{ "abstract": "Summary points: In 2015, a survey-based analysis across 16 sub-Saharan African countries estimated that nearly half of people living with HIV were undiagnosed, implying ~11 million people in the region were outside the treatment cascade. However, HIV self-testing (HIVST), a technology effectively positioned to close this gap, was deployed at negligible scale for a decade following WHO recommendation in 2016. The gap has narrowed, but through conventional testing rather than HIVST, and 2.6 million people in sub-Saharan Africa and 4.9 million globally still did not know their HIV status in 2025. The decade of delay carries a likely avoidable burden of millions of illnesses, deaths and onward transmissions, though this has not been formally modelled. The need for HIVST in low- and middle-income countries was estimated at 177 million self-tests in 2020, rising to 192 million by 2025. Confirmed procurement over the same period reached only 21 million kits in total, an average of 5.3 million per year, or 3% of estimated annual need. Four interlocking structural failures explain this missed opportunity: 1) research capture through demonstration projects that substituted for population-scale deployment; 2) the early supervised self-testing paradox in which provider-assisted delivery reconstituted the clinic barriers HIVST was designed to bypass; 3) procurement conservatism that suppressed market development; and 4) an accountability failure with no publicly accessible Africa-level volume series, making the scale of the missed opportunity impossible to measure from published data. Four actions could improve access: 1) mandatory public reporting of HIVST commodity volumes; 2) a dedicated Africa-specific distribution target of at least 50 million kits per year within the UNAIDS 95-95-95 framework; 3) community-based distribution as the default model for the general population; and 4) explicit HIVST volume commitments in the GHSD’s 2026–2030 memoranda of understanding and work plans. In this Policy Forum article, Isabelle Munyangaju and colleagues discuss why the roll-out and scale-up of HIV self-testing over the last decade has been inadequate, and highlight what is needed—learning from past failures around governance, distribution and financing—to close the diagnostic gap.", "abstract_shown": true, "affiliations": [ "Independent Global Health Consultant, Geneva, Switzerland", "Independent Global Health Consultant, New Delhi, India", "Tinpswalo Research Association to Fight AIDS and TB, Chokwe, Mozambique", "Nucleo de Pesquisa Pediatria, Faculdade de Medicina, Universidade Eduardo Mondlane, Maputo, Mozambique" ], "article_type": "Policy Forum", "arxiv": null, "author_total": 4, "authors": [ { "affs": [ 0 ], "name": "Reuben Granich" }, { "affs": [ 1 ], "name": "Somya Gupta" }, { "affs": [ 2 ], "name": "Isabelle Munyangaju" }, { "affs": [ 3 ], "name": "Mike Ruffner" } ], "bibtex": "https://research.draconitic.com/paper/402k3v50jaenv.bib", "cited_by": 0, "doi": "10.1371/journal.pmed.1005241", "fulltext_url": "https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1005241", "id": "402k3v50jaenv", "issns": [ "1549-1676" ], "landing_url": "https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1005241", "language": null, "licence": "CC-BY-4.0", "licence_label": "CC BY 4.0", "licence_source": "journal", "licence_url": "https://creativecommons.org/licenses/by/4.0/", "metadata_licence": null, "native_subjects": [ [ "openalex", "2725|HIV/AIDS Research and Interventions" ], [ "plos", "/Biology and life sciences/Immunology/Vaccination and immunization/Antiviral therapy/Antiretroviral therapy" ], [ "plos", "/Biology and life sciences/Microbiology/Medical microbiology/Microbial pathogens/Viral pathogens/Immunodeficiency viruses/HIV" ], [ "plos", "/Biology and life sciences/Microbiology/Medical microbiology/Microbial pathogens/Viral pathogens/Retroviruses/Lentivirus/HIV" ], [ "plos", "/Biology and life sciences/Organisms/Viruses/Immunodeficiency viruses/HIV" ], [ "plos", "/Biology and life sciences/Organisms/Viruses/RNA viruses/Retroviruses/Lentivirus/HIV" ], [ "plos", "/Biology and life sciences/Organisms/Viruses/Viral pathogens/Immunodeficiency viruses/HIV" ], [ "plos", "/Biology and life sciences/Organisms/Viruses/Viral pathogens/Retroviruses/Lentivirus/HIV" ], [ "plos", "/Medicine and health sciences/Diagnostic medicine/HIV diagnosis and management" ], [ "plos", "/Medicine and health sciences/Diagnostic medicine/Virus testing" ], [ "plos", "/Medicine and health sciences/Epidemiology/HIV epidemiology" ], [ "plos", "/Medicine and health sciences/Immunology/Vaccination and immunization/Antiviral therapy/Antiretroviral therapy" ], [ "plos", "/Medicine and health sciences/Pathology and laboratory medicine/Pathogens/Microbial pathogens/Viral pathogens/Immunodeficiency viruses/HIV" ], [ "plos", "/Medicine and health sciences/Pathology and laboratory medicine/Pathogens/Microbial pathogens/Viral pathogens/Retroviruses/Lentivirus/HIV" ], [ "plos", "/Medicine and health sciences/Public and occupational health/Preventive medicine/HIV prevention" ], [ "plos", "/Medicine and health sciences/Public and occupational health/Preventive medicine/Vaccination and immunization/Antiviral therapy/Antiretroviral therapy" ], [ "plos", "/Social sciences/Economics/Commerce/Procurement" ], [ "plos", "/Social sciences/Economics/Finance" ] ], "openalex": "W7213440056", "pdf_url": "https://journals.plos.org/plosmedicine/article/file?id=10.1371/journal.pmed.1005241&type=printable", "pmcid": null, "pmid": null, "published": "2026-09-16", "publisher": "Public Library of Science", "ris": "https://research.draconitic.com/paper/402k3v50jaenv.ris", "sources": [ { "first_seen": "2026-10-30T12:17:49Z", "native_id": "10.1371/journal.pmed.1005241", "source": "plos", "url": "https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1005241" } ], "subjects": [ { "field": "biology", "origin": "plos:immunology", "subfield": "immunology" }, { "field": "biology", "origin": "plos:microbiology", "subfield": "microbiology" }, { "field": "medicine", "origin": "plos:epidemiology", "subfield": "epidemiology-public-health" } ], "title": "HIV self-testing and the global diagnostic gap: Addressing a decade of missed opportunity", "title_text": "HIV self-testing and the global diagnostic gap: Addressing a decade of missed opportunity", "type": "peer-reviewed", "updated_at": "2026-10-30T12:17:49Z", "url": "https://research.draconitic.com/paper/402k3v50jaenv", "venue": "PLOS Medicine", "versions": [] }