TRACE INITIATIVE: HIV Testing Services (HTS)

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PATIENT FLOW

Patient Flow: Review of the HTS Diagnostic Flow Chart (1)

Patient Flow: Review of the HTS Diagnostic Flow Chart (2)

Patient Flow: Review of the HTS Diagnostic Flow Chart (3)

Patient Flow: Review of the HTS Diagnostic Flow Chart (4)

IMPORTANCE

When should recency testing be introduced? Recency testing should be introduced during HTS pre-test counseling as an option If a client is confirmed HIV positive according to the national algorithm and he or she is eligible, he or she should be offered to enroll in the recency testing Consent can either be done during routine pre-test counseling or after the confirmation of the HIV diagnosis

Integrating Recency into HTS Confirmatory 2nd HIV test done according to national algorithm (post-test counseling) Collect blood to perform RTRI Long term infection Newly identified HIV + consented for recency test HTS Facility Routine Testing for HIV at HTC Site (pre-test counseling) Introduce Recency and if feasible consent Positive Negative Post-test counseling (Viral load threshold met) Viral load testing Final RITA Classification documented and results prepared for facility RESULTS LAB Specimen for VL prepared for laboratory Recent Infection If not returning results the documentation in the laboratory is the final step

PRE-TEST COUNSELING

Pre-Test Counselling and Recency Testing Apply Principles of HIV Testing Services when Counselling on Recency Testing Client centered and client focused = focused on the needs and safety of client and his or her partner(s) and child(ren) Confidential: both the confidentiality of the client and recency testing results should be maintained at all times. The results of the client should not be revealed and no information about partners should be conveyed back to the client. All recency results are kept confidential and only for the client. Voluntary and non-coercive: the client can decline to receive results. Do not force the clients to receive the results, Non-judgmental: Recency counseling messages services should be delivered in a non-judgmental manner, free from stigma or discrimination Culturally and linguistically appropriate: Recency counseling message should be delivered in a nonjudgmental way. We work to be informed about what is appropriate for the culture and ensure that services are available in the languages spoken by our clients. Comprehensive and integrative: Recency counseling messages should include strong referral and linkages to HIV treatment and prevention services.

Introducing Recency Testing Who will be tested for recent HIV infection? Inclusion Criteria Newly diagnosed HIV cases at HTS visit Giving voluntary informed consent for supplementary testing using test for recent infection Aged ≥15 years

Introducing Recency Testing If a client meets inclusion criteria: Briefly explain that there is a test that can tell them if they acquired HIV recently, and ask if they would like to learn more about it. If yes, start the informed consent process with more detailed information. If possible, blood collected for routine HIV testing may be used to test for recent infection to avoid collecting an additional blood sample.

Pre-Test Counselling and Recency Testing Informed Consent is VERY IMPORTANT! Participation in Recency Testing is 100% voluntary It is the client’s right to choose. No one can be forced or coerced to participate or made to feel bad if they don’t. Routine ART services and offer of index testing services should not be affected by participation/non-participation. Withdrawal is an option at any time, even after consent. Consent forms and information sheets should reflect decisions about return of recency result and what result means.

Pre-Test Counselling and Recency Testing Communicate clearly at the patient’s level Avoid technical terms, jargon, or words the patient may not understand. Clearly explain medical and technical terms, as appropriate. Provide accurate information on recency testing. Correct the patient’s misconceptions. After giving factual information, use open ended questions to make sure the patient understands what you have just said. Offer options, not directives.

TESTING ALGORITHM

National Testing Algorithm The only way to know for sure whether a client has HIV is to get tested using the validated national HIV testing algorithm. [Insert information about the national testing algorithm for your country]

Integrating Recency into HTS Confirmatory 2nd HIV test done according to national algorithm (post-test counseling) Collect blood to perform RTRI Long term infection Newly identified HIV + consented for recency test HTS Facility Routine Testing for HIV at HTC Site (pre-test counseling) Introduce Recency and if feasible consent Positive Negative Post-test counseling (Viral load threshold met) Viral load testing Final RITA Classification documented and results prepared for facility RESULTS LAB Specimen for VL prepared for laboratory Recent Infection If not returning results the documentation in the laboratory is the final step RECENCY PROCEDURES

Linking Recency with the National Testing Algorithm Role of the clinic staff in recency testing: Screen for eligibility – to ensure that only newly HIV diagnosed individuals, 15 years and older are offered recency testing Consent for recency Collect specimen Conduct rapid recency test (if applicable) Results disclosure (if applicable) Documentation in registers Linkage to ART and index testing services Staff Responsible: HTS Counselors, ART staff Minimum eligible testing age is 12 years for Rwanda; however, for recency testing it will be 15 years

INDEX TESTING

Recency Test Results and Index Testing Recency results can help clients identify partners most at risk for HIV and, therefore, which to engage in index testing and partner notification Result showing recent infection means that partners within the past 12 months may be most at risk Result showing long-term infection means that partners from more than 12 months ago may be most at risk However, index testing should be carried out regardless of whether recency testing is done

Index Testing: What Is the Partner Notification? Index Client: an individual newly diagnosed as HIV-positive and/or an HIV-positive individual who is enrolled in HIV treatment services. Partner Notification: voluntary process where counsellors and/or health care workers ask index clients to list all of their: (1) sexual or injecting drug use partners within the past year, and (2) children.

Index Testing: What Is the Partner Notification? After obtaining verbal consent from the index client, each listed partner and child (& parent) is: (1) contacted, (2) informed that they have been exposed to HIV, and (3) offered voluntary HIV testing services (HTS). Goal of partner notification is to break the chain of HIV transmission by offering HTS to persons who have been exposed to HIV and linking them to: HIV treatment, if positive, or Prevention services (e.g. VMMC, PrEP, condoms), if negative.

Options for Notifying Your Partner about HIV Client Referral = You tell your partner about your HIV and encourage him or her to come to the health facility for an HIV test. Provider Referral = A counsellor or other health care provider will call or visit your partner and inform them that they need to test for HIV. Contract Referral = You and the counsellor will work together to notify your partner. You will have 30 days to tell your partner. After which, the counsellor will contact your partner after getting your permission.

Steps for Partner Notification Services (PNS): Use National Protocol Step 1: Introduce Partner Notification Services to the index client Step 2: Obtain a list of sex and needle-sharing partners in last 12 months Step 3: Screen all named partners for intimate partner violence (IPV) Step 4: Determine the preferred method of partner notification for each named partner and record on national partner information form Step 5: Contact all named partners using the preferred approach Step 6: Record partner notification outcomes on the national forms for PNS outcomes Use national protocol PNS talking points to introduce PNS to the index client and complete national form for index client information Use the national partner elicitation form to record partner(s)’ names and contact information Use the national partner information form to document results of IPV screening and preferred partner notification method. Complete one form for each named partner Exclude partners posing a high risk of IPV; refer index client to IPV services where available and discuss other options for disclosure. Client Referral: Provide referral slip and tips for telling the partner about HIV Contract Referral: Provide referral card and disclosure script to index client and agree that client will refer partner for HTS within 30 days Provider Referral: Initiate partner contact attempts using national telephone and home visit scripts  Was partner successfully contacted? Yes No Record successful partner contact (including HIV status) on national form for PNS outcomes If Contract Referral, initiate provider referral after 30 days; otherwise record unsuccessful contact on national form for PNS outcomes

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