The World Health Organization (WHO) has issued new recommendations for HIV Testing Services (HTS).
Background Information:
The term “HIV testing services” embraces the full range of services that should be provided together with HIV testing. This includes
- counselling (brief pretest information and post-test counselling);
- linkage to appropriate HIV prevention, care and treatment services and other clinical and support services; and
- coordination with laboratory services to support quality assurance.
Key Messages:
Demand Creation:
Demand creation to increase HTS uptake and engage those in greatest need of services is a valuable tool for mitigating stigma, discrimination and criminalization.
Evidence-based platforms for delivering demand creation include:
- peer-led demand creation interventions, including mobilization;
- digital platforms, such as short pre-recorded videos encouraging testing.
Approaches that have showed evidence of increasing demand include:
- advertisement of specific HTS attributes;
- brief key messages and counselling by providers (less than 15 minutes);
- messages during couples counselling that encourage testing;
- messages related to risk reduction and economic empowerment, particularly for people who inject drugs;
- motivational messages.
Evidence suggests that the following approaches may be less effective for demand creation:
- personal invitation letters;
- individualized content messaging;
- counselling focused on building relationship between the client and counsellor;
- general text messages, including SMS.
Facility Based HTS:
All pregnant women should be tested for HIV, syphilis and hepatitis B surface antigen (HBsAg) at least once and as early as possible.
Dual HIV/syphilis rapid diagnostic tests (RDTs) can be the first test in HIV testing strategies and algorithms in ANC.
a. High HIV burden settings
HIV testing should be offered to all populations and in all services (for example, services for sexually transmitted infection (STI), hepatitis, tuberculosis (TB), children under five, immunization, malnutrition, ANC and all services for key populations) as an efficient and effective way to identify people with HIV.
b. Low HIV burden settings
HIV testing should be offered for :
- adults, adolescents or children who present in clinical settings with signs and symptoms or medical conditions that could indicate HIV infection, including TB and STIs
- HIV-exposed children and symptomatic infants and children
- key populations and their partners
- all pregnant women.
Community Based HTS:
a. High HIV burden settings
WHO recommends community-based HIV testing services, with linkage to prevention, care and treatment services, in addition to routinely offering facility-based testing, particularly for key populations.
b. Low HIV burden settings
WHO recommends community-based HIV testing services, with linkage to prevention, care and treatment, in addition to facility-based testing, for key populations.
HIV self-testing:
HIV self-testing should be offered as an approach to HIV testing services.
Provider assisted referral (index testing/ assisted partner notification):
Provider-assisted referral should be offered for all people with HIV as part of a voluntary comprehensive package of testing, care and prevention.
Social network-based approaches:
Social network-based approaches can be offered as an HIV testing approach for key populations as part of a comprehensive package of care and prevention.
Lay provider HIV testing:
Lay providers who are trained and supervised can independently conduct safe and effective HIV testing using rapid diagnostic tests (RDTs)
Retesting:
All settings
Only specific groups of people in high HIV burden settings or individuals with HIV-related risks need post test counselling messages encouraging retesting at the appropriate intervals.
WHO guidance recommends annual retesting for:
all sexually active individuals in high HIV burden settings and;
people who have ongoing HIV-related risks in all settings. These include:
- key populations, defined as men who have sex with men, people in prison or closed settings, people who inject drugs, sex workers and transgender people;
- country or epidemic specific risk groups such as men and adolescent girls and young women in southern Africa
- people with a known HIV-positive partner.
Retesting in special groups.
In certain situations, individuals who have been tested for HIV in the past can be retested. These include:
- individuals presenting with a diagnosis or receiving treatment for STIs or viral hepatitis;
- individuals with a confirmed or presumptive TB diagnosis
- outpatients presenting with clinical conditions or symptoms indicative of HIV
- individuals with recent HIV risk exposure.
More frequent retesting, that is every 3–6 months, may be warranted based on individual risks factors and as part of broader HIV prevention interventions. For instance, individuals taking PrEP who require quarterly HIV testing or key populations who present to services with an STI.
Retesting in pregnant and post-partum women
a. High HIV burden settings
Retest all pregnant women with unknown or HIV-negative status in late pregnancy – at third trimester visit. If either the first test or retest is missed or delayed, “catch-up” testing is needed.
An additional retest for women of unknown or HIV-negative status in the post-partum period can be considered.
b. Low HIV burden settings
Retest pregnant women with unknown or HIV-negative status who are in serodiscordant relationships, where the partner is not virally suppressed on ART, or have other known ongoing HIV risk in late pregnancy – at a third trimester visit. If either the first test or retest is missed or delayed, “catch-up” testing is needed.
An additional retest for women of unknown or HIV-negative status in the post-partum period can be considered among women from key populations or who have partners with HIV who are not virally suppressed.
HIV Diagnosis and Testing Strategies:
a. Western blotting
Western blotting and line immunoassays should not be used in national HIV testing strategies and algorithms.
b. Pregnant women
Dual HIV/syphilis rapid diagnostic tests (RDTs) can be the first test in HIV testing strategies and algorithms in ANC settings.
c. HIV testing strategy/algorithm
WHO recommends that all HIV testing algorithms achieve at least 99% positive predictive value and use a combination of tests with ≥99% sensitivity and ≥98% specificity.
The first test in an HIV testing strategy and algorithm should have the highest sensitivity, followed by a second and third test of the highest specificity.
Countries should consider moving to a three test strategy as HIV positivity within national HTS programmes falls below 5% – meaning all people presenting for HTS should have three consecutive reactive test results in order to receive an HIV-positive diagnosis.
Key Populations:
HIV testing services should be routinely offered to all key populations both in the community and in facility based settings. Community-based HIV testing, with linkage to prevention, treatment and care, should be offered, in addition to routinely offering testing in facilities, for key populations in all settings.
Social network-based approaches can be offered as an HIV testing approach for key populations as part of a comprehensive package of care and prevention.
Adolescents:
HIV testing services, with linkages to prevention, treatment and care, are recommended for adolescents from key populations.
Adolescents should be counselled about the potential benefits and risks of disclosure of their HIV-positive status and empowered and supported to determine if, when, how and to whom to disclose.
a. High HIV burden settings
In high HIV burden settings, HTS, with linkage to prevention, treatment and care, are recommended for all adolescents.
b. Low HIV burden settings
HTS, with linkage to prevention, treatment and care, should be accessible to adolescents in low and concentrated epidemics.
Couples and Partners:
Social network-based approaches can be offered as part of a comprehensive package of testing and care for key populations .
Provider-assisted referral should be offered to all people with HIV as part of a voluntary comprehensive package of testing, care and prevention.
Couples and partners should be offered voluntary HIV testing services with support for mutual disclosure.
Infants and Children:
All settings
For HIV-exposed infants, virological testing for HIV as early as possible is recommended so that ART can be started immediately, and morbidity and mortality, prevented.
Nucleic acid testing (NAT) technologies that are developed and validated for use at, or near to, the point of care can be used for early infant HIV testing.
Addition of NAT at birth to existing early infant diagnosis (EID) testing approaches can be considered to identify HIV infection in HIV-exposed infants.
High HIV burden settings
In high HIV burden settings, infants and children with unknown HIV status who are admitted for inpatient care or attending malnutrition clinics should be routinely tested for HIV.
In high HIV burden settings, infants and children with unknown HIV status should be offered HIV testing in outpatient or immunization clinics.
Useful Links:
Link to the WHO news release:
Link to the new recommendations:
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