HIV testing and counselling (HTC) is a critical and essential gateway to HIV prevention, treatment, care, and support services. It is now known that:
Early knowledge of one’s positive HIV status maximizes opportunities for the people living with HIV (PLHIV) to access treatment, thereby greatly reducing HIV-related morbidity and mortality, and/or preventing mother-to-child transmission of HIV.
Being on effective HIV treatment reduces, by up to 96%, the likelihood that someone living with HIV will transmit HIV to his/her sexual partner.
Those who are HIV negative can continue to make efforts to protect themselves from acquiring HIV through evidence-based prevention methods: safer sex, use of condoms, voluntary medical male circumcision, safe injecting equipment, reduced number of sexual partners.
Universal access
The World Health Organization (WHO), Joint United Nations Programme on HIV/AIDS (UNAIDS), and many other organizations have endorsed the concept of “universal access” to knowledge of HIV status. They have also endorsed the concepts of universal access to HIV prevention, treatment, care, and support, as well as protection from discrimination based on HIV-positive status. This stance is articulated in UNAIDS’s vision of: zero new HIV infections, zero discrimination, and zero AIDS-related deaths and the Global Health Sector Strategy on HIV/AIDS 2011-2015.
The “5 Cs”
WHO has defined five key components—the “5 Cs”—that must be respected and adhered to by all HTC services. These components are:
Consent
Confidentiality
Counselling
Correct test results
Connection/linkage to prevention, care and treatment.
The five Cs, and the key principles they entail, apply to all models of HTC services:
People being tested for HIV must give informed consent to be tested. They must be informed of the process for HTC, the services that will be available depending on the results, and their right to refuse testing. Mandatory or compulsory (coerced) testing is never appropriate, regardless of where that coercion comes from: health-care providers, partners, family members, employers, or others.
Testing services must be confidential, meaning that the content of discussions between the person tested and the health-care worker, testing provider, or counsellor, as well as the test results, will not be disclosed to anyone else without the consent of the person tested.
Testing services must be accompanied by appropriate and high-quality pre-test information or pre-test counselling, and post-test counselling.
Provision of correct test results. Testing must be performed and quality assurance measures followed according to internationally-recognized testing strategies, norms, and standards based on the type of epidemic. Results must be communicated to the person tested unless that person refuses the results.
Connections to HIV prevention, treatment and care and support services should be supported through concrete and well-resourced patient referral, support, and/or tracking systems.
The UNAIDS World AIDS Day Report 2012 provides evidence that adhering to these principles and practices for HTC and linking those tested to HIV prevention, treatment, care, and support can enable countries to reduce the incidence of new HIV infections and reduce HIV-related morbidity and mortality. These gains are further enhanced when countries take steps to increase access to: voluntary HTC, including for key at-risk and vulnerable populations; prevention of mother-to-child transmission of HIV (PMTCT); and ARV treatment to all those who need it.
Voluntary HIV testing and counselling
WHO recommends that voluntary HTC be available through a wide range of services delivery models and approaches. These include provider-initiated testing and counselling (PITC), which involves the routine offer of testing to all people receiving medical care in high-prevalence settings and in clinical sites, such as sexual health and tuberculosis (TB) and drug treatment clinics, antenatal, childbirth, postpartum services and sites offering services to key at risk and vulnerable population, in all epidemic settings. They also include a range of other testing and counselling services, including the offer of testing in non-medical settings by non-medical personnel, such as in community outreach, couples testing, door-to-door offer of testing, home-based testing and others.
In this context, the use of rapid point-of-care HIV tests should be expanded as this type of testing enables testing providers and counsellors to quickly provide test results to those tested. This, in turn, can contribute to early enrolment in treatment, care, prevention, and other follow-up services as needed. Rapid tests can also reduce the burden on laboratories and allow trained and supervised lay personnel to provide the testing and counselling.
Regardless of the individual or population group being offered HTC, all aspects and models of HTC services must adhere to the 5 Cs and be provided in a compassionate, non-discriminatory, and ethical manner—deriving from the professional integrity of the testing provider/counsellor and respecting the human rights of the person being tested. Facilities providing HTC should have codes of conduct for providers and systems in place for redress for patients whose rights are infringed.
HTC policies
National HTC policies and practices should be reviewed to eliminate all non-voluntary forms of testing. There should be no compulsory or mandatory testing of members of key populations at higher risk of HIV infection and other vulnerable populations, including pregnant women, people who inject drugs and their sexual partners, men who have sex with men, sex workers, prisoners, migrants, refugees and internally displaced persons, and transgender people.
The expansion of voluntary HTC should include improved protection from stigma and discrimination related to positive HIV status and risk behaviours, as well as improved support to be connected/linked to prevention, treatment, care and support services.
Adolescents require special attention to their needs through the provision of youth-friendly testing and counselling and follow-up services. Public health strategies and human rights promotion are mutually reinforcing. A human rights-based approach to HTC must be ensured.
The following key factors should be addressed simultaneously
Ensuring expanded access through an ethical process for conducting HTC, including defining the purpose of the test and the risks and benefits to the person being tested.
Assuring linkages between the site where the test is conducted and appropriate treatment, care, prevention, and other services, in an environment that guarantees confidentiality of all medical information.
Addressing the implications of a positive test result, including the risk of discrimination and stigma and the importance of early enrolment in HIV treatment, care and follow-up services as needed.
Reducing HIV-related stigma and discrimination at all levels, including within health-care settings.
Ensuring a supportive legal and policy framework within which the response is scaled up, including safeguarding the human rights of people accessing HTC and other services.
Improving the healthcare infrastructure so quality services adhering to these principles can be sustained in the face of increased demand for testing, treatment, and related services and ensures effective monitoring and evaluation is in place.
Mandatory testing
The only mandatory testing that WHO and UNAIDS support are:
screening for HIV and other blood-borne infections of all blood destined for transfusion or for manufacture of blood products;
screening of donors prior to all procedures involving transfer of bodily fluids or body parts, such as artificial insemination, corneal grafts, and organ transplant.
WHO and UNAIDS do not support mandatory or compulsory testing of individuals on public health grounds.