Knowledge of HIV status

4.1 Overview of progress and key challenges

As a critical gateway to services, HIV testing and counselling are essential in expanding access to HIV prevention and treatment and ultimately achieving universal access. Facility-level data and population-based surveys show that both the availability and uptake of HIV testing have increased considerably across low- and middle-income countries in recent years. Most countries have now adopted client- and provider-initiated testing and counselling policies, which have decisively contributed to raising awareness of HIV status in the general population and among key populations at higher risk of HIV infection and transmission (1).

Nevertheless, the widespread increase in HIV testing and counselling availability and uptake across diverse settings has highlighted several key programmatic gaps that must be tackled to maximize the population-level benefi ts of testing and counselling services for scaling up HIV prevention and treatment. First, available data show that, in generalized epidemics, a large proportion of people with HIV are still unaware of their HIV status and that, in low and concentrated epidemics, despite high levels of testing in some contexts, such as antenatal care clinics, key populations at higher risk of HIV infection are often not reached. Greater efforts are needed to ensure that HIV testing and counselling adequately reach the population groups at higher risk of

HIV infection, for whom timely knowledge of HIV status is essential to implement prevention interventions and avoid late initiation of antiretroviral therapy.

Moreover, recent evidence indicates that extensive attrition takes place between HIV testing and counselling and treatment, care and support services.

In many circumstances, people informed of their HIV-positive status are not adequately linked with the appropriate services, thus preventing immediate enrolment in care and hindering follow-up for eventually initiating antiretroviral therapy. Links between HIV testing and counselling and other services, including prevention interventions, must therefore be greatly expanded and strengthened to ensure that testing and counselling services adequately fulfi l their role as the main gateway to a comprehensive HIV response.

Lastly, client age and structural, operational, logistical and social barriers, including stigma and discrimination, continue to limit access to existing HIV testing and counselling services and must be addressed. As national programmes search for ways to improve the performance of programmes, priority should be given to HIV testing and counselling approaches that are cost-effective and achieve maximum impact in increasing knowledge of serostatus.

To this end, WHO and UNAIDS support the adoption of a combination of innovative and cost-effective HIV testing and counselling models that protect the human

Box 4.1

Note on methods

The data discussed in this chapter are based on two sources. The fi rst consists of reports sent by countries to WHO, UNAIDS and UNICEF regarding policies, programmes and indicators based on information collected from health facilities. These data were compiled and verifi ed where feasible, in collaboration with countries. However, given the lack of adequate strategic information systems in many countries, they are often not formally validated. Data aggregation across countries may also be methodologically challenging, as defi nitions may not be standardized. Data on service availability and uptake may not cover all public, private and nongovernmental health facilities in a country or may not include all service delivery points where HIV testing and counselling services are provided. In addition, calculations of aggregate measures, especially regional medians, are based on subsets of countries with available comparable data that may not be fully representative of their respective regions. Specifi c numbers should hence be interpreted with caution.

The second source of data comprises national population surveys conducted in some low- and middle-income countries. These surveys are generally based on nationally representative samples and typically follow standardized methods that provide comparable data on respondents’

reports of their use of specifi c HIV services, thus enabling coverage to be estimated for various population groups. Some surveys also draw blood from respondents who agree to be tested and can thus provide information on the HIV status among specifi c groups. The extent to which such surveys can provide estimates of knowledge of HIV status depends on the specifi c information that is asked of respondents, in particular, regarding their HIV status. The estimates provided by these two sources of data may differ, especially if country reports do not include information from all nongovernmental facilities. Population surveys would generally provide more accurate estimates of uptake.

rights of all individuals, respect principles of informed consent and confi dentiality and are suitable to local epidemiology and context (2). An updated HIV testing and counselling framework is currently being developed to assist countries in developing an appropriate and effective combination of HIV testing and counselling approaches to maximize coverage and impact.

This chapter discusses national-level data on the availability and coverage of HIV testing and counselling among adults in the general population. Chapter 6 discusses testing among key populations at higher risk of HIV infection, and Chapter 7 reviews data on testing among pregnant women and among infants.

4.2 Policies and programmes for HIV testing and counselling

In 2010, 113 of 126 low- and middle-income countries providing data indicated having national guidelines on the implementation of provider-initiated testing and counselling in health facilities: 20 (77%) in East, South and South-East Asia, 23 (96%) in Latin America and the Caribbean, 15 (79%) in Europe and Central Asia, 37 (82%) in sub-Saharan Africa, and 8 (67%) in the Middle East and North Africa.

Among 38 reporting countries with generalized HIV epidemics, 32 stated that their policy guidelines advise health care providers to initiate testing and counselling

in all encounters patients, a substantial progress from the 19 countries reporting it in 2008. Among countries with low-level or concentrated epidemics, 86 of 93 providing data indicated having policies or guidelines to implement focused testing and counselling for populations at higher risk of HIV infection.

4.3 Availability and uptake of HIV testing and counselling

A total of 119 low- and middle-income countries submitted data on the availability of HIV testing and counselling services in health facilities through this year’s reporting process (Table 4.1). HIV testing and counselling services were provided by 131 000 health facilities in 2010 versus 107 000 health facilities in 2009 (118 countries), 78 000 in 2008 (111 countries) and 30 300 in 2007 (78 countries).

With respect to the uptake of testing and counselling, 108 countries reported that more than 79 million people received HIV testing and counselling in 2010, whereas 67.4 million tests were reported in 100 countries in 2009 (Table 4.2).¹ Country reports provide the total number of people tested, but these figures do not correct for the fraction of people tested more than once during the course of the year, which may vary considerably among countries.

1 Annex 2 provides country data.

Region

Number of facilities with HIV testing and

counselling

Number of countries reporting

Number of people 15–49 years old who received HIV testing and

counselling^a in the past 12 months and know the

results

Number of countries reporting

Sub-Saharan Africa 36 000 42 45 000 000 44

Latin America and the Caribbean 44 000 23 21 000 000 16

East, South and South-East Asia 29 000 24 19 000 000 23

Europe and Central Asia 20 000 18 8 900 000 16

North Africa and the Middle East 2 000 12 1 100 000 13

Total 131 000 119 95 000 000 112

a Based on the numbers of people tested as reported by countries but without correcting for the fraction of people who are tested more than once.

Table 4.1 Number of facilities with HIV testing and counselling and number of people aged 15–49 years who received HIV

testing and counselling

by region (low- and middle-income countries), 2010

Table 4.2 presents a ratio of facilities per 100 000 population and a ratio of tests per 1000 population to more adequately monitor changes in availability and uptake over time. To analyse trends and ensure methodological accuracy, these ratios have been calculated only for countries that provided comparable data in both 2009 and 2010. It is important to consider, however, that the sub-selection of countries included in the analysis may not be fully representative of their regions, and fi gures should be interpreted as such.

A total of 104 countries reported information on the number of facilities providing testing and counselling services in both 2009 and in 2010. In this group, the median number of facilities per 100 000 adult population increased by 44% year-on-year, from 5.7 to 8.2. However, there is considerable regional variation:

fewer than 2 facilities per 100 000 were reported in North Africa and the Middle East and in East, South and South-East Asia versus 12 in sub-Saharan Africa and 24 in Latin America and the Caribbean.

In a subset of 87 countries who provided data in both 2009 and 2010,the number of tests increased from 64 to about 72 million. Globally, the median number of tests per 1000 adult population rose from 47 to 55, a 17% increase. All regions recorded higher median numbers of tests per 1000 adult population, except for

Region

Median number of facilities per 100 000

adult population (number of countries

reporting)

Median number of tests per 1000 adult population (number of

countries reporting)

2009 2010 2009 2010

Sub-Saharan Africa 8.6 12 70 82

(n = 41) (n = 43)

Latin America and the Caribbean 18 24 52 56

(n = 22) (n = 12)

East, South and South-East Asia 1.2 1.6 15 22

(n = 20) (n = 17)

Europe and Central Asia 3.0 3.4 35 36

(n = 15) (n = 10)

North Africa and the Middle East 0.9 1.1 3.7 3.6

(n = 6) (n = 6)

Median (all countries) 5.7 8.2 47 55

a Based on the numbers of people tested as reported by countries but without correcting for the fraction of people who are tested more than once.

b Country data can differ from those published in the 2010 universal access report (3) due to updates and corrections subsequently submitted by countries.

Table 4.2 Number of facilities that provide HIV testing per 100 000

population and number of tests

per 1000 population for countries reporting data for 2009

and 2010, by region

North Africa and the Middle East, where this remained broadly stable. Variation is also great within region:

from 3.6 tests per 1000 in North Africa and the Middle East to 82 in sub-Saharan Africa.

4.4 Coverage of HIV testing and counselling

A growing number of countries are conducting national surveys, including Demographic and Health Surveys, which contain an HIV module. These provide information on the proportion of respondents who have been tested for HIV in the 12 months preceding the survey and on the proportion of those who have ever been tested for HIV. Such surveys, when repeated, can also help identify trends in testing uptake and monitor the extent to which individuals use HIV testing and counselling services.

An analysis of data from countries that have conducted repeat population surveys between 2003 and 2010 reveals substantial increases in HIV testing rates among both women and men (Fig. 4.1). In Lesotho, for instance, the percentage of women tested in the 12 months preceding the survey increased almost seven-fold between 2004 and 2009, from 6.3% to 42%, and almost fi ve-fold among men, from 4.8% to 24%. In the United Republic of Tanzania, testing rates in the last 12 months grew from a baseline of 4.9% in 2003–2004 to 29.5% in 2010 among women and from 7.3% to 25.0% among men.

In addition, HIV testing rates were generally higher among women than among men in five of the six countries conducting repeat surveys in 2009–2010. In the Congo, the proportions of men and women tested in the last 12 months were similar: 7.2% and 6.5%, respectively. Earlier surveys showed higher percentages of testing among men, as observed in Kenya, Mozambique and the United Republic of Tanzania in 2003–2004, whereas results from surveys carried out in 2009–2010 showed the opposite sex distribution.

This suggests that recent efforts to increase HIV testing and counselling, including through national campaigns, implementing provider-initiated testing and counselling policies and improving integration between HIV and maternal and child health services have provided greater benefi ts to women than men.

HIV testing uptake differs between men and women in East, South and South-East Asia and may refl ect local epidemiological patterns. Among countries submitting data in 2010, the proportion of men receiving an HIV test was higher in countries with larger numbers of people who inject drugs (such as Bangladesh, Indonesia and Myanmar). Relatively more women were tested for HIV in countries with epidemics with unprotected sex as the primary mode of HIV transmission (such as India, Nepal, Sri Lanka and Thailand), where many pregnant women receiving HIV testing through maternal and child health care services.

Lack of knowledge of serostatus by people living with HIV is a major obstacle to realizing the goal of universal access to treatment and prevention. A significant proportion of people living with HIV continue to present late for treatment because they are unaware that they are seropositive, including in high-income countries (4),¹ thus reducing the effectiveness of antiretroviral therapy on morbidity, survival and preventing HIV infection.

Surveys that ask people about testing uptake and include a seroprevalence component provide an

1 In the European Union, an estimated one third of people living with HIV are unaware of their HIV status (4). In the United States, the percentage of people with late HIV diagnoses was 32% in 2007, suggesting that at least a similar proportion remained unaware of their serostatus (5).

Country

Year of

survey Women Men Both

Congo 2009 35.2 21.1 30.9

Kenya 2008–2009 73.5 58.6 68.9

Lesotho 2009 70.8 51.8 64.4

Mozambique 2009 43.2 30.1 38.7

Sao Tome and Principe 2008–2009 a a 41.0

United Republic of Tanzania 2007–2008 43.7 30.8 39.0 Sources: Demographic and Health Surveys [web site] (6).

a When denominators are based on less 50 cases, the corresponding indicator is not reported.

Table 4.3 Percentage of people living with HIV who have ever

received an HIV test and their test results before the survey: national population surveys, 2007–2009

approximate indication of knowledge of HIV status among people living with HIV (5). Table 4.3 reports data on knowledge of HIV status before the survey among people living with HIV for a subset of six African countries with surveys conducted between 2007 and 2009. The percentage of respondents living with HIV who report that they have been tested for HIV provides an upper limit of the estimated number of people living with HIV who know their status.² The results show

2 The accuracy of serostatus knowledge is lower than suggested by this percentage, because some people who have tested may not have received their results or may have seroconverted after an earlier negative test. For example, this is well documented in the 2007 Kenya AIDS Indicator Survey (5).

Fig. 4.1 Percentage of women and men receiving an HIV test and test results in the past 12 months preceding the survey in selected countries

with repeat population surveys, 2003–2010

45%

Box 4.3