Through the USAID/PATH Serving Life Project, an NGO social worker associated with the Life Plus self-help club provides assisted self-testing services to a contact of a PWID index client in his home.
Photo Credit : Olena Zhevets/Self-Help Club “Life Plus” City, country: Odessa, Ukraine, May 14, 2020
HIV Testing Services
An individual's knowledge of their HIV status is essential to a successful HIV response. HIV testing services (HTS) are the first step in the clinical cascade and ensuring that people living with HIV (PLHIV) are diagnosed and linked to prevention, treatment and care. HTS also ensures that individuals receive the most recent, fact-based information about HIV and treatment, as well as recommendations for retesting that are consistent with national testing guidelines. A client-centered, positive, and compassionate approach to HIV Testing Services prepares the client for antiretroviral therapy (ART) or links them to preventive services, such as voluntary medical male circumcision (VMMC). Achieving the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) goals related to saving lives depends upon access to continuously improving, high quality HTS, and effective linkages to care and treatment services.
There have been impressive gains in the uptake of HIV testing across the world. According to UNAIDS, by the end of 2019, 81% of people living with HIV knew their status. However, 7.1 million people did not know that they were living with HIV, demonstrating a need to continually adapt and strengthen HTS to fill this gap. Moreover, the COVID-19 pandemic has slowed down global progress in HIV services. UNAIDS, the World Health Organization (WHO) and the United Nations Children’s Fund have tracked national, regional, and global disruptions to HIV services caused by COVID-19 and have identified significant decreases in HTS in nearly all countries with available data.
WHO identified the following services that encompass the full range of HTS:
- Counseling (pre-test information and post-test counseling)
- Linkage to appropriate HIV prevention, treatment and care services, and other clinical and support services
- Coordination with laboratory services to support quality assurance and delivery of correct results
WHO also identified a set of minimum standards that all HIV testing services, including index testing, must meet: The 5 Cs of HTS: Consent; Confidentiality; Counseling; Connections to care, treatment and other services; and Correct test results.
In programming and implementation across all countries, USAID follows the normative guidance on HTS that is published by the WHO. In addition, many individuals at USAID contribute to the creation of that guidance during the review process. In 2016, the WHO developed guidelines for self-testing and index testing, in order to bolster global HIV response efforts. HIV self-testing (HIVST) refers to when a person collects their own specimen (oral fluid or blood) and performs an HIV screening test and interprets the results, either alone or with a trusted person. HIVST is a test-for-triage and should not be used to provide a definitive diagnosis of HIV; a reactive, or “positive” self-test result warrants further and confirmatory testing from a trained tester using a national testing algorithm. HIVST can be delivered through various modalities and can increase and encourage the uptake of HIV testing, especially among high-risk groups and populations with lower testing coverage. The privacy, convenience, and immediate results of HIVST have made it a viable option for many users. HIVST has been instrumental during COVID-19, as it is an acceptable alternative to maintaining HTS while adhering to physical distancing guidelines. There have also been opportunities to integrate HIVST with COVID-19 contact tracing. HIVST is prioritized in areas and populations with the greatest needs and gaps in testing coverage. Facility and community sites, online platforms, and pharmacies serve as some of the priority settings for HIVST.
Index testing, also known as assisted partner notification services, is the process in which sexual partners, drug injecting partners, or biological children of PLHIV are offered HTS in a safe and ethical manner. It is critical that all people with HIV are informed that assisted partner notification services are voluntary, and that partners or contacts identified through index testing are also made aware that HIV testing is voluntary, not mandatory.
Client is self-testing for HIV with assistance from a Community Based Distributor Agent during a PSI Zimbabwe/UNITAID HIV Self Testing Distribution exercise in Mazowe.
Credit: Eric Gauss for PSI Zimbabwe
USAID is a key implementing partner of PEPFAR, expanding HTS in countries across the globe and contributing to global policy and research agendas. Our work includes implementation of a range of HTS approaches, including targeted community-based and facility-based testing, index testing, self-testing, and support of HTS strategies that reach specific priority and key populations. These populations include pregnant mothers, couples, men, children, adolescents, and key populations at higher risk of infection. Additional efforts help to inform expanded approaches to accelerating entry into HIV care and treatment after diagnosis.
Since 2004, access to HTS for persons diagnosed has dramatically increased – often identifying individuals earlier in their infection. As countries achieve higher levels of ART coverage, HIV testing approaches have evolved accordingly to include innovations in modalites which USAID has been at the forefront of implementing. HIV rapid testing, with same-day results, is a critical tool in the global HIV response — expanding HIV testing to areas with limited laboratory facilities and increasing the number of people who learn about their HIV status at the testing site. Index testing has also shown to be an effective case finding strategy among adults. USAID ensures that HTS and linkage to care, treatment, and prevention efforts are undertaken in both facility and community settings by health professionals, community health workers, and trained volunteers. Settings include:
- antenatal care
- inpatient and outpatient departments
- tuberculosis clinics
- sexually transmitted infection and reproductive health clinics
- mobile clinics
- index testing and voluntary counseling testing sites at the community and facility levels
- pediatric clinics
- emergency clinics
- voluntary medical male circumcision clinics
- malnutrition clinics
- provider-initiated testing and counseling
Through HTS, USAID works to ensure that counselors, community health workers, and clinical professionals provide clients with accurate information, tools, and access to prevention, care and treatment interventions, which allow protection from acquiring or transmitting the virus.
In FY 2021, USAID:
- Provided HIV testing services to 22.4 million people;
- Helped nearly 900,000 people learn of their HIV positive status and linked 93% (approximately 835,000) to treatment;
- Expanded HIV self-testing to mitigate losses experienced during the onset of COVID-19, with over two million individuals participating in HIV self-testing;
- Strengthened the health systems that drive responsive, resilient, and enduring health care through more than 10,000 HIV testing sites and over 3,000 sites that provide lab-based testing making critical services accessible in over 50 supported PEPFAR countries.
USAID supported the development of the following resources that illustrate the state-of-the-art evidence, best practices, or recommendations on key issues related to HTS:
- PEPFAR Solutions Platform:
- Index Testing and Risk Network Referral: Program Implementation Orientation and Training Package
- HIV Self-Testing Operational Guide: For the Planning, Implementation, Monitoring and Reporting of HIV Self Testing
- HIV Self-Testing Quick Reference Guide
USAID also provides technical input into numerous WHO guidelines and references on HTS