HIV/AIDS DEPARTMENT WHO Rachel Baggaley Reuben Granich Amitabh Suthar

1. HIV/AIDS • DEPARTMENT • WHO • Rachel Baggaley • Reuben Granich • Amitabh Suthar • Marco Antonio De Avila Vitoria • Eyerusalem Negussie • Kathleen Fox • Ying-Ru Lo • Andrew Ball • Gottfried Hirnschall

2. 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

3. 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 TestingWHO 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

4. 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

5. Provider-initiated testing and counselling(PITC) in Africa Adoption of a policy on PITC, 2003-2010 • 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 2003 - 2004 2005 - 2006 2007 - 2008 2009 - 2010 Date not identified Not adopted Data not available 1Baggaley (2012) Bulletin WHO, 2WHO, Global TB control, 2011, 3Etirbet (2004) AIDS Care; Byamugisha (2010) J IntAIDS,4Corneli (2008) IJTBLD,5Mutanga (2012) PloSOne, 6MacPherson (2012) Trop Med

6. 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 IntHealth,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?

7. 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 individuals • Package given to 5203 (100%) of people, regardless whether or not they decided to have HIV test • 100% tested for HIV • 329 (6.3%) tested HIV positive • 255 (78%) had CD4 count determination (median 536)

8. 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.pdf 2 http://www.test-hiv-yourself.com; http://positivelite.com ; 3 Spielberg (2003) JAIDS; 4Choko (2011) PloS Med ; 4http://clinicaltrials.gov/ct2/show/NCT01161446

9. 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

10. 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 TasPguidance • WHO addresses operational issues also considered in the guidelines • http://www.who.int/hiv/pub/guidelines/9789241501972/en/index.html.

11. What we need for universal HTC • Strengthen anti-discrimination laws • Strengthen linkages to prevention, care, & ART • Community accompaniers • e-technology • Community/media promotion