Governments and civil society expand access to HIV testing and counselling

A feature article on HIV testing and counselling

30 September 2009

A brightly coloured van known as the ‘Tutu Tester’ has become a familiar sight in Cape Town, South Africa, as part of an accelerating drive to persuade people to know their HIV status. More than 10 000 people have been tested and counselled since May 2008 when the mobile clinic from the Desmond Tutu HIV Foundation took to the road.

It is one of many initiatives in sub-Saharan Africa designed to dispel the stigma and fear long associated with HIV/AIDS through imaginative campaigns ranging from sex worker advice at truck stops to peer counselling in mining areas to national testing weeks spearheaded by celebrities. The campaigns are part of wider national and international efforts to expand the number of people receiving testing and counselling—which is often referred to as ‘the gateway to HIV prevention, treatment and care’ because it is a precondition for timely access to all three, including antiretroviral therapy which cuts mortality rates.

Ninety percent of low- and middle-income countries last year reported that they have national HIV testing and counselling polices, up from 70% in 2007, according to the 2009 Towards universal access progress report, published by WHO, UNICEF and UNAIDS. Countries hardest hit by the pandemic—Botswana, Kenya, Lesotho, Malawi, Namibia, Rwanda, South Africa, Swaziland, Tanzania and Uganda—are testing and counselling pregnant mothers as the basis for prevention of mother-to-child transmission (PMTCT) to cut the number of infants born with HIV, and to help HIV-negative pregnant women stay negative.

There is encouraging evidence that more countries are adhering to WHO-UNAIDS guidance on provider-initiated testing and counselling in health facilities. This recommends HIV testing and counselling as part of the standard care to all persons with symptoms or medical conditions that could indicate HIV infection, to infants born to HIV-positive women, and in generalized epidemics to all persons attending health facilities. The guidelines are key to facilitating early diagnosis in countries which are struggling with a dual HIV-TB epidemic.

The number of health centres providing HIV testing and counselling is on the increase. In 15 reporting nations in East, South and South-East Asia, the number of such facilities rose from 13 000 to 15 000 between 2007 and 2008; in reporting Latin American and Caribbean countries it doubled, while sub-Saharan Africa boasted a 50% increase.

Nearly 90% of reporting countries had national HIV testing and counselling policies in 2008, compared to 70% in 2007.

Some countries have made more progress than others. Ethiopia increased its number of facilities from 1005 to 1469 and reported that 4.5 million people received testing and counselling in 2008, up from 1.9 million in 2007. At the other end of the scale, less than 10% of health centres in Nigeria and the Democratic Republic of Congo had testing and counselling facilities.

Cameroon adopted provider-initiated testing and counselling in 2007. This was part of the government commitment to increase the number of people on treatment, up from 600 in 2001 to 60 000 in November 2008, according to WHO’s National Programme Officer for HIV/AIDS in Cameroon, Etienne Kembou. Although much remains to be done to train health professionals to implement the government model at local level, Kembou says about 85% of pregnant women at health facilities agree to be tested, as do growing numbers of men. “HIV/AIDS is not stigmatised like it was in the 1990s and many people who are HIV-positive are open about it,” Kembou says, adding that the annual national testing week and peer education projects aimed at 15–25 year-olds have helped enormously.

Uganda and Kenya have expanded coverage through home-based testing and counselling, whereby trained counsellors go from door to door. The advantage is that couples can be counselled together in a familiar environment without the stigma of going into a government facility. As a result, there are fewer disclosure problems which may arise with the male or female partner testing separately. It means that undiagnosed children with the virus can access HIV services and that high-risk areas such as the Kibera slum near Nairobi can be targeted.

In nations like Botswana and Swaziland, the government drive to scale up male circumcision for HIV prevention has led to an upsurge in testing and counselling among males, an often underserved group, as a precondition for the surgical intervention. WHO’s country representative in Botswana, Eugene Nyarko, says intensified prevention campaigns targeting youth are bearing fruit. "Across the board there is an increase in testing because young people know they can benefit from interventions if they know their status."

In South Africa, which has the highest number of people in the world living with HIV, a national population-based survey in 2008 by the Human Sciences Research Council showed that 50% of respondents over 15 years of age said they had received an HIV test, compared to 20% in 2002. Between 2005 and 2008, the percentage of women and men who reported having an HIV test in the past 12 months more than doubled.

Civil society groups in South Africa, like the Treatment Action Campaign, have mounted high profile ‘Get Tested’ campaigns. There are many local initiatives backed by foreign donor funding and the government, and the message is getting through.

Sweetness Mzoli, runs an organisation called Kwakhanya (‘Light’) which helps care for 300 beneficiaries in Khayelitsha, a poor suburb of Cape Town with high HIV prevalence rates. She tours minibus taxi ranks trying to persuade men to be tested and counselled and notes there is far less resistance than even a year ago. “It’s coming right. There’s a lot of men out there who want to talk about their status and who want to know their status,” she comments.

The ‘Tutu Tester’ is also a regular visitor to Khayelitsha’s taxi ranks, as well as to shopping malls and other crowded areas. The testing and counselling process is efficient, thorough and friendly. Clients can avoid lengthy queues at public health facilities, while knowing they will receive high quality, confidential service.

"When you make it quick and efficient, people are willing to undergo testing," says project coordinator Nienke van Schaik. The mobile clinic now offers a package, including testing for hypertension and diabetes "to make it less scary," she says. "We literally just pitch up. People see us and run off and fetch their partners and family members. People are willing to test."