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 urgency 1  More tests are being performed in 2010 95M people 15–49 yrs received HTC 2  More health centers offer HTC in 2010 131,000 health centers globally offered HTC 2  More pregnant women accessing HTC in 3010 35% pregnant women tested globally 67% in eastern and southern Africa 2 1 Baggaley (2012) From Caution to Urgency: the Evolving Response to HIV Testing WHO bulletin WHO(2011) 2 Progress 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 Date not identified Adoption of a policy on PITC, 2003-2010 Not adopted Data not available 2009 - 2010 2003 - 2004 2005 - 2006 2007 - 2008  42/53 countries in Africa have PITC policies 1  42/53 in ANC  31/53 in TB  3/53 in adults/pediatrics  75% of TB patients 2 tested for HIV 2  High PITC acceptance by ANC 3 & TB patients 4  Introduction of PITC ↑pediatric testing to 98% in Zambia 5  But many missed opportunities  Many clinical settings in generalized epidemics not offering HTC 6 1 Baggaley (2012) Bulletin WHO, 2 WHO, Global TB control, 2011, 3 Etirbet (2004) AIDS Care; Byamugisha (2010) J Int AIDS, 4 Corneli (2008) IJTBLD, 5 Mutanga (2012) PloS One, 6 MacPherson (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 Int Health, 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 workers 1  included in Kenyan HTC Guidelines  available over the internet & in pharmacies in some countries 2  Key populations (MSM & PWID) express interest in self-testing 3  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, NIMH 3 )  PrEP? – need for those taking PrEP to re-test regularly ? Supervised self-testing programme, Malawi. Liz Corbett LSHTM 2 1 Napierala 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; 4 Choko (2011) PloS Med ; 4 http://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 TasP guidance 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 Community approaches Generalized epidemics - outreach for key pops, consider door to door, workplace, schools augmented by campaigns Low and Conc epidemics outreach to key pops Couples/partner testing Generalized epidemics offer to all Low and Conc epidemics offer to partners of +ves Effective PITC Generalized epidemics PITC in every health contact Low and Conc epidemics PITC in select services (TB, STI, Key pops) Strengthen anti-discrimination laws Strengthen linkages to prevention, care, & ART Community accompaniers e-technology Community/media promotion