Progress in Providing HIV Testing and Counseling in Health Facilities

Abstract

IN 2007, THE GUIDANCE ON PROVIDER-INITIATED TESTING AND Counseling in Health Facilities was launched by the World Health Organization and the United Nations Joint Programme on HIV/AIDS (UNAIDS) to help ensure that human immunodeficiency virus (HIV) is systematically diagnosed to improve treatment outcomes and increase access to prevention services. Since then, many HIV programs have adopted the global guidance. This has been associated with earlier diagnosis and treatment compared with other HIV testing and counseling approaches in health facilities. According to the 2009 Universal Access progress report, among 110 countries reporting on provider-initiated testing and counseling (PITC), 95 countries indicated their policies promoted it and 89 countries reported that their guidelines ensure confidentiality and informed consent. PITCshouldberecommendedto(1)allpersonsseeninhealth facilitiesingeneralizedepidemics(areasinwhichHIVhasbecome firmly established in the general population; ie, prevalence is consistently 1%inpregnantwomen); (2) selectpopulations and persons with clinical indications for HIV in concentrated epidemics (the spread of HIV has occurred in a defined subpopulation; ie,prevalence isconsistently 5%inadefinedsubpopulationbut is 1%inpregnantwomeninurbanareas);and (3)selectpopulationsandpersonswithclinical indications for HIVinlow-levelepidemics(HIVmayhavebeenpresentformany years but never spread to substantial levels in any subpopulation; ie, prevalence has not been consistently 5% in any defined subpopulation). This guidance addresses the 2010 HIV prevention, care, and treatment universal access goals of combating HIV (Millennium Development goal 6), reducing child mortality (goal 4), and improving maternal health (goal 5). It is also consistent with the United Nations General Assembly’s special session goals on preventing mother-to-child transmissionofHIVandUNAIDS’call forvirtualeliminationofmotherto-child transmission of HIV by 2015. Enhanced HIV diagnosis leading to antiretroviral therapy for decreased HIV-associated morbidity and mortality and improved access to prevention necessitates that PITC become an established part of medical care. Furthermore, scientific evidence increasingly supports that antiretroviral therapy reduces HIV transmission because reducing HIV plasma viral load significantly lowers the risk of transmission. This includes HIV transmission through injection drug use (in many settings, injection drug users are unjustifiably excluded from both HIV prevention and treatment). The hypotheses that antiretroviral therapy may lead to reductions in populationlevel HIV transmission must continue to be tested. Testing and counseling for HIV is also associated with risk reduction and is considered a prevention strategy. Among serodiscordant heterosexual couples, the benefits may be particularly pronounced, given that a significant proportion of HIV transmission occurs in cohabiting couples in sub-Saharan Africa. However, these studies were not conducted with an abbreviated HIV testing and counseling protocol typical of the PITC strategy in health care settings. EvaluatingoutcomesfromPITCandother formsofHIVtestingandcounselingcanbechallenging.There iswidevariation in programs’ definitions of what constitutes PITC and clientinitiatedtestingandcounseling(inwhichapersonseekstesting), andawiderangeof settings(clinics,workplace,home)andapproaches (eg, pretest counseling can range from minimal pretesteducationtoin-depthindividualpretestcounselingorfrom opt-in to opt-out in which an individual must specifically decline testing). Moreover, it is difficult to infer generalizability or causality because study designs are likely not randomized controlled trials and PITC requires some adaptation to the local context. It is important while PITC services are rolled out toevaluatetheeffect,acceptability,andcost-effectiveness inoperational settings. This should include systems of quality assurance and quality improvement. Programs should monitor respect for human rights, including measures of the quality of counseling(eg, informedconsentandconfidentiality), andacceptability,andalsotheproportionof individualsreceivingHIV testingrecommendations,HIVtestsandresults, risk-reduction messages, and referral for further HIV prevention counseling, care, and treatment services. Now is the time for country-level programs to demonstrate results. Data on high-risk populations are often incomplete or insufficient, which makes it difficult to measure program results and challenging to measure program effectiveness. For example, in 2008, of 149 low-income and middle-incomecountries, only 41 countries reported conducting systematic sur-