Ade Fakoya, Senior Disease Coordinator HIV at The Global Fund to Fight AIDS, Tuberculosis and Malaria, and Aji-Mallen Sanneh, Consultant, HIV Program Quality & Efficiency at The Global Fund to Fight AIDS, Tuberculosis and Malaria
HIV testing is a key gateway to HIV control efforts for treatment and prevention programmes. As the number of people living with HIV on treatment continues to increase, the number of those undiagnosed, as a proportion of the total number, will be reduced. New strategies are thus required to tailor HIV testing to identify those undiagnosed early after infection, and to then link them to care and commence immediate treatment. Using differentiated HIV testing to enhance prevention efforts, while less recognized, requires more focus.
Let’s first acknowledge how far we have come since the beginning of the HIV pandemic over 35 years ago. Over 20 million people on life-saving treatment from a baseline of less than 200,000 in 2002. New HIV infections in 0-15 year olds have fallen dramatically because of very successful programmes of prevention of HIV transmission from mother to child (PMTCT). There have been enormous progresses in basic and clinical sciences, and service delivery models.
Having said this, the next part will be much harder – reaching epidemiological control. The fast track HIV prevention and treatment goals aim to reduce HIV incidence to 500,000 per year by 2020 from approximately 2 million and a reduction in HIV mortality to 500,000 whilst ensuring that for all groups, the 90 90 90 targets are achieved.
Globally, 30% of HIV infections are still undiagnosed. Identifying the 12 million people or so not yet on HIV therapy means doing things very differently than before. Improving the quality of HIV testing seeks to improve the efficiency and effectiveness of how HIV testing services are provided. This in turn ensures those that are most hard to reach have access to HIV testing, particularly vulnerable and marginalized groups, and also those groups for whom gaps in their care cascade exist such as men in Sub-Saharan Africa.
It is very clear that there are major variations in global, regional and local HIV epidemiology, coverage and effectiveness of services. In West and Central Africa (WCA) for example, new infections have declined by only 9% between 2010 and 2016, compared to 29% for East and Southern Africa, and only 35% of PLHIV had access to ART in 2016. It is also noteworthy that the HIV care cascade may vary widely with different populations. In Uganda 27% of males 15-24 know their status compared to 53% of females (2016) and this increases to 75% and 85% respectively for 35-49 year olds. In order to make continued impact it will be necessary to adopt differentiated methods whilst maintaining a public health approach to service delivery.
As models for differentiated HIV testing are being developed, what are some considerations for those who wish to implement or extend these services? Differentiation, as its name suggests, implies providing different types of services according to people’s needs. There has been much investigation and publications on differentiated HIV service delivery models for (as an example) HIV positive individuals who are stable on their treatment.
Differentiated HIV testing might explore:
- Focus and targeting of testing – different individuals need different service arrangements to access HIV testing so the development of differentiated HIV testing strategies, including among children and adolescents, key populations and couples;
- Implementing a strategic mix of HIV testing modalities to improve testing, coverage, yield and efficiency of HIV testing services.
The Global Fund has recognized the need to differentiate the response at country level. Thus for the current funding cycle, as well as the country allocations, the Board set aside funds to catalyse key areas of the response and support a number of special initiatives. These include initiatives for adolescent girls and young women, key populations and human rights as well as strengthening community responses and data (quality) systems. Resources were also allocated to provide additional targeted technical support from partner agencies.
In an environment of scarce resources, both financial and human, approaches which garner greater coverage, quality improvement and efficiencies are imperative to achieving national and global HIV targets, especially 90 90 90. While more evidence is needed in this area, differentiated HIV testing has the potential to identify efficiencies, optimize use of health care workers and increase health outcomes. Scaling-up these approaches is not impossible. With comprehensive national policies and international guidance, along with stronger political will and financing, differentiated HIV testing can make a difference to improving treatment (and prevention) cascades.
