Examining the WHO guidelines on HIV testing services
The consolidated World Health Organisation (WHO) guidelines on HIV testing services (HTS), published in July, recommend standardised HTS for correct diagnosis. David Rowlands examines the document, with particular regard to HIV testing in the UK.
The WHO guidance addresses the issues and elements around effective delivery of HTS that are common in a variety of settings, contexts and diverse populations. As well as supporting HTS provided by trained providers, it considers the potential of HIV self-testing.
HIV testing services are the gateway to prevention services and life-saving treatment and care.
Recent estimates suggest that only 54 per cent of people with HIV know their HIV status. In order to reach the UN 90-90-90 goals1 it is critical that HTS be strategically expanded to diagnose as many people with HIV as early as possible.
Between 2010 and 2014 nearly 600 million adults (ages 15+) are reported to have received HTS in 122 low- and middle-income countries.
In 2014 approximately 150 million children and adults in 129 low- and middle-income countries are reported to have received HTS. About 3 million children and adults tested HIV-positive according to 81 reporting low- and middle-income countries in 2014.
Nearly 70 per cent of adults receiving HTS are women. Much testing is occurring in antenatal care settings, even in low and concentrated epidemic settings.
Across all WHO regions, more than 60 per cent of adults testing HIV-positive were women; outside the WHO African Region, however, those who tested HIV-positive were more likely to be adult men.
Enabling environment for scaling-up HTS
WHO strongly recommends community-based HIV testing services. In 2014, 93 out of 124 (75 per cent) reporting countries had policies recommending community-based HTS. WHO’s new ‘test for triage’ approach and recommendation for lay-provider-delivered HTS can be used in settings where there are barriers to introducing or scaling-up community-based HTS.
Although many countries permit lay-provider HIV testing and pre- and post-test counselling, task sharing can be expanded. In 2014, 65 out of 124 (52 per cent) reporting countries had policies recommending lay provider HIV testing using rapid diagnostic tests.
WHO strongly recommends voluntary HTS for key populations.
Progress continues to be made as more countries are including key populations in national guidelines. In 2014, 110 out of 129 (85 per cent) countries reported that their national HIV testing policies addressed key populations. However, translating policy into implementation lags behind.
Couples and index partner HTS are critical to diagnosing new infections.
In terms of identifying serodiscordant couples and linking couples and partners to prevention, treatment and care services, services can be scaled up, as only 88 out of 125 (70 per cent) reporting countries had policies recommending couples and index partner HTS in 2014.
Quality HIV testing services
The quality of HTS is a growing concern. According to a review of 48 national testing policies, fewer than 20 per cent of national HIV testing policies included WHO-recommended testing strategies. In addition 68 countries reported lack of stock of rapid HIV kits in 2014.
Getting the right results
An HIV test result can have life-altering and life-long consequences. Correct test results are crucial. However, misdiagnosis of HIV status is too common – as high as 10 per cent in one study that retested people initially diagnosed HIV-positive. To assure test results are accurate and prevent misdiagnosis, it is critical that national programmes follow validated testing algorithms and WHO-recommended testing strategies.
People attending health care services should be offered diagnostic tests for HIV in accordance with current national guidance.
Approximately 25 per cent of people living with HIV in the UK are unaware of their HIV status. Late diagnosis of HIV (CD4 count <350 cells/mm3 at the time of diagnosis) is associated with increased short- and long-term morbidity and mortality; in 2010 50 per cent of people who were newly-diagnosed HIV positive were diagnosed late. Survival following HIV-associated opportunistic disease is associated with avoidable, potentially life-long, morbidity. UK data from a wide range of health care settings has demonstrated that HIV testing is acceptable to patients, deliverable and saves lives.
Prompt HIV diagnosis affords opportunities to reduce transmission to others.
For those who test HIV negative the repertoire of interventions to avoid infection is increasing. Recognising primary HIV infection is important. This is a stage of high viraemia and hence infectiousness. Assays used must be appropriate to capture all stages of HIV infection. There are significant personal and social consequences of an HIV-positive diagnosis which must be recognised in any setting where HIV diagnostic testing is being carried out. Arrangements must be in place for appropriate onward treatment, care and support as required.
People presenting to clinical services where HIV may be an explanation for their condition should be recommended an HIV test.
In areas where the prevalence of diagnosed HIV infection is 2:1000 or greater, all men and women admitted for secondary general medical care should have routine, opt-out HIV testing included in their initial health checks and medical work-up.
• HIV is now a treatable medical condition and the majority of those living with the virus remain fit and well on treatment.
• Despite this a significant number of people in the UK are unaware of their HIV infection and remain at risk to their own health and of passing their virus unwittingly on to others.
• Late diagnosis is the most important factor associated with HIV-related morbidity and mortality in the UK.
• Patients should therefore be offered, and encouraged to accept, HIV testing in a wider range of settings than is currently the case.
• Patients with specific indicator conditions should be routinely recommended to have an HIV test.
• All doctors, nurses and midwives should be able to obtain informed consent for an HIV test in the same way that they currently do for any other medical investigation.
In the UK
The vast majority of patients have access to healthcare free at the point of delivery, all patients have access to a general practitioner and there are pressures on Emergency Departments to achieve four-hour waiting targets. Universal opt-out testing in all settings may not be the most feasible approach but the use of opt-out testing in certain situations should be supported.
Confidentiality and HIV testing
Historically HIV testing has been treated differently to testing for other serious medical conditions. The outlook for individuals testing positive for HIV is now better than for many other serious illnesses for which clinicians routinely test. While there remains stigma associated with HIV infection, this can be minimised by following the general principles of confidentiality for any medical condition as laid down by the GMC in its guidance Confidentiality: protecting and providing information.
Post-test discussion for individuals who test HIV negative
It is considered good practice to offer health promotion screening for sexually-transmitted infections and advice around risk reduction or behaviour change, including discussion relating to post-exposure prophylaxis (PEP) to those individuals at higher risk of repeat exposure to HIV infection. This is best achieved by onward referral to genitourinary medicine (GUM) or HIV services or voluntary sector agencies.
The need for a repeat HIV test if still within the window period after a specific exposure should be discussed. Although fourth-generation tests shorten the time from exposure to seroconversion a repeat test at three months is still recommended to definitively exclude HIV infection.
Occasionally HIV results are reported as reactive or equivocal. These patients may be seroconverting and management of re-testing may be complex, so such individuals should be promptly referred to specialist care.
Read the WHO’s Consolidated guidelines on HIV testing services
1 The United Nations’ 90-90-90 goals are that by 2020, 90 per cent of all people living with HIV will know their HIV status, 90 per cent of all people with diagnosed HIV infection will receive sustained antiretroviral therapy and 90 per cent of all people receiving antiretroviral therapy will have viral suppression.
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About the author:
David Rowlands is the director of Design-Redefined.co.uk, delivering effective healthcare communications to enable people with HIV and/or hepatitis C (HCV) to become better engaged with their treatment and care.
Drawing on his established networks and collaboration with partners, David is able to bring healthcare together, by engaging patients and organisations, healthcare providers, physicians, stakeholders and policy makers.
Read more from David Rowlands:
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