WHO/UNAIDS guidance

In 2007, the World Health Organization and UNAIDS issued joint guidance on “provider-initiated” HIV testing and counselling.¹

They noted that previous testing strategies which relied on “client-initiated” testing (also often referred to as VCT, voluntary counselling and testing) had failed to reach enough people, both in high-income and resource-constrained countries (in Africa, just 12% of men and 10% of women have ever been tested).

Client-initiated approaches still need to be scaled up, but the guidance calls for additional, innovative and varied approaches. They argue that many opportunities to diagnose and counsel individuals at health services are being missed, and that provider-initiated HIV testing and counselling can help expand access to HIV treatment, care and support.

A far greater use of opt-out, provider-initiated testing and counselling is called for. They stress that mandatory or compulsory testing is not supported, and that all testing must continue to observe "the three Cs": informed consent, counselling and confidentiality.

A number of advocates have criticised the WHO/UNAIDS guidance for failing to take into account the many healthcare services and staff in some countries which do not always observe the three Cs. Moreover, many have questioned the appropriateness of the strategy for settings where antiretroviral therapy is not always available or where stigma and discrimination are rife. The guidance does state that testing must be accompanied by an “enabling environment” including the availability of antiretroviral therapy, prevention and support services, and a supportive social, policy and legal framework.

In countries in which HIV is firmly established in the general population (a prevalence above 1%, for example in sub-Saharan Africa), and as long as there is an enabling environment and adequate resources, universal testing is recommended in healthcare services.

HIV testing and counselling should be recommended to all adults and adolescents attending health care, regardless of whether the patient has signs or symptoms of HIV infection, and regardless of the patient’s reason for attending.

If resources do not allow for this policy to be followed, healthcare providers should recommend HIV testing and counselling to any person with signs, symptoms or medical conditions that could indicate HIV infection.

Testing should also be recommended for infants of HIV-positive women, malnourished children and men seeking circumcision as an HIV prevention intervention.

If provider-initiated testing and counselling is to be implemented in phases, priority services for its implementation are listed as follows:

• Medical inpatient and outpatient facilities, including tuberculosis clinics
• Antenatal, childbirth and postpartum health services
• Health services for most-at-risk populations
• Services for younger children (under ten years of age)
• Surgical services
• Services for adolescents
• Reproductive health services, including family planning

In countries in which HIV infection is largely limited to sub-populations (for example, the United Kingdom), HIV testing and counselling should not be recommended to all people attending health care as most people will have a low risk of exposure.

The priority should be for healthcare providers to recommend HIV testing and counselling, as part of the standard of care, to any person with signs, symptoms or medical conditions that could indicate HIV infection, and to children of HIV-positive mothers.

However, depending on the epidemiological and social situation, recommending HIV testing and counselling to all patients could be considered in certain healthcare services where HIV prevalence is higher. These could include:

• Sexual health services
• Specialised services for men who have sex with men, migrants, sex workers, drug users, etc.
• Antenatal, childbirth and postpartum health services
• Tuberculosis services

The guidance makes recommendations for the pre-test information that needs to be provided (as opposed to pre-test counselling) and for the post-test counselling , which should be provided both to people with negative and positive results.

Depending on the setting, rapid tests or ELISAs (i.e. third- or fourth-generation tests) may be appropriate.

Monitoring and evaluation are essential. Regular evaluations of healthcare provider performance and patient satisfaction (including testing processes, pre-test information, consent process and post-test counselling) will help improve the effectiveness, acceptability and quality of HIV testing and counselling services.