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WHO and UNAIDS issue new guidance on HIV testing and counselling in health facilities

New recommendations aim for wider knowledge of HIV status and greatly increased access to HIV treatment and prevention

WHO and UNAIDS today issued new guidance on informed, voluntary HIV testing and counselling in the world's health facilities, with a view to significantly increasing access to needed HIV treatment, care, support and prevention services. The new guidance focuses on provider-initiated HIV testing and counselling (recommended by health care providers in health facilities).

Today, approximately 80% of people living with HIV in low- and middle-income countries do not know that they are HIV-positive. Recent surveys in sub-Saharan Africa showed on average just 12% of men and 10% of women have been tested for HIV and received their test results.

Increased access to HIV testing and counselling is essential to promoting earlier diagnosis of HIV infection, which in turn can maximize the potential benefits of life-extending treatment and care, and allow people with HIV to receive information and tools to prevent HIV transmission to others.

"Scaling up access to HIV testing and counselling is both a public health and a human rights imperative," said WHO HIV/AIDS Director Dr Kevin De Cock. "We hope that the new guidance will provide an impetus to countries to greatly increase availability of HIV testing services in health care settings, through realistic approaches that both improve access to services and, at the same time, protect the rights of individuals. Without a major increase in HIV testing and counselling in health facilities, universal access to HIV prevention, treatment and care will remain just a noble goal."

Additional approaches needed to expand access

Until recently, the primary model for providing HIV testing and counselling has been client-initiated HIV testing and counselling - also known as voluntary counselling and testing (VCT) - in which individuals must actively seek an HIV test at a health or community-based facility. But uptake of client-initiated HIV testing and counselling has been limited by low coverage of services, fear of stigma and discrimination, and the perception by many people - even in high prevalence areas - that they are not at risk.

Current evidence also suggests many opportunities to diagnose HIV in clinical settings are being missed, even in places with serious HIV epidemics. While, therefore, expanded access to client-initiated HIV testing and counselling is still necessary, other approaches are also required if coverage of HIV testing and counselling is to increase and, ultimately, universal access to HIV prevention, treatment, care and support is to be achieved.

The new WHO/UNAIDS guidance was prepared in light of increasing evidence that provider-initiated testing and counselling can increase uptake of HIV testing, improve access to health services for people living with HIV, and may create new opportunities for HIV prevention. Provider-initiated HIV testing and counselling involves the health care provider specifically recommending an HIV test to patients attending health facilities. In these circumstances, once specific pre-test information has been provided, the HIV test would ordinarily be performed unless the patient declines.

Provider-initiated HIV testing and counselling has already been implemented in a range of clinical settings in several low- and middle-income countries, including Botswana, Kenya, Malawi, Uganda and Zambia, as well as in pre-natal settings in parts of Canada, Thailand, the United Kingdom, and the United States.

"If we are going to get ahead of this epidemic, rapidly scaled up HIV treatment and prevention efforts are critical - and increased uptake of HIV testing will be fundamental to making this a reality," said Dr Paul De Lay, Director of Monitoring and Evaluation, UNAIDS. "At the same time, and in all cases of HIV testing and counselling, the 3 Cs - that is consent, confidentiality and counselling - must be respected," he added.

Guidance tailored to different types of epidemics and health facilities

The new WHO/UNAIDS guidance advises that health care providers globally should recommend HIV testing and counselling to all patients who present with conditions that might suggest underlying HIV disease.

Additional guidance is tailored to local circumstances. In generalized HIV epidemics1, HIV testing and counselling should be recommended to all patients attending all health facilities, whether or not the patient has symptoms of HIV disease and regardless of the patient's reason for attending the health facility. In concentrated2 and low-level3 HIV epidemics, depending on the epidemiological and social context, countries should consider recommending HIV testing and counselling to all patients in selected health facilities (e.g. antenatal, tuberculosis, sexual health, and health services for most-at-risk populations). The guidance also includes special considerations for HIV testing and counselling for adolescents and children.

WHO and UNAIDS recognize that resource and other constraints may prevent immediate implementation of the guidance. The document therefore provides advice about how to prioritize implementation in different types of health facilities.

The new guidance builds on previous policy positions of WHO and UNAIDS and responds to a growing demand from countries for more detailed policy and operational advice in this area. Its recommendations were developed following a review of available evidence and a broad consultative process with experts and implementers, including submissions received from over 150 organizations and individuals.

Other key recommendations

Other key WHO/UNAIDS recommendations for provider-initiated HIV testing and counselling in health facilities include:

  • All HIV testing must be voluntary, confidential, and undertaken with the patient's consent.
  • Patients have the right to decline the test. They should not be tested for HIV against their will, without their knowledge, without adequate information or without receiving their test results.
  • Pre-test information and post-test counselling remain integral components of the HIV testing process.
  • Patients should receive support to avoid potential negative consequences of knowing and disclosing their HIV status, such as discrimination or violence.
  • Testing must be linked to appropriate HIV prevention, treatment, care and support services.
  • Decisions about HIV testing in health facilities should always be guided by what is in the best interests of the individual patient.
  • Provider-initiated HIV testing and counselling is not, and should not be construed as, an endorsement of coercive or mandatory HIV testing.
  • Implementation of provider-initiated HIV testing and counselling should be undertaken in consultation with key stakeholders, including civil society groups, acknowledging that what works and is ethical will inevitably differ across countries.
  • When implementing provider-initiated HIIV testing and counselling, equal efforts must be made to ensure that a supportive social, policy and legal framework is in place to maximize positive outcomes and minimize potential harms to patients.
  • A system that monitors and evaluates the implementation and scale-up of provider-initiated testing and counselling should be developed and implemented concurrently.

As countries work towards universal access to HIV prevention, treatment, care and support, the new guidance on provider-initiated HIV testing and counselling offers an important opportunity to introduce new approaches and improve the standards of HIV testing and counselling in both public and private health facilities. Together with their partners, WHO and UNAIDS will continue to help countries expand access to the full range of HIV testing and counselling services, as well as to other needed health sector interventions against HIV/AIDS.

1 HIV is firmly established in the general population. Numerical proxy: HIV prevalence consistently over 1% in pregnant women.
2 HIV has spread rapidly in a defined sub-population, but is not well-established in the general population. Numerical proxy: HIV prevalence is consistently over 5% in at least one defined sub-population, but is below 1% in pregnant women in urban areas.
3 HIV has never spread to significant levels in any sub-population. Numerical proxy: HIV has not consistently exceeded 5% in any sub-population.

For further information, please contact:
London

WHO
Anne Winter
Tel.: +41 79 440 6011
E-mail: wintera@who.int

Cathy Bartley
Tel.: +44 20 8694 9138
Mobile: +44 7958 561 671
E-mail: cathy.bartley@bartley-robbs.co.uk

Geneva

WHO
Iqbal Nandra
Tel.: +41 22 791 5589
Mobile: +41 79 509 0622
E-mail: nandrai@who.int

UNAIDS
Yasmine Topor
Tel.: +41 22 791 3501
Mobile: +41 76 512 8853
E-mail: topory@unaids.org

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