a test were discovered, and through relational scrutiny, the sense that partners, family members, or neighbors were constantly evaluating a young woman’s choices. Confidentiality concerns compounded this anxiety, because participants worried that clinic staff or visible service points could expose their prevention activities to their communities. The fourth domain was structural: inconsistent availability of services meant that even motivated women could not count on finding supplies, financial barriers put testing kits and clinic visits out of reach for some, geographic inequities concentrated resources in places easier for urban than rural women to access, and health system practices themselves sometimes deterred rather than welcomed young clients.

The analytical insight of the study lies in how these domains interact. A young woman might possess accurate knowledge about PrEP, for example, but cultural norms that moralize female sexuality could make it socially costly to visit a clinic, while financial constraints and unreliable stock could render the trip futile even if she overcame her hesitation. Conversely, a well-stocked facility in her neighborhood would not help if she feared being seen entering it. The researchers mapped each barrier to the level at which it manifested, individual, interpersonal, socio-cultural, or structural, and then aligned the co-created strategies to those manifestations. This multilevel mapping matters for implementation science because interventions that address only one layer tend to be overwhelmed by the others. A peer education program, however well designed, will struggle if the nearest clinic has no PrEP in stock or if faith leaders publicly condemn its use.

The strategies that participants designed were strikingly concrete and culturally embedded. Storytelling emerged as a central vehicle: narratives grounded in local experience could carry prevention information in forms that felt legitimate rather than clinical, allowing sensitive topics to be discussed without triggering the moral judgments that direct messaging provoked. Participants also proposed deliberate engagement with faith leaders, recognizing that religious authorities shape the very norms that moralize female sexuality, and that their endorsement could either unlock or foreclose community acceptance of HIV prevention services. Rather than treating religion as an obstacle to be circumvented, the young women positioned faith communities as potential allies whose involvement could reframe prevention as responsible and respectable behavior.

Digital tools featured prominently in the co-designed package, but with an attention to developmental nuance that top-down programs often miss. Participants envisioned peer-led education delivered through WhatsApp, the messaging platform that dominates social communication in Ghana, with content tailored to different stages of adolescence and young adulthood. The rationale was that a fourteen-year-old girl navigating school and family supervision has different prevention needs, relationship contexts, and communication preferences than a twenty-two-year-old woman in a partnership or running her own household. A single undifferentiated message, the participants argued, would speak to neither. Alongside the peer-led channels, they proposed anonymous digital support mechanisms that would allow young women to ask questions and seek reassurance without revealing their identities, directly targeting the confidentiality fears that the analysis had identified as a core barrier.

The final strand of the co-designed strategy addressed the structural layer through decentralized, community-based service delivery. By moving HIV self-testing kits and PrEP access out of centralized facilities and into community settings, the participants aimed to reduce the geographic and financial costs of prevention while shrinking the visibility that made clinic visits socially risky. The emphasis on decentralization reflects a broader recognition in health services research that access is not merely a matter of distance but of the total burden, in time, money, and social exposure, that a service imposes on its user. For young women whose mobility and spending money may be controlled by others, a service that requires a long, conspicuous journey is effectively unavailable regardless of its official existence.

The WISE WOMAN findings now set the stage for a pilot phase intended to evaluate the feasibility and acceptability of the co-created strategies and to refine them for broader scale-up. The study’s authors emphasize that grounding intervention design in lived experience and structural reality offers contextually specific guidance that imported models cannot supply, and the ethical architecture of the work, approved by the University at Buffalo’s Institutional Review Board and Ensign Global College’s ethics committee and conducted in accordance with the Declaration of Helsinki and Ghana’s Data Protection Act, underscores the care taken with a vulnerable population. The research was funded through the University at Buffalo’s global research seed funding program, with the funders having no role in the design or interpretation. Whether storytelling circles, faith-leader partnerships, WhatsApp peer networks, and community distribution points can measurably raise testing and PrEP uptake remains to be demonstrated, but the study makes a compelling methodological claim: the young women closest to the problem are also the most precise diagnosticians of it, and interventions that begin with their analysis stand a far better chance of surviving contact with the communities they aim to serve.

Subject of Research: Women-centered co-design of HIV self-testing and PrEP implementation strategies for adolescent girls and young women in Ghana

Article Title: Co-developing women-centered strategies to improve HIV self-testing and PrEP uptake among adolescent girls and young women in Ghana: Findings from the WISE WOMAN study

Article References: Aidoo-Frimpong, G., Mensah, W. K., Anyidoho, D. S., Obeng, Y. A., Abubakar, A. T., & Oduro, M. A. (2026). Co-developing women-centered strategies to improve HIV self-testing and PrEP uptake among adolescent girls and young women in Ghana: Findings from the WISE WOMAN study. BMC Health Services Research. https://doi.org/10.1186/s12913-026-15750-1

Image Credits: AI Generated

DOI: 10.1186/s12913-026-15750-1

Keywords: HIV self-testing, PrEP, adolescent girls and young women, Ghana, participatory research, implementation science, human-centered design, nominal group technique, HIV stigma, women's health, community-based services, sub-Saharan Africa