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Strategies to reach first 90 Community based testing, Self-testing, Index testing,
Partner notification
Elena Vovc, Technical Officer
Joint TB, HIV and viral hepatitis programme
WHO Regional Office for Europe
Source: ECDC/WHO. HIV/AIDS Surveillance in Europe 2017 – 2016 data. Stockholm: ECDC 2017
Consider
Cost of testing approach (staff, settings, opportunity costs)
Positivity rate
Outcomes related to individual health, prevention of
transmission to sexual (and drug using) partners and
infants, linkage of both HIV+ and HIV– to prevention and
other services
Key populations outreach services • high unit
cost • high
positivity rate
• greater impact
Mass testing campaigns • low unit cost • low
positivity rate
• limited impact
1. Increase efficiency of testing
Partner Testing (incl. Assisted Partner Notification/index testing)
General epidemics - offer to all
Concentrated epidemics - offer specifically to partners of +ves
Effective Focused Provider-Initiated Testing (PITC)
General epidemics - PITC in every health contact
Concentrated epidemics Strategic PITC in select services - ANC,
TB, STI, key populations, indicator conditions
Community Approaches
General epidemics - outreach for KP, men, YP consider
home-based
Concentrated epidemics - outreach to key populations, men and young key populations, geographic prioritization “hotspots” - promotion of self-testing
Focusing HIV Testing Services (HTS)
2. Community based testing and lay provider testing
Trained lay providers can safely and effectively perform HIV testing services using rapid diagnostic tests. (strong recommendation, moderate quality evidence)
Important considerations
•Choose wisely –select and train lay providers well-matched to clientele •Ongoing training, mentoring and support is key—having a QMS in place is essential •Adequate remuneration – trained lay providers should receive adequate compensation •National policies need to establish a role for trained lay providers to perform HTS
Lay provider: any person who performs functions related to health-care delivery and has been trained to deliver specific services but has received no formal professional or paraprofessional certificate or tertiary education degree.
Positivity Rate
• Home based
• Campaigns
• KP outreach
• Index partner
Community-Based HIV testing services
Unit Cost
• But cost effectiveness may be acceptable especially for KP
Linkage to Care
• Highly variable
and problematic
?
Earlier Diagnosis
• 11 studies (3190 participants) CD4 >350 - 59%.
✔ Missing Populations
• Key Populations
Highly Acceptable
• Home based 82% (#18)
• Index partner 93% (#6)
• Mobile/outreach 93%
(#9)
• Workplace 59% (#4)
✔ ✔
? ?
Individual collects sample, performs the test and interprets the result: • Accurate • Highly acceptable • Increase access for those not accessing
current testing services • Increase frequency of testing for KP • Good linkage to ART and prevention • No evidence of serious social harms
Self-testing is not new: widely available for many other medical conditions eg. diabetes, pregnancy, cholesterol
3. HIV Self-Testing
WHO Guidelines on HIVST- December 2016
Follow up activities Increasing community awareness
• Events – community consultations • Media https://www.youtube.com/watch?v=BA5E9wsEbPw
• In our hands
https://www.youtube.com/watch?v=N3ywFoNZXgA
• Literature, leaflets…… other
Evaluating which HIVST approaches are most successful and appropriate
• Awaiting the results of many implementation projects
• Which groups need special focus
WHO recommendation HIV self-testing should be offered as an additional approach to HIV testing services (strong recommendation, moderate quality evidence)
Further information http://www.who.int/hiv/en/ www.hivst.org
• Self-testers with a reactive (positive) result need further testing from a trained provider
• Self-testers with a non-reactive (negative) test result should retest if they have been exposed to HIV in the preceding six weeks, or are at high ongoing HIV risk.
• HIVST is not recommended for people
taking anti-retroviral drugs, as this may cause a false non-reactive result.
*Any person uncertain about how their self-test result, should be encouraged to access facility- or community-based HIV testing
HIVST as A0
HIV self-testing products and approaches
Products: • Oral fluid HIVST pre-qualified by
WHO July 2017 • Blood-based HIVST in the
pipeline
Approaches
Where to begin with HIV self-testing
Know your epidemic
& testing gap Approaches
Partners of people with HIV
Key populations
Other at risk
populations
Community-based outreach
Facility-based (STI, drop-in centres)
Pharmacies & Kiosks
Integrated in KP Programmes
Internet & Apps Social networks
Vending machines
Partner-delivered
Considerations
Benefits & Risks to Populations
Support tools
Linkage
Increased
access
Increased coverage
HIVST - Note of caution Regulation and use of quality products
HIV self-test available everywhere • Often unregulated • Often of unknown quality • Often unclear IFU and lack of contact for referral
for post-test support
5. Partner notification (PN) services
Definition: Partner notification, index partner testing, or contact tracing, is a voluntary process whereby a trained provider asks people diagnosed with HIV about their sexual partners and/or drug injecting partners and then, if the HIV-positive client agrees, offers partners HTS.
• PN increases uptake of HIV testing among partners of people with HIV
• PN result in high proportions of HIV+ people being newly diagnosed (20-72% of partners in RCTs were +ve)
• PN increases linkage to ART among partners of people with HIV
Few cases of harm resulted from PN in studies and programmes
WHO recommendation Voluntary assisted partner notification services should be offered as part of a comprehensive package of testing and care for people with HIV (strong recommendation, moderate quality evidence)
Source Johnson 2017 add ref
6. Improving quality HIV testing
Review identified various studies with quality issues. Few studies reported on misdiagnosis, but 2 MSF studies report misclassification range from 2.6% to 10.3%1,2
National Testing Policies in Line with WHO
Recommendations 48 Countries
Studies (N=64) Reporting Factors Related to Misdiagnosis
Category #
Studies
Incorrect / suboptimal testing
strategy or algorithm 37
User error 25
Poor or inadequate
management and supervision
21
Other factors (e.g. acute
infection, cross-reactivity,
known HIV status / on ART)
18
Clerical/technical errors 16
Weak reactive test results (e.g.
faint or ghost lines appearing
on test strip)
14
HIV misdiagnosis False + and false – have serious individual and public health consequence Increasing media attention to anecdotal reports
• All sites & facilities providing HTS should participate in quality assurance programmes to ensure access to correct test results
• QA implemented through quality management systems essential for any testing service- HIV testing conducted in labs, health facilities community settings, including RDTs performed by lay providers
12 Quality System
Essentials
Correct test results
