H I V / A I D SDEPARTMENT

WHORachel BaggaleyReuben GranichAmitabh Suthar

Marco Antonio De Avila VitoriaEyerusalem Negussie

Kathleen FoxYing-Ru LoAndrew Ball

Gottfried Hirnschall

Universal access to ART needs universal HIV testing and counselling (HTC)

The HIV testing crisis: 34 million with HIV, only 14 million know it

AIDS health-care foundation satellite

Universal access to ART needs universal HIV testing and counselling (HTC)

Where we are Change in the HTC dialogue

• From caution to urgency1

More tests are being performed in 2010• 95M people 15–49 yrs received HTC2

More health centers offer HTC in 2010• 131,000 health centers globally offered HTC2

More pregnant women accessing HTC in 3010• 35% pregnant women tested globally 67% in eastern and southern Africa2

1Baggaley (2012) From Caution to Urgency: the Evolving Response to HIV Testing WHO bulletin WHO(2011) 2Progress report 2011: Global HIV/AIDS response: Epidemic update and health sector progress towards universal access http://www.who.int/hiv/pub/progress_report2011/en/index.html

Universal access to ART needs universal HIV testing and counselling (HTC)

But… Despite new urgency to test – many people still not convinced

<40% of people with HIV aware (less men know their status than women, in generalized epidemics)

Many people test late

Many tests are re-tests

Inequity – poor service provision for & uptake by key populations, including adolescents

People test alone – confidentiality emphasized & discloser often not actively supported

Poor linkages to prevention, care, & treatment in most HTC settings

Sometimes poor quality services including testing

Provider-initiated testing and counselling(PITC) in Africa

Date not identified

Adoption of a policy on PITC, 2003-2010

Not adopted

Data not available

2009 - 2010

2003 - 2004

2005 - 2006

2007 - 2008

42/53 countries in Africa have PITC policies1

42/53 in ANC 31/53 in TB 3/53 in adults/pediatrics

75% of TB patients2 tested for HIV2

High PITC acceptance by ANC3 & TB patients4

Introduction of PITC ↑pediatric testing to 98% in Zambia5

But many missed opportunities Many clinical settings in generalized epidemics

not offering HTC6

1Baggaley (2012) Bulletin WHO, 2WHO, Global TB control, 2011, 3Etirbet (2004) AIDS Care; Byamugisha (2010) J Int AIDS, 4Corneli (2008) IJTBLD, 5Mutanga (2012) PloS One, 6MacPherson (2012) Trop Med

PITC – achieving near universal HTC in many ANC settings

Hensen. Universal voluntary HIV testing in antenatal care settings: a review of the contribution of PITC. Trop Med Int Health, 2011

But… Is PITC in ANC a priority in low-prevalence epidemics? … Is it acceptable, cost effective, and does it have any impact? How do you balance PITC in ANC with the need to provide HTC for key populations?

Moving testing out of the health center and into the community

Home-based (door-to-door) Community Index-case

Campaigns plus HTCplus – malaria, safe water,

non-communicable diseases (IHD, DM, BP, BMI etc.)

Outreach (mobile) General populations Key populations

Workplaces, schools Kisii (Nyanza) campaign reached 5203 individualsPackage given to 5203 (100%) of people, regardless whether or not they decided to have HIV test 100% tested for HIV329 (6.3%) tested HIV positive255 (78%) had CD4 count determination (median 536)

A new approach – self-testing

Already practiced 'informally' by many health workers1

included in Kenyan HTC Guidelines available over the internet & in pharmacies

in some countries2

Key populations (MSM & PWID) express interest in self-testing3

Uptake and accuracy of oral kits in Malawi “acceptable and accurate"4

Future potential General population? High risk MSM? - Ongoing trial (iTest, University of

Washington, NIMH3) PrEP? – need for those taking PrEP to re-test regularly

?

Supervised self-testing programme, Malawi. Liz Corbett LSHTM2

1Napierala S, (2011). HIV self-testing among health workers. http://whqlibdoc.who.int/publications/2011/9789241501033_eng.pdf2 http://www.test-hiv-yourself.com; http://positivelite.com ; 3 Spielberg (2003) JAIDS; 4Choko (2011) PloS Med ; 4http://clinicaltrials.gov/ct2/show/NCT01161446

A move from an exclusively individual approach → supporting testing for couples and partners

For 30 years• HIV seen as an individual problem• Confidentiality (and secrecy) emphasised• Disclosure not actively encouraged• Little emphasis on partner interventions• Little understanding of serodiscordancy

Couples HTC• Supported disclosure• ↑testing for men• Support for ART access & adherence• Support for PMTCT access & adherence• TasP

Increasing CHTC could have significant prevention, treatment, & social impact

• Inadvertent• Stigma &

discrimination• Ongoing

transmission within relationships

• Increased openness

• ↓stigma & discrimination

• Prevention of transmission within relationships

• ↑access to ART• ↑ adherence• ↑access to PMTCT• Safer conception

WHO CHTC guidelines – 2012

• There are multiple benefits for greater sharing of HIV status and couples testing together

• WHO strongly recommends couples testing & counselling in all settings

• WHO recommends ART for prevention in serodiscordant couples – irrespective of CD4 count – the first formal WHO TasP guidance

• WHO addresses operational issues also considered in the guidelines

http://www.who.int/hiv/pub/guidelines/9789241501972/en/index.html.

What we need for universal HTC

Community approachesGeneralized epidemics - outreach for key pops, consider

door to door, workplace, schools augmented by campaignsLow and Conc epidemics

outreach to key pops

Couples/partner testingGeneralized epidemics

offer to allLow and Conc epidemics offer to partners of +ves

Effective PITC Generalized epidemics

PITC in every health contactLow and Conc epidemics

PITC in select services (TB, STI, Key pops)

• Strengthen anti-discrimination laws• Strengthen linkages to prevention, care, & ART • Community accompaniers• e-technology• Community/media promotion