KEY POINTS
The 5 Cs are essential for all HTS: consent, confidentiality, counselling, correct test results and connection to HIV prevention, treatment and care (see section 1.7).
HTS should be prioritized for and promoted to those who are at high risk and have not been tested recently.
Verbal consent is usually adequate, but all individuals should have a private opportunity to refuse testing. Mandatory testing is never warranted.
HTS must ensure that all tests results and client information are confidential. Although disclosure to sexual partners, supportive family members and health workers is often beneficial, this must be done only by or with the consent of the person being tested.
Retesting for individuals thought to be in the window period is needed only for those who report specific recent risk.
It is the ethical and professional responsibility of the person providing HIV test results to adhere to international and national guidelines to ensure correct test results.
People who test HIV-negative will usually need only brief health information about their HIV status report, how to prevent acquisition of HIV in the future and where and how to link to HIV prevention services, as appropriate. People with significant ongoing risk may need more active support and linkage to HIV prevention services. Everyone who is diagnosed HIV-positive should receive post-test counselling, including couples where one or both are diagnosed HIV-positive.
People whose test results are not yet confirmed or whose HIV status is reported as inconclusive need follow-up services to ensure that they receive an HIV diagnosis.
Key populations need tailored approaches and messages.
Connection to prevention, treatment and care is an essential component of HTS.
3.1. Introduction
Linkage to appropriate services following diagnosis should be regarded as a key component of effective and comprehensive HTS.
Attaining the UN 90–90–90 targets depends on the first 90 – diagnosing 90% of people with an HIV infection. Many people with HIV have already been diagnosed, as evidenced by such achievements as the estimated 13 million people on ART worldwide. Many people needing care and treatment remain undiagnosed, however. Successful linkage from diagnosis to prevention, treatment and care services is also essential to reach the second and third 90s – that 90% of HIV-positive people who have been diagnosed are on ART and that 90% of people with HIV receiving ART have achieved viral suppression (20).
Receipt of an HIV diagnosis empowers individuals to make informed decisions about HIV prevention, treatment and care that will affect both HIV transmission and an individual's health and survival. Therefore, linkage to appropriate services following diagnosis should be regarded as a key component of effective and comprehensive HTS (see Fig. 1.2, page 8).
This chapter discusses essential services prior to HIV testing as well as post-test messages and counselling services. Post-test services are described specifically for individuals who test HIV-negative, individuals who are diagnosed HIV-positive, individuals who receive a reactive test result but need further testing and individuals who have an inconclusive HIV status. The importance of linkages to prevention, treatment and care is explained, and innovative approaches to improve successful linkages are explored.
3.2. Services prior to HIV testing
Certain basic services should be provided prior to testing in all settings, regardless of the approach used to deliver HTS (see Chapter 4 for description of various approaches). These services apply to all adults, couples or partners, and adolescents. Specific pre-test services for testing of children are described in Operational guidelines on HIV testing and counselling of infants, children and adolescents for service providers in the African region (http://tinyurl.com/hivtestguideafro) (46).
3.2.1. Promoting HTS
Many countries and programmes have vigorously promoted HTS through mass media, including radio, television, billboards and posters, the Internet and electronic social media. The use of the mass media has been shown to increase the uptake of HTS in the short term (47). In both high and low HIV prevalence countries, as a result of campaigns and promotional activities, there is widespread knowledge that HTS are available and where they are available. For example, among countries with generalized epidemics, recent Demographic and Health Surveys indicate that in Zambia (2014) 96% and in Tanzania (2011–2012) 91% of both men and women know where to receive an HIV test. Knowledge of where to receive HIV testing in countries with concentrated epidemics is lower but still widespread. For example, among both men and women, 69% in Cambodia (2010) and 71% in Sierra Leone (2013), know where to receive a test. Some countries report gender differences. For example, in the Dominican Republic (2010) 96% of women and 85% of men knew where to receive a test, and in Ethiopia (2011) 66% of women and 82% of men knew where to receive one.
Since knowledge of HIV testing and of where it is available is widespread, the continued need for promotion addressing the general population should be assessed. Depending on the goals of the HTS programme, general promotion and awareness campaigns for HTS may no longer be necessary. Even in countries with generally widespread knowledge of HIV testing, however, promotional activities may need to focus on populations where HIV testing rates remain suboptimal, including key populations and adolescent groups, which will likely require tailored messages and approaches – for example, via social media.
Case examplesPromoting HIV testing services
In China a 24-hour online HIV test scheduler and “Easy Tell”, an anonymous partner notification system, supported HIV self-testing.
In Macedonia members of parliament received HIV testing through mobile services; this event publicized the benefits of HIV testing.
In Kenya a professionally designed four-phase mass media campaign significantly increased testing when it directly mentioned HIV and the personal, family and prevention benefits of testing (48).
In Lebanon activities including word-of-mouth, outreach campaigns, referrals from health-care providers and social media promoted a specialized medical centre offering sexual health services for men who have sex with men, sex workers and transgender people.
In Lithuania an association of women affected by HIV and their families organized a mobile HIV testing tour. To promote uptake, city mayors, other municipal leaders, public health and prison authorities, and local media were informed about the programme, and newspapers, radio and television presented over 80 communications about the mobile services.
Sources: Marum et al., 2008 (48); Annex 3.
In addition to outreach and promotion, clear signs that direct prospective clients to testing are important. This applies to testing in health facilities, in the community and through mobile services. In certain clinic settings, where HIV testing is routinely offered, such as ANC, STI clinics and TB services, signs, printed information and posters and group health education sessions can efficiently inform pregnant women, other clients and family members that testing is offered.
3.2.2. Creating an enabling environment
Critical enablers are elements outside of health sector interventions that allow health interventions and services to be provided effectively and safely. Examples range from tolerance among the larger population toward people from key populations to laws and policies that enable young people to be tested without parental consent. While these factors are not directly the responsibility of the health sector, health-care providers and organizations delivering HTS should work with community-based organizations, legal authorities and advocacy organizations to ensure that the environment supports and enables people to learn their HIV status. For a description of critical enablers, see Chapter 4 and the Consolidated guidelines on diagnosis, prevention, care and treatment for key populations (http://www.who.int/hiv/pub/guidelines/keypopulations/en/) (10).
WHO recommendation
Initiatives should be put in place to enforce privacy protection and institute policy, laws and norms that prevent discrimination and promote tolerance and acceptance of people living with HIV. This can help create environments where disclosure of HIV status is easier (strong recommendation, low quality of evidence).
Source: WHO, 2011 (49).
3.2.3. Ensuring a confidential setting and preserving confidentiality
All HTS providers must remain committed to preserving confidentiality, one of the 5 Cs of HTS (see Section 1.7). Confidentiality applies not only to the test results and reports of HIV status but also to any personal information, such as information concerning sexual behaviour and the use of illegal drugs. HTS should avoid practices that can inadvertently reveal a client's test results, or HIV status, to others in the waiting room or in the health facility. Such practices might include counselling all people diagnosed HIV-positive in a special room or by a specific provider or making it obvious to others which clients will need or is receiving additional testing or lengthy post-test counselling. Lack of confidentiality discourages people from using HTS. For example, in Cambodia some sex workers refused HIV testing because the outreach setting where peer educators were providing counselling was not perceived as private (50). Health workers and others who provide HIV testing may need special training and sensitization regarding the confidentiality of medical records, particularly where key populations are concerned.
3.2.4. Providing pre-test information
Historically, HIV counselling has been provided both before and after HIV testing. Before the introduction of RDTs, same-day results were not feasible, so counsellors included comprehensive information in the pre-test session in case the client did not return for their test results. Moreover, in the pre-treatment era pre-test counselling often focused on providing a risk assessment, preparing clients to cope with an HIV-positive diagnosis in the absence of treatment and encouraging clients to return to receive their test results.
With the widespread use of HIV RDTs, most people receive their HIV test results – at least results of the first test – and often a diagnosis on the same day. Therefore, intensive pre-test counselling is no longer needed and may create barriers to service delivery (51, 52). Individual risk assessment and individualized counselling during the pre-test information session is no longer recommended. Depending on local conditions and resources, programmes may provide pre-test information through individual or group information sessions and through media such as posters, brochures, websites and short video clips shown in waiting rooms. When children and adolescents are receiving HTS, information should be presented in an age-appropriate way to ensure comprehension.
Offering or recommending HIV testing to a client or a group of clients includes providing clear and concise information on:
the benefits of HIV testing
the meaning of an HIV-positive and an HIV-negative diagnosis
the services available in the case of an HIV-positive diagnosis, including where ART is provided
the potential for incorrect results if a person already on ART is tested
a brief description of prevention options and encouragement of partner testing
the fact that the test result and any information shared by the client is confidential
the fact that the client has the right to refuse to be tested and that declining testing will not affect the client's access to HIV-related services or general medical care
potential risks of testing to the client in settings where there are legal implications for those who test positive and/or for those whose sexual or other behaviour is stigmatized
an opportunity to ask the provider questions.
Special considerations for pregnant or postpartum women
Pre-test information or health education for women who are or may become pregnant or are postpartum should also include:
the potential risk of transmitting HIV to the infant
measures that can be taken to reduce mother-to-child transmission, including the provision of ART to benefit the mother and prevent HIV transmission to the infant
counselling on infant feeding practices to reduce the risk of HIV transmission
the benefits of early HIV diagnosis for mothers and infants
encouragement for partner testing.
Supporting intensified tuberculosis case finding at HIV testing facilities
Tuberculosis (TB) is the most common presenting illness among people with HIV. It is fatal if undetected or untreated and is the leading cause of death among people with HIV, responsible for about one of every four HIV-associated deaths. Early detection of TB and prompt linkage to TB treatment along with ART can prevent these deaths. HTS provides an important opportunity for intensified TB case finding and, thus, early detection and treatment of TB.
HTS should integrate screening for TB symptoms into the information session before HIV testing, both at health facilities and in community-based testing.
HTS should integrate screening for TB symptoms into the information session before HIV testing, both at health facilities and in community-based testing. All clients with TB symptoms should be thoroughly investigated, and post-test counselling should discuss the outcome of this investigation. All clients diagnosed with TB should be promptly registered with the national TB programme and started on anti-TB treatment. HIV-positive clients diagnosed with active TB should be urgently started on ART, regardless of CD4 count, while those not having TB should consider TB preventive therapy (for example, isoniazid preventive therapy) as indicated in the schema in Fig. 3.1.
Fig. 3.1
HIV/TB testing and screening algorithm to increase TB case finding in HTS. * Per national guidelines.
Case exampleIn India intensified TB case finding is systematic at all HIV testing facilities
Health workers or trained lay providers at HIV testing facilities screen each client for the presence of cough for two weeks, fever, weight loss and night sweats or other symptoms suggestive of pulmonary or extra-pulmonary TB. This screening is an integral part of pre-test information. All symptomatic clients are systematically referred and enrolled for investigations in the same facility. This activity is routinely reported to the district, state and national levels. The following table summarizes the data for four recent years.
| Year | Total clients attending HIV testing centres (excluding pregnant women) | Presumptive TB cases identified | Total TB cases diagnosed among presumptive | Proportion of HIV-positive TB patients started on ART |
|---|---|---|---|---|
| 2010 | 7 678 746 | 484 617 | 51 412 | 57% |
| 2011 | 9 774 581 | 580 695 | 55 572 | 59% |
| 2012 | 9 193 113 | 552 350 | 46 863 | 59% |
| 2013 | 7 264 722 | 620 539 | 64 506 | 88% |
Source: TB India, 2014 (53).
Special considerations for couples or partners who ask to be tested together
An increasing number of countries offer couples counselling and partner testing, which promotes mutual disclosure of HIV status and increases adoption of prevention measures, especially in the case of discordant couples (one HIV-positive partner and one HIV-negative partner). The pre-test information session for couples should not ask about past sexual behaviour or risks, as this is unnecessary and may create problems for the couple. The person conducting a pre-test information session should make clear that both testing and post-test counselling can be provided individually, if either partner prefers, and that disclosure of HIV status to the other person is not required. For more information on couples testing, see Guidance on couples HIV testing and counselling including antiretroviral therapy for treatment and prevention in serodiscordant couples (http://apps.who.int/iris/bitstream/10665/44646/1/9789241501972_eng.pdf) (16).
Special considerations for key populations
There are many reports of discrimination and stigma against people from key populations in health-care settings. In many settings health workers lack experience, knowledge or training on how to provide inclusive and non-judgemental HTS for key populations. Countries should prioritize the training of health workers so that they can provide acceptable services, better understand the needs of key populations and be familiar with local support and prevention services (10). Links with key population networks and community-based organizations to support or provide HTS, including services delivered by peers, may increase reach, uptake and acceptability.
Consent by adults
Informed consent remains one of the essential 5Cs of testing services. It should always be obtained individually and in private by an HTS provider. In most settings verbal consent for HIV testing is sufficient. The provider must ensure that the client has learned enough about testing to give informed consent. HTS may provide information about testing and the need for consent in a group setting, such as group health education, but clients should give consent in an individual and private manner. In settings such as ANC or TB clinics, where HIV testing is routine, health workers should carefully explain how a client can decline testing and ensure that each person has a private opportunity to opt out of testing. People who are under the influence of drugs or alcohol or otherwise mentally impaired should not be tested, as they are not able to give informed consent. HTS should ensure that no one coerces clients into being tested.
Consent by adolescents
Policies related to age of consent for testing can pose barriers to adolescents' access to HIV testing and other health services. While policies on age of consent for HIV testing vary among countries, ministries of health are encouraged to review these policies in light of the need to uphold adolescents' rights to make choices about their own health and well-being (with consideration for different levels of maturity and understanding). All training materials should address applicable laws and regulations regarding age of consent for HIV testing and situations in which minors may consent for themselves. All staff involved in HTS should be aware of their countries' laws and regulations. For more information see HIV and adolescents: guidance for HIV testing and counselling and care for adolescents living with HIV (http://www.who.int/hiv/pub/guidelines/adolescents/en/) (54) and Adolescent HIV testing, counselling and care: implementation for health providers and planners (http://apps.who.int/adolescent/hiv-testing-treatment/page/Informed_consent_and_HIV_testing) (55).
3.3. Services for those who test HIV-negative
Individuals who test HIV-negative should receive brief health information about their test results. Research to date has not demonstrated that a lengthy counselling session is needed or is beneficial. Further, lengthy post-test counselling for people testing negative may divert counselling resources that are needed by those who test HIV-positive, those whose results are inconclusive and those who are found to be in a serodiscordant relationship (52, 56).
Counselling for those who test HIV-negative should include the following:
an explanation of the test result and reported HIV status;
education on methods to prevent HIV acquisition and provision of male or female condoms, lubricant and guidance on their use;
emphasis on the importance of knowing the status of sexual partner(s) and information about the availability of partner and couples testing services;
referral and linkage to relevant HIV prevention services, including voluntary male medical circumcision (VMMC) for HIV-negative men, PEP, PrEP for people at substantial ongoing HIV risk;
a recommendation on retesting based on the client's level of recent exposure and/or ongoing risk of exposure (see next section);
an opportunity for the client to ask questions and request counselling.
3.3.1. Retesting during the window period
In many settings post-test counselling messages recommend that all people who have a non-reactive (HIV-negative) test result should return for retesting to rule out acute infection that is too early for the test to detect – in other words, in the window period. However, retesting is needed only for HIV-negative individuals who report recent or ongoing risk of exposure. For most people who test HIV-negative, additional retesting to rule out being in the window period is not necessary and may waste resources.
For most people who test HIV-negative, additional retesting to rule out being in the window period is not necessary.
The routine and widely reiterated advice to everyone with a negative test result to retest after a “three-month window period” is not appropriate. This is because most people who receive HIV testing and test HIV-negative, particularly where HIV testing is offered routinely in clinical settings, will not be at risk from recent infection. For a small minority who identify a specific recent suspected exposure, retesting after four to six weeks can be advised.
See Table 3.1, page 31, and Delivering HIV test results and messages for retesting and counselling in adults (http://www.who.int/hiv/pub/vct/hiv_re_testing/en/) (12) for detailed and specific guidance on messages concerning retesting.
Table 3.1
HIV care and prevention services by test status.
3.3.2. Retesting for those who remain at high risk of HIV acquisition
People who are diagnosed HIV-negative but remain at high risk, such as some people from key populations, may benefit from regular retesting. Retesting gives these people both the opportunity to ensure early HIV diagnosis and to receive ongoing health education on HIV prevention. WHO recommends that people in high-risk categories retest at least annually (12).
3.3.3. Services for adolescents who test HIV-negative
Particularly in high prevalence settings, adolescents who test HIV-negative need information and education about healthy behaviours, such as correct and consistent condom use, reduction of risk-associated behaviours and prevention of HIV and unwanted pregnancy and about the need for retesting if they have new sexual partners. Those testing negative also need referral to appropriate prevention services, such as VMMC, contraception and harm reduction (54). For more information see HIV and adolescents: guidance for HIV testing and counselling and care for adolescents living with HIV (http://apps.who.int/iris/bitstream/10665/94334/1/9789241506168_eng.pdf) (55).
3.3.4. Services for partners who both test HIV-negative
Particularly in high prevalence settings, couples and others who test for HIV with a sexual partner and are both diagnosed HIV-negative can benefit from the standard health information and prevention education given to individuals who test negative. In addition, the counsellor or health worker may offer further counselling at the couple's or a partner's request.
3.4. Services for those whose HIV status is inconclusive or test results are not yet confirmed
An HIV-inconclusive status means, in high prevalence settings, that the first reactive test result was not confirmed by additional testing using subsequent HIV assays or that, in low prevalence settings, the first two test results were reactive but the third assay was non-reactive (see Chapter 7). All clients with an HIV-inconclusive status should be encouraged to return in 14 days for additional testing to confirm their diagnosis.
Receiving an HIV-inconclusive status may be confusing and stressful for the individual or couple and may be difficult for the provider to explain. As with many other tests for medical conditions, resolving the discrepancy with a third test is not useful, given the high probability that it may equally produce a false-reactive result. Most, if not all, HIV-inconclusive statuses can be resolved with retesting 14 days later. (For a full discussion of discrepant test results and resolving an HIV-inconclusive status, see Chapter 7.) Clients with an HIV-inconclusive status should be told that a definitive diagnosis cannot be provided that day and that immediate referral to HIV care or ART initiation is not appropriate. They should be given a clear plan for follow-up testing.
Unconfirmed results occur when clients who have an initially reactive HIV test result do not receive additional testing in the same visit to confirm their HIV diagnosis. This may occur in community settings where only one assay is performed, an approach known as test for triage (see Chapter 4). It is the responsibility of providers and counsellors to explain that this initial result is not an HIV diagnosis and needs confirmation and to refer clients with a reactive test result to a site where they can receive an HIV diagnosis. These providers should encourage clients to go as soon as possible to a facility, such as a clinic or laboratory, for additional HIV testing and a diagnosis. It is not necessary for these clients to wait 14 days to go to the facility. After the test result is confirmed and an HIV diagnosis is given, HIV-positive clients should receive post-test counselling. In particular, every effort is needed to reduce loss to follow-up between a test for triage and additional testing and HIV diagnosis.
3.5. Services for those whose test results are HIV-positive
An HIV-positive diagnosis is a life-changing event. Before giving HIV-positive test results, the health worker, trained lay provider, or counsellor should keep in mind the 5 Cs of HTS, as recommended by WHO and UNAIDS, in particular correct test results (see section 1.7). It is the professional and ethical duty of the person providing the HIV diagnosis to ensure that testing procedures follow WHO-recommended testing strategies as described in Chapter 7.
A diagnosis of HIV infection is a life-changing event. Before giving these results, the provider should keep in mind the 5 Cs of HTS.
Once health workers or lay providers are confident of adherence to all measures to ensure correct test results, they should provide post-test health education and counselling. All post-test counselling should be “client-centred”, which means avoiding formulaic messages that are the same for everyone regardless of their personal needs and circ*mstances. Instead, counselling should always be responsive to and tailored to the unique situation of each individual or couple. Health workers, professional counsellors, social workers and trained lay providers can provide counselling. People with HIV who are trained in counselling may be particularly understanding of the needs and concerns of those who receive an HIV-positive diagnosis.
WHO good practice recommendation
To ensure that clients who are misdiagnosed are not needlessly placed on lifelong ART (with potential side-effects, waste of resources and psychosocial and emotional implications), WHO recommends that all clients be retested to verify their HIV diagnosis prior to enrolling in care and/or starting ART.
Source: WHO, 2012 (44); WHO, 2014 (57).
The information and counselling that health workers, or others, should provide to HIV-positive clients is listed below. Absorbing all of this information in one session may be very challenging, and a follow-up counselling session may be required. Indeed, the shock of learning of an HIV-positive diagnosis may make it difficult for a person to take in further information immediately.
Explain the test results and diagnosis.
Give the client time to consider the results and help the client cope with emotions arising from the diagnosis of HIV infection.
Discuss immediate concerns and help the client decide who in her or his social network may be available to provide immediate support.
Provide clear information on ART and its benefits for maintaining health and reducing the risk of HIV transmission, as well as where and how to obtain ART.
Make an active referral for a specific time and date. (An active referral is one in which the tester makes an appointment for the client or accompanies the client to an appointment, including an appointment for co-located services, and enrolment into HIV clinical care.) Discuss barriers to linkage to care, same-day enrolment and ART eligibility assessment. Arrange for follow-up of clients who are unable to enrol in HIV care on the day of diagnosis.
Provide information on how to prevent transmission of HIV, including information of the reduced transmission risk when virally suppressed on ART; provide male or female condoms and lubricants and guidance on their use.
Discuss possible disclosure of the result and the risks and benefits of disclosure, particularly among couples and partners. Offer couples counselling to support mutual disclosure.
Encourage and offer HIV testing for sexual partners, children and other family members of the client. This can be done individually, through couples testing, index testing or partner notification.
Assess the risk of intimate partner violence and discuss possible steps to ensure the physical safety of clients, particularly women, who are diagnosed HIV-positive.1
Assess the risk of suicide, depression and other mental health consequences of a diagnosis of HIV infection.
Provide additional referrals for prevention, counselling, support and other services as appropriate (for example, TB diagnosis and treatment, prophylaxis for opportunistic infections, STI screening and treatment, contraception, ANC, opioid substitution therapy (OST), and access to sterile needles and syringes, and brief sexuality counselling (58)).
Encourage and provide time for the client to ask additional questions.
Case exampleAdhara HIV/AIDS Association, Spain
In Seville a community-based outreach programme of the Adhara HIV/AIDS Association (http://www.adharasevilla.org) makes sure that the partner of someone testing HIV-positive is promptly linked to a consultation with an HIV specialist. They have compared this strategy with voluntary HIV testing at community centres and found that the number of newly diagnosed HIV-positive cases at the detached community centre was was lower compared with using the index partner testing strategy.
Source:Annex 3.
3.5.1. Special considerations concerning disclosure
People who test HIV-negative rarely need assistance or support with disclosing their HIV status to others. In contrast, maintaining privacy about testing HIV-positive and deciding about disclosure are serious concerns for many who are diagnosed HIV-positive.
There are three forms of disclosure relevant and appropriate to HIV testing:
Disclosure by the individual to a sexual partner, family member or friend. Such disclosure can have considerable benefits, particularly for couples and sexual partners. However, many clients who learn that they are HIV-positive need time to absorb the diagnosis before they are ready to disclose and may benefit from additional counselling. Research findings on the consequences of disclosure, especially disclosure by women to their male partners, are mixed. Women who have experienced intimate partner violence prior to testing may experience violence from their partner after disclosing their HIV status. Providers and counsellors should assess the risk of intimate partner violence in the individuals they serve (59, 60) and make referrals as needed.
Disclosure by a health worker to a sexual partner of the individual. In some settings laws or regulations require the disclosure of HIV-positive status to sexual and/or drug-injecting partners. Where this is the case, providers should discuss this with clients before asking for informed consent for testing. Providers need to be sensitive to clients who may be more susceptible to adverse outcomes of disclosure, such as discrimination, violence, abandonment or incarceration and to adapt counselling accordingly. Such clients may need additional counselling both before and after testing.
Disclosure by a health worker to other health workers involved in the client's care. Providers need to inform people who test positive that, in order to assure appropriate medical care, the diagnosis will be shared with other medical workers as needed. Such disclosure should respect the client's basic right to privacy and confidentiality of all medical information.
Disclosure by a health worker to the police or other legal authorities is not considered ethical in the context of HTS unless the client has consented to this disclosure. In this case HTS providers should obtain written consent to disclose a client's HIV status to legal authorities.
3.5.2. Post-test counselling for special populations
Key populations. Intensified post-test counselling combined with follow-up counselling by community health workers significantly increases the proportion of people with HIV from key populations who enrol in HIV care (61). Also, people who inject drugs are more likely to start and stay in HIV treatment if they are participating in OST programmes (62). Therefore, referral to community health workers and to other services such as OST should be included in post-test counselling for people from key populations. Some people from key populations who test HIV-positive may lack social networks and/or a supportive family to help them deal with their diagnosis. These people may need additional counselling as well as peer support services to cope with this diagnosis. A peer counsellor may particularly help people understand and cope with the diagnosis and support linkage to care and treatment by serving as a “peer navigator”, who assists with finding, choosing and obtaining a full range of services.
The 2014 WHO Consolidated guidelines on HIV prevention, diagnosis, treatment and care for key populations (http://www.who.int/hiv/pub/guidelines/keypopulations/en/) (10) describes essential services for key populations. In terms of HTS these guidelines describe interventions to reduce barriers to testing and to linkage to care after testing.
Couples and partner HIV testing services. Couples counselling requires additional training and enhanced counselling skills. Post-test counselling for serodiscordant couples may be especially challenging, as these results may be hard for the provider to explain and difficult for the couple to accept. For more guidance on post-test counselling and services for discordant couples, see Guidance on couples HIV testing and counselling including antiretroviral therapy for treatment and prevention in serodiscordant couples (http://apps.who.int/iris/bitstream/10665/44646/1/9789241501972_eng.pdf) (16).
Pregnant women. Post-test counselling for pregnant women who are diagnosed with an HIV infection should include the following, in addition to the standard messages described above for all people diagnosed with HIV infection:
childbirth plans: providers should encourage HIV-positive pregnant women to deliver in a health facility for their own well-being as well as to ensure access to PMTCT services;
use of ARVs for the client's health, when indicated and available, as well as the use of ARVs to prevent transmission to the infant;
the importance of partner testing and information on the availability of couples testing services;
ensuring screening for TB and testing for other infections such as syphilis;
counselling on adequate maternal nutrition, including iron and folic acid;
advice on infant feeding options and support to carry out the mother's infant feeding choice;
HIV testing for the infant and needed follow-up for HIV-exposed infants.
Adolescents. Along with standard messages for all those diagnosed with an HIV infection, post-test counselling for adolescents with HIV should include (54):
tailored help with linkage to HIV care and treatment;
counselling, referral and linkage to specific psychosocial and mental health services tailored to both the situation in which infection happened and the developmental age of the individual;
information on adolescents' rights and responsibilities, especially their right to confidentiality;
an opportunity to ask questions and discuss issues related to sexuality and the challenges they may encounter in relationships, marriage and childbearing;
individualized planning on how, when and to whom to disclose HIV status and engage families and peers in providing support;2
referral for small-group counselling and structured peer support groups, which may particularly benefit adolescents with HIV.
Children. Informing children of their HIV diagnosis is complex, and the approach depends on the child's age and the counselling skills of the health-care provider. For information on disclosure to children, see Guidance on HIV disclosure counselling for children 12 years of age and younger (http://www.who.int/hiv/pub/hiv_disclosure/en/) (49).
3.6. Linkage to care
Without linkage to treatment and care, testing and learning one's HIV-positive status have limited value. Also, those who test HIV-negative, if at continuing high risk, as well as those who test HIV-positive, need linkage to prevention services. Table 3.1 classifies the variety of services that may be appropriate links for people with HIV and for people who test HIV-negative. WHO provides guidance on the HIV care and prevention services that may be offered according to client needs and overall context (13).
Key messages about linkages and connections to prevention, treatment and care
There appear to be good practices that support linkage to prevention, treatment and care (see box, next page). However, evidence is limited.
All people who test HIV-positive need immediate linkage to care to maximize the benefits of ART.
Special efforts will be needed to link people who have a reactive test result in a community setting to facility-based services for additional testing and an HIV diagnosis. For those diagnosed HIV-positive, retesting to verify diagnosis is critical before care or treatment is initiated.
People diagnosed HIV-positive and those testing HIV-negative with ongoing HIV risk need to be linked to prevention services.
National policies and strategic planning are needed to improve access to and uptake of HIV testing as well as linkage from testing to prevention, treatment and care.
3.6.1. Linkage to treatment and care
Linkage is defined as a process of actions and activities that support people testing for HIV and people diagnosed with HIV to engage with prevention, treatment and care services as appropriate for their HIV status. For people with HIV, it refers to the period beginning with HIV diagnosis and ending with enrolment in care or treatment (64).
Linkage to care after receiving an HIV-positive diagnosis remains challenging. In resource-limited settings, primarily sub-Saharan Africa, it is estimated that as much as 40% of people who are diagnosed through HTS are not linked to care (25, 37, 38), and late initiation of ART continues to be common (39). Factors that may contribute to poor linkage and particularly to poor rates of enrolment in care and treatment following HIV testing range from client factors, such as feeling healthy, depression, lack of social or family support and fear of disclosure, to social or cultural factors, such as stigma and discrimination, structural or economic factors, including legal issues and lack of transportation, and health system barriers, such as poor referrals, stigmatizing or unfriendly services and long waiting times in facilities (65, 66).
Good practices to increase linkage
Providers of HTS have a crucial role in ensuring linkage to care for people diagnosed with an HIV infection, whether that linkage is quick or delayed. Prompt linkage to HIV care and treatment is ideal and should be encouraged. However, many people do not link to care and treatment immediately. Often, people need time to accept the diagnosis and seek support from partners and families before linking to care (67), and others cycle in and out of care (37). Systematic reviews and several studies describe practices, listed below, that may improve linkage to care and treatment of people who have received an HIV-positive diagnosis.
Good practices include
Comprehensive home-based HIV testing, which includes offering home assessment and home-based ART initiation (52, 68–70);
Integrated services, where HIV testing, HIV prevention, treatment and care, TB and STI screening and other relevant services are provided together at a single facility or site (34);
Providing on-site or immediate CD4 testing with same-day results (37, 70–74);
Providing assistance with transport, such as transportation vouchers, if the ART site is far from the HTS site (37, 75);
Decentralized ART provision and community-based distribution of ART (76);
Support and involvement of trained lay providers who are peers and act as peer navigators, expert patients/clients and community outreach workers to provide support and to identify and reach people lost to follow-up (76–78);
Intensified post-test counselling by community health workers (79);
Using communication technologies, such as mobile phones and text messaging, which may help with disclosure, adherence and retention (80–82), particularly for adolescents and young people (54);
Providing brief strengths-based case management, which emphasizes people's self-determination and strengths, is client-led and focuses on future outcomes, helps clients set and accomplish goals, establishes good working relationships among the client, the health worker and other sources of support in the community, and provides services outside of office settings (52, 83, 84);
Promoting partner testing may increase rates of HIV testing and linkage to care, as may approaches in PMTCT settings that encourage male involvement (85, 86).
Intimate partner notification by the provider, with permission, is feasible in some settings; it identifies more HIV-positive people and promotes their early referral to care (87–90).
Case examples“Test, treat and retain” – continuum of care and assessment tool in the Eastern Mediterranean
In an effort to improve linkage to services, the WHO Regional Office for the Eastern Mediterranean developed a tool to assess the barriers to HIV testing, treatment and care. As a result of this assessment, Egypt, Iran, Pakistan and Sudan all were able to identify programmatic weaknesses that caused poor linkage rates.
In Egypt the assessment identified client factors as the key barriers to linking to HIV treatment. Clients fear disclosure and lack of confidentiality along the continuum of care.
In Iran the assessment showed that loss to follow-up is highest among people who inject drugs; 62% of people who inject drugs who had an initial reactive RDT did not link to laboratory-based confirmatory testing.
In Pakistan also, it was difficult to link people who inject drugs to confirmatory testing and, as appropriate, to HIV care and treatment. In fact, many people who inject drugs in Pakistan refused services, often due to fear of stigma and discrimination.
In Sudan efforts are underway to improve linkage to care from outreach mobile testing, which has had poor linkage rates, by introducing peer navigators to help and support clients in linking to services.
Sources: EMRO, 2014 (91); Annex 3.
3.6.2. Linkage to HIV prevention services
A range of HIV prevention services should be available for those with HIV, in addition to timely initiation of ART (92), and for those who are HIV-negative, (see Table 3.1).
Linkage to prevention services for people who test HIV-negative is not well-documented or studied. It is important to support linkage to prevention services for those with the greatest ongoing risk, for example, people in settings of high HIV incidence, people from key populations and others at high risk of HIV, such as serodiscordant couples. In VMMC-priority countries, linking HIV-negative men to VMMC services is important. Although linkage of men and boys eligible for VMMC from HIV testing to VMMC services can be challenging, it can succeed when linkage is prioritized. For example, in a Mozambique programme where lay providers' HTS was performed, 68% of HIV-negative males were linked to VMMC services (93).
Case exampleGovernment of Mozambique and Jhpiego VMMC programme
The Government of Mozambique and Jhpiego provide a voluntary medical male circumcision (VMMC) programme and a related home- and community-based HTS programme. The HTS programme uses lay providers employed by local community and faith-based groups; they are known as community counsellors. Home-based HTS has been very acceptable to Mozambican communities, with more than one million clients tested between 2007 and 2014. Over the years the role of the community counsellors has expanded to include additional health screening and education.
The Mozambican VMMC programme began in November 2009 and had reached 322 129 men as of February 2015. In 2012, as the number and capacity of VMMC sites expanded, a decision was taken to train the community counsellors to refer men testing HIV-negative at home or at other community settings to VMMC services. Considerable effort was made to ensure that the community counsellors would be perceived as credible sources of information about VMMC. First, they attended a VMMC counselling training, followed by a two-week internship at a VMMC site. During their internship, they provided HTS for VMMC clients and had the opportunity to observe client flow from group education to post-operative follow-up. Two-thirds of men linked to the VMMC site received circumcisions.
Source:Annex 3.
3.6.3. Linkage policy
Countries should consider policies and strategies to improve and prioritize linkage between HTS and prevention, treatment and care services.
For example, in 2009 the Ethiopia Ministry of Health developed its National Referral and Linkage Strategy (94). Key aspects of this strategy include activities to:
strengthen the community environment to reduce stigma and increase community-based support for treatment adherence and retention
improve service delivery, reporting and feedback mechanisms
reduce barriers to care, such as administrative processes and the requirement for identification cards for enrolment in HIV care (94).
Monitoring people's linkage following HIV testing is critical to strengthening treatment and prevention cascades. For additional guidance on the monitoring and evaluation of linkage to prevention, treatment and care services, see:
Consolidated strategic information guide for HIV in the health sector (http://www.who.int/hiv/pub/guidelines/strategic-information-guidelines/en/) (95).
Metrics for monitoring the cascade of HIV testing, care and treatment services in Asia and the Pacific (http://www.wpro.who.int/hiv/documents/Metrics_to_Mmnitor_and_evaluate_the_Impact_of_ART/en/) (96).
- 1
Training in assessment of intimate partner violence and knowledge of referral sources is helpful.
- 2
Additional WHO guidance on disclosure to and by adolescents appears at: http://apps
.who.int/adolescent /hiv-testing-treatment /page/disclosure.
