WHO Releases New HIV Testing Guidelines To Help Expand Treatment Coverage, Reduce HIV Transmission

The World Health Organization has issued new HIV testing recommendations to help countries expand treatment coverage and reach the estimated 8.1 million people living with HIV who have not yet been diagnosed. The WHO guidelines were released on Wednesday ahead of World AIDS Day on December 1 and the International Conference on AIDS and Sexually Transmitted Infections in Africa (ICASA2019), which will take place in Kigali, Rwanda on December 2-7.

“The face of the HIV epidemic has changed dramatically over the past decade,” said WHO Director-General Dr Tedros Adhanom Ghebreyesus in a press release. “More people are receiving treatment than ever before, but too many are still not getting the help they need because they have not been diagnosed.”

A woman prepares for an HIV test in Uganda.

The launch of the WHO guidelines comes right on the heels of a UNAIDS report published Wednesday that highlighted mixed success in tackling the HIV/AIDS epidemic. Access to HIV treatment has expanded and new HIV infections have declined by 28% from 2010 to 2018 in eastern and southern Africa, the region most affected by HIV, but women and girls are still disproportionately affected. Four out of five new HIV infections among adolescents in the Sub-Saharan Africa region occur in girls. Additionally, new HIV infections are increasing in eastern Europe, central Asia, northern Africa, and parts of Latin America.

WHO estimates that at the end of 2018, there were 36.7 million people with HIV worldwide. Of these, 21% have not yet been diagnosed. Expanding testing for HIV helps ensure that people are diagnosed early and can start treatment. Testing also helps identify people who are HIV-negative but may be at high risk for contracting the infection and link them to appropriate and effect prevention services.

Both publications highlight that key populations such as injecting drug users, sex workers, transgender people and prison populations are at higher risk of testing positive for HIV, but may be less engaged in HIV decision-making and have less access to healthcare services. Additionally, in countries where high proportions of people have already been tested and treated, it can be difficult to reach the remaining proportion of people living with HIV who have not yet been tested, according to WHO.

The new “WHO consolidated guidelines on HIV testing services” recommends strategies for expanding a package of HIV-related services to those hardest to reach including:

  • Adoption of a standard HIV testing strategy which uses three consecutive reactive tests to provide an HIV positive diagnosis. Previously, most high burden countries were using two consecutive tests. The new approach can help countries achieve maximum accuracy, particularly in high-prevalence settings.
  • Use of HIV self-testing as a gateway to diagnosis based on new evidence that finds people who are at higher HIV risk and not tested in clinical settings are more likely to be tested if they can access HIV self-tests.
  • Implement social network-based HIV testing to reach key populations who are at high risk but have less access to services, and use peer-led, innovative digital communications such as short messages and videos to build demand and increase uptake of HIV testing.
  • Focus on community-based delivery of rapid testing through lay providers for relevant countries in the European, South-East Asian, Western Pacific and Eastern Mediterranean regions. Rapid testing methods cost less and can provide results up to 2-3 weeks earlier than traditional laboratory-based diagnostic tests.
  • Use HIV/syphilis dual rapid tests in antenatal care as the first HIV test to help eliminate mother-to-child transmission of both infections.
Power to Choose, Power to Know, Power to Thrive, Power to Demand

The UNAIDS report, Power to the People, found that significant progress has been made in expanding access to treatment, with an estimated 24.5 million people with HIV accessing anti-retroviral drugs and other therapies. However, progress to slow HIV transmission has stalled, and an estimated 1.7 million people were newly infected with the virus in 2018.

In Eastern and Southern Africa, the hot spots of the global HIV/AIDS epidemic, new infections declined by 28% between 2010 and 2018. However, outside of eastern and southern Africa, new HIV infections have declined by only 4% since 2010. Of concern is the rise of new HIV infections in certain regions. The annual number of new HIV infections rose by 29% in eastern Europe and central Asia, by 10% in the Middle East and North Africa and by 7% in Latin America. the report notes.

“In many parts of the world, significant progress has been made in reducing new HIV infections, reducing AIDS-related deaths and reducing discrimination, especially in eastern and southern Africa, but gender inequality and denial of human rights are leaving many people behind,” said Winnie Byanyima, executive director of UNAIDS in a press release.

The report aims to highlight the importance of including people and communities affected by HIV in HIV service delivery and policy-making. Specifically, stigma and discrimination can still prevent people from seeking knowledge on how to prevent HIV transmission, or accessing diagnosis and treatment.  But when people living with HIV are empowered, these barriers are more frequently overcome. Specifically, the report notes four areas of empowerment for programmes to target:

  • Power to Choose – The report finds almost 40% of adult women and 60% of adolescent girls (aged 15–19 years) in sub-Saharan Africa have unmet needs for modern contraception. Family planning services are closely tied to HIV treatment and prevention services. In sub-Saharan Africa, young women’s uptake of medicine to prevent HIV—pre-exposure prophylaxis (PrEP)—is high in projects that integrate PrEP into youth-friendly health services and family planning clinics and when provision of PrEP is separated from treatment services.
  • Power to Know – Knowledge of HIV among young people is alarmingly low in many regions. In countries with recently available survey data, just 23% of young women (aged 15–24 years) and 29% of young men (aged 15–24 years) have comprehensive and correct knowledge of HIV. This can lead to people finding out their HIV status too late, sometimes years after they became infected, facilitating transmission and leading to a delay in starting treatment.
  • Power to Thrive – Certain populations are being left behind. In 2018, 160 000 children (aged 0–14 years) became newly infected with HIV, and 100 000 children died from an AIDS-related illness. In Eswatini, a recent study showed that adolescent girls and young women who experienced gender-based violence were 1.6 times more likely to acquire HIV than those who did not. The same study also showed that economic empowerment of girls and women helped reduce new HIV infections among women by more than 25% and increased the probability of young women and girls going back to school and finishing their education.
  • Power to Demand – There have been reports of crackdowns, restrictions and even attacks on groups and campaigns supporting key populations most affected by HIV. Some governments refuse to recognize, support or engage community organizations in their national responses to HIV and are subsequently missing out on their enormous potential to reach the people most affected by HIV.

Image Credits: 2011, Sokomoto Photography for International AIDS Vaccine Initiative (IAVI).

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