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MINISTRY OF HEALTH

NATIONAL HIV TESTING SERVICES POLICY


AND IMPLEMENTATION GUIDELINES
UGANDA

Printed with support from

4TH EDITION
PEPFAR
OCTOBER 2016
Ministry of Health

National HIV Testing Services Policy


and Implementation Guidelines

Uganda

4th Edition

October 2016

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National Implementation guidelines for HTS in Uganda, October 2016
 Uganda Ministry of Health 2016

This material may be freely used for non-commercial


purposes as long as the Ministry of Health is acknowledged.

The Ministry of Health welcomes feedback and comments from both


users and experts in HIV Testing Services (HTS). Please address this
to:
The Director General Health Services
Attn: Program Manager
STD/AIDS Control Program
Ministry of Health
P.O. Box 7272 Kampala, Uganda
Tel: + 256 41 4340874
Fax: +256 41 231584

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National Implementation guidelines for HTS in Uganda, October 2016
Contents
Abbreviations............................................................................................vii
Foreword....................................................................................................x
Acknowledgements.................................................................................xiii

1.0. Introduction.............................................................................1
1.1. Overview............................................................................1
1.2. Situational Analysis of HIV and AIDS in Uganda................2
1.3. History of HTS in Uganda.........................................................4
1.4. Rationale for Policy Review......................................................5
1.5. Policy Framework......................................................................7
1.6. Target Audience.........................................................................8
1.7. Process of Policy Review..........................................................8
1.8. Guiding Principles and Values.................................................9
1.9. Lay-out.........................................................................................12

2.0. Purpose and Objectives of the HTS Policy and guidelines..13


2.1. Purpose.........................................................................................13
2.2. Objectives.....................................................................................13

3.0. Priority Populations...................................................................14


3.1. Couples and sexual partners......................................................16
3.2. Infants, Children and Adolescents...........................................17
3.2.1. Infants and children below 18 months.....................................17
3.2.2. Children 18 months to below 10 years.....................................18
3.2.3. Adolescents (10-19 years)..........................................................19
3.3. Youths..........................................................................................21
3.4. Persons with Disability (PWDs)...............................................22
3.5. Health workers...........................................................................23
3.6. HTS for Key populations (KPs)................................................24
3.7. Pregnant and breastfeeding women........................................25
3.8. Men...............................................................................................26
3.9. Refugees, Internally Displaced Persons (IDPs) and other
Persons of concern to the United Nations High Commission
for Refugees (UNHCR).............................................................27

4.0. Ethical-legal Issues in HTS.......................................................28


4.1. Human Rights.............................................................................30
4.2. Consent for HTS..........................................................................32
4.3. Counselling.................................................................................36

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National Implementation guidelines for HTS in Uganda, October 2016
4.4. Confidentiality............................................................................39
4.5. Correct Results............................................................................43
4..6. Linkage to care............................................................................43

5.0. Social Behaviour Change Communication (SBCC)


for HTS........................................................................................45
5.1. SBCC Integration in HTS Cascade...........................................46
5.2. Communication and Mobilisation for HTS............................49
5.3. Demand creation.........................................................................51
5.4. Tracking and reporting SBCC interventions for HTS............51

6.0. Delivery of HIV Testing Services.............................................52


6.1. Settings and Approaches for HIV Testing Services................54
6.1.1. HTS at health facilities................................................................57
6.1.2. HTS at community settings.......................................................59
6.2. Integration, decentralisation and Task-Sharing of HTS........63
6.2.1. Integration of HTS in other health services.............................64
6.2.2. Decentralization of services.......................................................70
6.2.3. Task sharing of HTS...................................................................71
6.3. Differentiated models for HTS..................................................73
6.4. The HIV Testing Services Protocol...........................................77
6.5. Counselling in HTS.....................................................................90
6.5.1. Consenting procedure for HTS.................................................90
6.5.2. Counselling for Disclosure of test results................................91
6.6. HIV Testing.................................................................................93
6.6.1. Diagnostics for HIV...................................................................94
6.7. Re-Testing and Repeat Testing................................................102
6.7.1. Re-testing....................................................................................102
6.7.2. Repeat Testing............................................................................106
6.7.3. HIV Self- testing (HIVST)........................................................106

7.0. Linkage to Prevention, Care, Treatment and Support


Services......................................................................................108
7.1. Intra and Inter-facility linkages................................................109
7.2. Tracking Inter-Facility Linkage after Referral........................114
7.3. Referral Directory......................................................................116
7.4. Good practices to increase linkage to HIV care....................118
7.5. Linkage for HIV Positive individuals....................................120
7.6. Linkage for HIV Negative individuals..................................120
7.7. Linkage Facilitators...................................................................121

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National Implementation guidelines for HTS in Uganda, October 2016
7.8. Monitoring Linkage...................................................................123

8.0. HTS Health Systems requirements........................................124


8.1. Leadership and Governance of HTS......................................126
8.1.1. Coordination and oversight.....................................................126
8.1.2. Accountability...........................................................................127
8.2. Infrastructure for HTS.............................................................129
8.2.1. Physical accessibility.................................................................129
8.2.2. Counselling space.....................................................................130
8.2.3. Testing space.............................................................................130
8.2.4. Storage space for HTS supplies and commodities...............130
8.2.5. Records storage rooms..............................................................131
8.3. HTS Logistics Supply Chain Management...........................131
8.3.1. Stock monitoring and management of test supplies............132
8.3.2. Forecasting and Quantification...............................................132
8.3.3. Procurement and distribution................................................133
8.3.4. Storage of HTS supplies and commodities at district and
Facility.........................................................................................134
8.3.5. Training in logistics management..........................................134
8.4. Financing for HTS......................................................................135
8.5. Human Resources for HTS.....................................................137
8.5.1. HTS service providers..............................................................137
8.5.2. Use of Lay Providers.................................................................138
8.5.3. HTS Provider qualifications...................................................139
8.5.4. Performing an HIV test............................................................139
8.5.5. Training in HIV counselling and testing...............................139
8.5.6. Qualification of HTS Counsellor Trainers...............................140
8.5.7. HTS Provider Support Supervision and Mentorship............141
8.5.8. Composition of HTS Providers...............................................142
8.5.9. HTS staff-client ratio..................................................................146
8.6. Health Information Management system for HTS................147
8.6.1. HTS data collection...................................................................147
8.6.2. Data Management....................................................................148
8.6.3. Reporting...................................................................................148
8.7. Quality Assurance and control for HTS................................151
8.7.1. Adherence to standards and policies.....................................151
8.7.2. Certification of HTS Providers and Site accreditation..........152
8.7.3. Quality assurance for Laboratory reagents and test kits.....154
8.7.4. Quality assurance for Laboratory processes and
procedures.................................................................................154

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National Implementation guidelines for HTS in Uganda, October 2016
8.7.5. Evaluation of test kits and other laboratory reagents...........157
8.7.6. Quality assurance/control measures for monitoring and
evaluation.................................................................................157
8.8. Research.....................................................................................158
8.8.1. HIV testing in surveillance settings........................................159

9.0. Monitoring and Evaluation for HTS......................................160


9.1. Collection and reporting systems for periodic
assessments................................................................................161
9.2. Process indicators....................................................................161
9.3. Quality of care indicators........................................................161
9.4. Outcome indicators...................................................................162

10.0. Desired Policy Outcomes.........................................................162


11.0. Policy Performance Indicators................................................163
12.0. Policy Implementation Framework........................................164
13.0. Policy Review Plan..................................................................169

14.0. References..................................................................................170
14.1. Annex 1. Policy Guidance for development of HTS
implementation guidelines......................................................172
14.2. Annex 2: Glossary of terms......................................................174

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National Implementation guidelines for HTS in Uganda, October 2016
Abbreviations
ACP AIDS Control Programme
ADPs AIDS Development Partners
AIDS Acquired immune deficiency syndrome
ANC Antenatal Clinic
ART Antiretroviral therapy
ARV Antiretroviral drug
BCC Behavioural Change Communication
CDC Centre of Disease Control and
Prevention
CHAI Clinton Health Access Initiative
CITC Client Initiated Testing and
Counselling
CPD Continuous Professional
Development
CPHL Central Public Health Laboratory
CQI Continuous Quality Improvement
DBS Dry Blood Spot Sample
DHO District health office/officer
DNA Deoxyribonucleic Acid
EID Early Infant Diagnosis
ELISA Enzyme-linked immune-sorbent assay
EQA External Quality Assurance
FP Family planning
GBV Gender-Based Violence
HBHCT Home Based HIV Counselling and
Testing
HEI HIV Exposed Infants
HIV Human Immunodeficiency virus
HMIS Health Management Information
System

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National Implementation guidelines for HTS in Uganda, October 2016
HSSIP Health Sector Strategic & Investment
Plan
HTS HIV Testing Services
HCT HIV counselling and testing
ICF Intensified Case Finding
IDPs Internally displaced persons
IEC Information Education and
Communication
ILO International Labour Organisation
IPC Interpersonal Communication
IQC Internal Quality Control
JMS Joint Medical Stores
KPs Key Populations
M&E Monitoring and Evaluation
MoEST Ministry of Education, Sports and
Technology
MoH Ministry of Health
MSM Men who have Sex with Men
NGO Non-governmental organization
NHRL National Health Reference Laboratory
NHSP National HIV and AIDS Strategic
Plan, 2016-2020
NMS National Medical Stores
NQIT National Quality Improvement
Teams
OVC Orphans and Vulnerable Children
PCR Polymerase Chain Reaction
PEP Post Exposure Prophylaxis
PITC Provider Initiated Testing and
Counselling
PLHIV People Living with HIV
PMTCT Prevention of Mother to Child
Transmission of HIV
PPP Public-Private Partnership

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National Implementation guidelines for HTS in Uganda, October 2016
PTC Post-Test Clubs
PWDs Persons with Disabilities
QA Quality Assurance
QC Quality Control
QIT Quality Improvement Teams
RCT Routine HIV Counselling and Testing
RHT Rapid HIV Antibody Test
SGBV Sexual Gender- Based violence
SOPs Standard Operating Procedures
SRH Sexual Reproductive Health
STD Sexually Transmitted Disease
STI Sexually Transmitted Infection
SW Sex Worker
TB Tuberculosis
TWG Technical Working Group
UCA Uganda Counselling Association
UDHS Uganda Demographic Health Survey
UHPC Uganda HIV Prevention and Control
Act, 2014
UNAIDS The Joint United Nations
Programme on HIV and AIDS
UNHCR United Nations High Commission
for Refugees
USAID United States Agency for
International Development
UVRI Uganda Virus Research Institute
VCT Voluntary HIV Counselling and
Testing
VSMC Voluntary Safe Male Circumcision
WHO World Health Organization

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National Implementation guidelines for HTS in Uganda, October 2016
Foreword
The Government of Uganda (GoU) has made the fight
against HIV and AIDS one of its top priorities. The strategies
aimed at responding to the HIV and AIDS epidemic, are
an integral part of the Health Sector Development Plan
2016-2020, National HIV and AIDS Strategic Plan (NHSP
2015/16-2019/20) and the National Health Policy (NHP
II). HIV Testing Services are offered within a legal and
human rights framework ensuring quality counselling,
confidentiality, informed consent, giving of correct results
and connecting those tested to further care and prevention.
MoH acknowledges the need to continuously adopt new
approaches in response to the changing epidemic. This
enables the country to appropriately focus the response
to target priority areas and population groups; hence the
need for periodic HTS policy reviews to incorporate new
evidence-informed approaches.

HIV Testing in Uganda began in 1990 with Voluntary


Counselling and Testing (VCT) as the main mode of
delivery. The country developed the first VCT policy in
2002 with an aim of scaling up VCT. The review of the 2005
policy introduced Routine HIV testing and counselling
and Home-Based HIV Testing and Counselling (HBHCT)
to complement VCT. The second review in 2010 separated
the HIV Counselling and Testing (HCT) implementation
guidelines from the HCT policy and aimed at increasing
coverage for HCT services to achieve universal access.

The changes made in the second review resulted in


significant achievements. The number of facilities

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National Implementation guidelines for HTS in Uganda, October 2016
providing HCT services increased to 3,565 in 2014;
including all public and private hospitals and HC IVs.
There has been a progressive increase in the number of
individuals tested since 2011 from 5,524,327 individuals
to 9,564,992 in 2014 with nearly two thirds of these being
women, and about 10% being children under the age of
15 years. About 1,727,465 were pregnant women during
Antenatal Care (ANC) visits. Over the last three years
the percentage of women and men aged 15 -49 years who
received an HIV test in the past 12 months and know their
results has ranged from 42% to 51.4%1,2. While this may be
explained by the increase in the population, it still shows
that there are many missed opportunities for HCT HTS

The drive to end the HIV epidemic and meet the new
nationally adopted global 90-90-90 targets towards
elimination of HIV by 2030 as enshrined in the National
HIV/AIDS Strategic Plan 2016-2020, underpins the review
of the HTS policy and guidelines.

The review of the 2010 HTS policy is therefore aimed at


galvanising efforts to achieve the first and second 90s of
the UNAIDS fast-track 90*90*90 targets for Uganda. This
shall be done through: improving efficiency and cost-
effectiveness; addressing quality issues to ensure correct
test results and scale up connection to prevention, care
and treatment; enhancing HTS approaches and models
to reach out to priority populations; strengthening quality
assurance for HTS; adoption of new testing kits; streamlining
strategic behavioural change communication; promotion
of public and private partnerships; further integration
1 LQAs 2012/14
2 MOH 2011, Uganda AIDS Indicator Survey 2010/1011

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National Implementation guidelines for HTS in Uganda, October 2016
of HTS into general health care and, strengthening
coordination, monitoring and evaluation. The HTS policy
and Implementation guidelines are aligned to the 2015
World Health Organization Consolidated HTS guidelines
and the Uganda HIV Prevention and Control Act, 2014.

This document provides guidance on how HTS should


be planned, delivered/ implemented, monitored
and evaluated. Therefore, the document serves as a
useful resource for policy-makers and planners, AIDS
Development Partners (ADPs), HTS implementers,
academicians, researchers and service providers.

The policy review process was participatory and included


establishment of a Technical Working Group (TWG) to
spearhead the process; a rapid performance appraisal of
the 2010 Policy and Stakeholder consultations.

It’s my conviction therefore that this policy is based on


cutting-age evidence, vast experiences in planning and
delivering HIV testing services and addresses diverse
community HIV Testing needs.

Prof. Anthony K. Mbonye


Ag. Director General Health Services

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National Implementation guidelines for HTS in Uganda, October 2016
Acknowledgements
This document was developed through
through the
the contributions
contributions
and expertise of a number of people and Institutions.

The Ministry of Health (MoH)


(MoH) wishes
wishes to
to acknowledge
acknowledge
the following members of the HIV
HIV Testing
Testing Services
Services (HTS)
(HTS)
Technical Working Group (TWG) and and other
other Resource
Resource
Persons for the invaluable work done;

Organisation Name
Organisation Name
Ministry of Health (MOH)
Dr. Allan Muruta
Ministry of Health (MOH) Dr. Patrick Tusiime
Dr. Joshua Musinguzi
Dr. Allan Muruta
Dr. Wilford Kirungi
Dr. Joshua Musinguzi
Dr. TumwesigyeBenson
Dr. Tumwesigye Benson
Geoffrey Taasi
Taasi Geoffrey
Dr. Kadama Herbert
Dr. Kadama Herbert
Dr Norah Namuwenge
Tinkasiimire Talugende
Nyegenye
Tinkasiimire Wilson
Talugende
Dr Linda
Nyegenye WilsonNabitaka
Dr.Katureebe
Dr Linda Cordelia
kisakye Nabitaka
Juilet Cheptoris
Dr. Katureebe Cordelia Mboijana
Dr. Doreen Ondo
Juliet Cheptoris
Micheal
Dr.Doreen Muyonga
Olowo Ondo
Dr. Barbara Asire
Micheal Muyonga
Dr. Shaban Mugerwa
Dr Peter Kyambadde
Florence Nampala
Dr. Barbara Asire
Uganda AIDS Commission Dr. Peter Mudiope
Dr.ShabanMugerwa
Dr. Carol Nakkazi
Florence Nampala Busingye
Judith Kyokushaba
Uganda AIDS Commission Dr.Peter Mudiope
Dr. Carol Nakkazi

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National Implementation guidelines for HTS in Uganda, October 2016
Organisation NameName
Centres
Centres for
for Disease
Disease Control StevenDr.
Control and Wiersma
Esther Nazziwa
and Prevention
Prevention (CDC) (CDC), Dr Stella Alamo
Apolot Talisuna
Madina
Uganda
Dr. Esther
Aleti Nazziwa
Philliam
ApolotSamMadina
Wasike
Aleti Rose Apondi
Aleezaibo Philliam
Dr. Stella Alamo
Sam Wasike
Neetu Abad
Rose Apondi
World Health
Centres Organisation
for Disease Control Behel Rita Nalwadda
Stephanie
(WHO)
and Prevention (CDC), Dr. Kaggwa Mugaga
Atlanta William Lali
World
ClintonHealth
HealthOrganisation Rita Nalwadda
Access Initiative Dr. Betty Mirembe
(WHO)
(CHAI) Catherine Amulen
Clinton Health Access Dr. Betty Mirembe
Brenda Kunya
Kabasomi
Initiative (CHAI) Catherine
VickyAmulen
Abenakyo
Baylor Uganda Brenda Kabasomi Mbeine
Dr. Denise Birungi
STAR-EC Vicky Silver
Abenakyo
Mashate
Baylor Uganda Dr. Denise Birungi
Dorothy Namuganga
STAR-EC
Makerere University School of Silver Mashate
Prof. Rhoda Wanyenze
Public Health (Mak. SPH) Dorothy Namuganga
Dr.Edgar Kansiime
Makerere University
Infectious Diseases Institute (IDI) Florence Namimbi
School of Public Health Prof. Rhoda Wanyenze
ANECCA Rose Nasaba
(Mak. SPH) Dr.Edgar Kansiime
Pretium Solutions LTD Musoke Nassir
Infectious Diseases
USAID/CHC
Institute Venansio
Florence Namimbi Ahabwe
Uganda Virus Research Rose Nasaba
ANECCA Rose Akide
InstituteSolutions LTD
Pretium Musoke Nassir
Makerere University, School
USAID/CHC Agatha
Venansio AhabweKafuko
of Humanities
Uganda Virus Research In-
stitute
NAFOPHANU Rose Akide
Nanyanzi Prossy

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National Implementation guidelines for HTS in Uganda, October 2016
Organisation
Organisation NameName
Name
Makerere
Makerere University,
MildmayUniversity,
Uganda Grace
Agatha Kabunga
Kafuko
Agatha Kafuko
School of Humanities
School Humanities
Ministry of Justice and Kyampaire Dorothy
NAFOPHANU
NAFOPHANU Nanyanzi
Nanyanzi Prossy
ProssyLuzige
Luzige
Constitutional Affairs Lillian Andama
Mildmay Uganda
Mildmay UgandaPersons Grace Namuddu
GraceKawooyaVicentKabunga
Namuddu Kabunga
Other Resource
Kyampaire
KyampaireDorothy
Dorothy
Ministry
Ministry ofofJustice andand
Justice Janet Kabatebe Bahizi
Constitutional Affairs
Constitutional Affairs LillianNabalonzi Jane Kisitu
LillianAndama
Andama
Consultants Teddy
Rosemary Chimulwa
RosemaryKidyomunda
Kidyomunda
UNFPA Dr. Enid Mbabazi
UNFPA Judith Amongin
JudithDr. Denis Nansera
Amongin
KawooyaVicent
United States Agency
TheInternational
for HTS policy and implementation
Dan Wamanya
Janet Kabatebeguidelines
Bahizi review
process was made
Development possible with financial support from
(USAID)
Other
the Resource
ELMA Persons
Philanthropies Nabalonzi
and Bill Jane
and Kisitu
Melinda Gates
Central Public Health
Foundation throughthe Wilson
Teddy Nyegenye
Nabwire Chimulwa
Clinton Health Access Initiative
Laboratories (CPHL)
(CHAI), Medical
National and theStores
UnitedDr.Nations Population Fund
Enid Sunday
Mbabazi
Izidoro
(UNFPA) to whomthe MoH is very grateful.
(NMS)
Consultants Dr. Denis Nansera
Kawooya Vicent
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is extended to the guidelines
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providing backstopping support to the review process. Gates
Foundation throughthe Clinton Nabalonzi
Health Jane KisituInitiative
Access
(CHAI), and the United
The Consultants comprising Teddy
Nations Nabwire
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to whomthe
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Nanseraand Dr. grateful.
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Consultants Dr. Enid Mbabazicommended
for leading
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gratitude review process
is extended to theand compiling
Members of the
the
Policy and implementation Dr. Denis
guidelines. Nansera
National HIV Testing Services Committee (NHTSC) for
providing
The backstopping support to the review process.
It isHTS
mypolicy andhope
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that this HTS guidelines
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The made possible with
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xv | Page
National Implementation guidelines for HTS in Uganda, October 2016
(CHAI), and the United Nations Population Fund (UNFPA)
It is my sincere hope that this HTS Policy and implementation
tofast-track
whomthethe MoHNational
is veryHIV and AIDS Strategic Plan target
grateful.
guidelines will provide the necessary guidance for the
of identifying 90 percent of HIV infected Ugandans and
provision
Special of accessible, equitable, quality, of
human-rights
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HIV Testing Services Committee (NHTSC) for providing fast-track the
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90 percent of HIV infected Ugandans and linking them to
Sincerely
The
HIV Consultants comprising
care and support servicesMs.
by Teddy
2020 N. Chimulwa,Dr.
Denis Nanseraand Dr. Enid Mbabaziare commended for
leading the policy review process and compiling the Policy
and implementation guidelines.
Sincerely
ItDr
is my sincere
Joshua hope that this HTS Policy and implementation
Musinguzi
guidelines will provideSTD/ACP
Programme Manager, the necessary guidance for the
provision of accessible, equitable, quality, human-rights
sensitive and high impact HTS in order to fast-track the
………………………………..
National HIV and AIDS Strategic Plan target of identifying
90 percent of HIV infected Ugandans and linking them to
Dr Joshua Musinguzi
HIV care and support services by 2020
Programme Manager, STD/ACP

Sincerely

………………………………..

Dr Joshua Musinguzi

Programme Manager, STD/ACP

xvi | Page
National Implementation guidelines for HTS in Uganda, October 2016
1.0. Introduction
1.1. Overview
The revised HTS policy and Implementation guidelines
replace the 2010 Uganda HIV Counselling and Testing
(HCT) Policy and National Implementation guidelines for
HCT, 2010. It is informed by new evidence generated from
implementation of HTS at international, regional and
national levels as well as lessons and good practices from
the East African region. Uganda has adopted the WHO
terminology “HIV Testing Services (HTS)” to replace ‘HIV
Counselling and Testing (HCT)’in order to incorporate all
services aimed at ensuring delivery of high quality HTS.
These include: counselling, coordination with laboratory
services for quality assurance and correct results and
linkage to care and Prevention services.
Definition of HTS
HIV testing services (HTS) in Uganda will include the full
range of services that shall be provided together with HIV
testing. This includes pre-test information, HIV testing,
post-test counselling, linkage to appropriate HIV prevention,
treatment and care services and other clinical and support
services; and coordination with laboratory services to support
quality assurance and the delivery of correct results. The
human rights approach shall encompass use of the essential 5Cs;
Consent, Confidentiality, Counselling, Correct test results and
Connection (linkage to prevention, care and treatment). This
includes HTS services provided to various population groups
including key Populations at-risk and Vulnerable populations,
prevention of mother-to-child transmission of HIV (PMTCT)
and ARV treatment to all those who need it.

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National Implementation guidelines for HTS in Uganda, October 2016
The 2016 HTS policy and implementation guidelines
integrate both the policy statements and implementation
guidelines.

1.2. Situational Analysis of HIV and AIDS in


Uganda
Uganda’s HIV epidemic is described as mature,
generalized and heterogeneous, with heterosexual
intercourse and mother-to-child transmission as the main
modes of transmission. This is coupled with concentrated
sub-epidemics in different key populations which pose
the risk factors and drivers responsible for fuelling HIV
transmission3.With an estimated national HIV prevalence
rate of 7.3% in 2011 among men and women aged 15 – 49
years, up from the previous 6.4% in 2005, Uganda has the
highest national adult HIV prevalence in the East African
Community4.

Uganda is still classified as a high burden country with high


number of persons living with HIV which has continued
to increase. This is a result of continuing spread of HIV,
and increased longevity among persons living with HIV.
The national projections based on Spectrum estimates
indicate an increasing number of people living with HIV;
1.4million in 2011 to 1.6M in 2013, and to 1,500,000 in 2014
and high number of orphans due to AIDS of about one
million. However, there is a window of hope as evidenced
by reduction in number of new infections among the
adults over the last five years from 160,000 in 2010 to
3 UAC, 2015. Know your Epidemic Know your Response: Modes of Transmission Synthesis
Study 2014.
4 MoH 2011, Uganda AIDS Indicator Survey 2010-2011

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National Implementation guidelines for HTS in Uganda, October 2016
140,000 in 2013 and to 95,000 in 2014. Similarly the new
infections among children reduced from 31,000 in 2010
to 15,000 in 2013 and to 5200 in 2014. Other remarkable
improvements have been witnessed in the reduction of
annual AIDS related deaths from 67,000 to 63,000 in 2010
to 2013 respectively and to 31,000 in 20145.
Urban areas continue to have a higher HIV prevalence
rate (8.7%) than rural areas (7.0%)6and a rising epidemic
in adolescents and young people with girls and women
disproportionately affected7. The MOT 2015 synthesis
also notes that women carry much of the burden of the
epidemic in Uganda- with higher prevalence rates in many
categories when compared to their male counterparts.
According to the 2015 MOT synthesis, on average, of the
total new infections, about 22% occurred among stable
married couples who constitute about 42% of the total
population, 25% among those with one partner (non-
marital) who constitute about 15% of the total population,
32% among casual heterosexual partners who constitute
about 23% of the total population and 20% among sex
workers, clients of sex workers and partners of these
clients who constitute about 5% of the total population.
Therefore the populations most susceptible to risk of new
HIV infections are the Key Populations, contributing 21%
of the total new infections although they are just 5% of the
total population.
There are several risk factors and key drivers that are

5 UAC 2015, The Uganda HIV and AIDS Country Progress Report 2014
6 MoH, 2011. Uganda AIDS Indicator Survey, 2010
7 Uganda Bureau of Statistics (UBOS) and ICF International Inc. 2012.Uganda
Demographic and Health Survey 2011.Kampala, Uganda: UBOS and Calverton, Maryland:
ICF International Inc.

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National Implementation guidelines for HTS in Uganda, October 2016
fuelling the epidemic and play a crucial role in the spread
of HIV. The key factors include multiple concurrent sexual
partners, lack of condom use, transactional sex, cross
generational sex, early sex, sexually transmitted diseases,
discordance and non-disclosure, and lack of circumcision.
The drivers of the epidemic on the other hand are:
negative socio-cultural norms and values, wealth, income
inequality and poverty, gender inequality, human rights,
stigma and discrimination and inequity8.

1.3. History of HTS in Uganda


HTS in Uganda began in 1990, with Voluntary Counselling
and Testing (VCT) as the main approach to delivery. The
country developed the first VCT policy in 2002, with
an aim of scaling up VCT. The first policy review done
in 2005 introduced Provider Initiated HIV Testing and
Counselling (PITC) and HBHCT to complement VCT;
with HCT service points more than doubling from 554
sites in 2007 to 1,215 sites in 20099. During this period,
emphasis was put on new models of HCT, expansion
of entry points; scale up of HCT to children, use of Lay
Providers and testing in the community.

The second review in 2010 separated the HCT


implementation guidelines from the HCT policy and
aimed at increasing coverage for HCT services to achieve
universal access.

8 Uganda AIDS Commission (UAC) 2015. KYE,KYR Modes of Transmission Synthesis 2014
9 Uganda Bureau of Statistics (UBOS) 2012. Uganda Demographic and Health Survey 2011

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1.4. Rationale for Policy Review
By end of 2014, access to HTS in Uganda had improved,
with 3,565 HTS outlets spread across the country, and at
least 51.4% of the population aged 15-49 knowing their
HIV sero-status. While the number of people testing for
HIV surpassed annual targets (8million people tested
annually), the rate of HIV re-testers was high (40%)10. HTS
coverage in infants, under 5 years, children, adolescents,
Orphaned and Vulnerable Children (OVC), couples,
People With Disabilities (PWDs), and Key populations
{Sex Workers (SWs), Men who have Sex with Men
(MSM), truck drivers, the fisher folk, uniformed services
personnel, prisoners}, and among the emerging high risk
groups (alcoholics and drug addicts, boda-boda cyclists,
music artists, health workers, plantation workers) remains
low11.

Other gaps in HTS programming include the weak


community-facility linkages of the newly diagnosed
clients,low staffing and inadequate capacity resulting into
missed opportunities, inadequate counseling, attrition
of HIV exposed infants (HEIs) after first DNA PCR
testing,inadequate behavioral change communication for
HTS,stock outs and inconsistent supply of essential HIV
testing supplies and commodities.

Of critical concern is the dire need to appropriately target


the remaining increasingly smaller group of HIV positive
people with unknown HIV status. Large numbers
of people are increasingly testedwith very low yield.
10 UAC 2015. Uganda HIV and AIDS Country Progress Report 2014
11 Ibid

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National Implementation guidelines for HTS in Uganda, October 2016
Routine HTS program data shows a stagnating average
HIV prevalence of 3.5% among the general population
and above 10% among key populations12. Clearly HIV
testing is becoming more inefficient and expensive as we
approach the first 90 while the resources are declining. An
assessment of the effectiveness of facility and home-based
HTS approaches in 2013 shows that $6.4 and $5 are spent
to test oneindividualfor HIV in a facility-based and home-
based model respectively The same assessment shows that
it takes $86.5 and $54.7 to identify an HIV positive person
through the two models respectively13.

There is thus a need to re-orient and strengthen community


and facility HTS delivery approaches; strengthen public
and private partnerships; increase uptake of HTS inpriority
populations; strengthen health system bottlenecks
(coordination,M&E, Human resources, supply chain
management); behavioral change communication and
strengthen linkages to care and prevention.

These gaps need to be addressed or mitigated if the


country is to realize its National HIV and AIDS Strategic
Plan 2019/20 target of 90% of the HIV positives knowing
their HIV sero-status by 2020.

In addition, the need to address the issues below


necessitated a review of the current HTS Policy and
implementation guidelines;

12 MoH Routine Program Data 2013-2015


13 EM Mulogo, V. Batwala, F. Nuwaha and OS Baine: Cost effectiveness of facility and home-
based HIV Voluntary Counseling and testing strategies in rural Uganda. Afr Health Sci. 2013
Jun; 13(2): 423-429 doi: 10.4314/ahs.v13i.32

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National Implementation guidelines for HTS in Uganda, October 2016
• Address emerging Global, Regional and National
issues such as goal 3 (Good Health and wellbeing-
healthy lives and promote wellbeing for all at all ages) of
the Sustainable Development goals and UNAIDS
fast track 90 -90- 90 treatment targets by 2020
• Regularize HTS related legal issues arising out of
the East African and National HIV prevention and
Management Acts
• Streamline testing for adolescents and children
• Align the HTS policy with the new WHO consolidated
technical guidelines for HTS (2015) and address HTS
priorities of the new National HIV strategic plan and
the National AIDS Action Plan (2016-2020)
• Appropriately and more efficiently target the HIV+
with unknown HIV status

In addition, the revision was inspired by new scientific and


programmatic advances in HIV testing as well as the new
strategic direction in the HIV/AIDS response including
emerging policies such as combination HIV prevention,
‘test and treat’ and the new more cost effective testing
models and technologies.

Finally, the need to have a new policy framework for the


provision of HTS services that is aligned to the revised
National HIV and AIDS strategic Plan 2015/16-2019/20
also prompted the revision of the current policy.

1.5. Policy Framework


This document is based on, supports and operationalizes
principles outlined in National, Regional and International

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strategic and policy instruments as outlined in Appendix 1
of this document.

This policy provides a framework for establishing systems


to ensure that relevant aspects and aspirations from
all these instruments that relate to rights of persons in
Uganda to access non-discriminatory services including
HTS are realized.

This policy and guidelines will operate within the scope


of the national and international polices; in alignment
with national plans and in harmony with other MOH
implementation guidelines. They will be used in
conjunction with other operational guidelines for Social
Behaviour change communication, HTS training and
delivery, monitoring and evaluation and quality assurance
standards.

1.6. Target Audience


This policy and guidelines target different stakeholders
including: policy makers, HTS programmers and planners,
AIDS development partners and donors, programme
and health facility managers and in-charges, district and
facility HTS coordinators/supervisors and focal persons,
academicians, People Living with HIV (PLHIV) and HIV
activists, researchers and beneficiaries of HIV Testing
Services.

1.7. Process of Policy Review


This policy was developed through a highly consultative
process which began with formation and commissioning
of the HTS Policy Technical Working Group (TWG).

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The TWG had specific terms of reference (TORs) which
ensured close coordination with the Consulting team. A
desk review of high- impact evidence and good practices
in HTS programming, appraisal of the 2010 HTS policy
through a rapid assessment, and consultations with
research and academic institutions in Uganda were carried
out to generate recommendations to inform the 2016 policy.
Policy writing workshops were conducted where the TWG
and technical stakeholders reviewed the various chapters
of this document. Input was sought through Consultative
meetings withthe Ugandan parliament Committee
for Health; other line Ministries and departments;
Uganda Counselling Association (UCA); Civil Society
Organizations (CSOs), HTS Implementing Partners;
and Special Interest and vulnerable groups (adolescents
and youth, People With Disabilities (PWDs), uniformed
officers and other KPs) and Development partners.

The draft was reviewed by a team of technical Peer


reviewers who also provided input and finally the TWG
and National HIV Testing Services Committee (NHTSC)
reviewed and refined the final draft before presentation
to MoH Health Policy Advisory Committee (HPAC) and
Senior Management for approval

1.8. Guiding Principles and Values


It is the mandate of the Ministry of Health to deliver
quality, affordable and non-discriminative healthcare to
all citizens of Uganda. The HTS Policy and implementation
Guidelines derive their validity from and conform to
relevant items of National legislations and core ethical

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National Implementation guidelines for HTS in Uganda, October 2016
principles. The circumstances and conditions under
which people undergo HIV testing must be anchored in
an approach which protects their rights. The HTS policy
therefore upholds the basic human rights of individuals
and families as enshrined in the various legislations and
implementation principles.

In addition, HTS in Uganda shall conform to the UNAIDS


Reference Group on HIV and Human Rights statement
that supports policy directions that are focused on greater
impact and greater speed in order to “end the AIDS
epidemic as a public health threat by 2030.” The statement
recognizes that effective interventions need to respond to
epidemiological context and to the barriers to accessing
HIV testing, prevention services, and sustained treatment.

The guiding principles for this HTS policy and guidelines


are;

Protection of Human Rights: HIV counselling and testing


must be ethical, based on human rights and conducted
within a supportive environment.

Right to dignity:
• Privacy and Confidentiality: All information
concerning a client, including information relating
to his or her health status, treatment or stay in a
health establishment is confidential. No one shall be
subjected to arbitrary or unlawful interference with
his or her privacy. Clients’ information shall only be
released if the client consents, ordered by the court

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National Implementation guidelines for HTS in Uganda, October 2016
of law and or if necessary for the advancement of the
client’s care and treatment.

• Personal responsibility to preventing HIV Infection:


All people in Uganda have a responsibility to protect
themselves and others from HIV infection, to know
their status and to seek appropriate prevention, care,
treatment and support.

Right to Access: Access covers aspects of availability,


convenience, quality, affordability and acceptability
of HTS to all those who need the service. All essential
commodities and information for HTS, should be made
available, affordable and accessible and be of the required
and approved quality.

Promoting equality for priority populations: The


vulnerable position of women, girls, children, key
populations and persons living with disabilities, with
respect to HIV and AIDS and its social impact is recognized
and addressed.

Promoting HTS in the best interests of Children:


Respect for the best interests of the child dictates that
children’s rights and needs must be at the forefront of all
interventions for HIV prevention, treatment and support

Conformity to the Core Principles of HTS: WHO


recommends that HTS services should be offered in
consideration of Confidentiality, Consent, Counselling,
Correct test results and Connection to care, treatment and
support

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National Implementation guidelines for HTS in Uganda, October 2016
1.9. Lay-out
The overarching aspiration of these guidelines is to ensure
identification of HIV infected persons currently not
reached with HTS and appropriately link them to care,
treatment and Prevention services. This shall be achieved
through implementing the HTS continuum of linkage to
care and prevention as prescribed by WHO (figure 1)

Figure 1: Continuum of Linkage to care and Prevention

Adopted from WHO consolidated guidelines on HTS, 2015


The guidelines are written in line with the five broad but
inter-linked thematic areas namely; Priority Populations,
Ethical-legal issues, Social behavioural Change
Communication, Service delivery and Health Systems.

Under each thematic area, policy statements are


highlighted and below each policy statement, guidance
for implementation is provided. The guidelines also
provide guidance for disseminating, implementing,
monitoringand evaluating the results of the policy.

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National Implementation guidelines for HTS in Uganda, October 2016
2.0. Purpose and Objectives of the HTS
Policy and guidelines
2.1 Purpose
The purpose of the revised HTS policy and guidelines
is to provide a framework to regulate the planning,
implementation, monitoring and evaluation of high
quality HIV Testing Services by standardizing guidance
to HTS providers to achieve universal HTS coverage in
Uganda to ensure identification of HIV infected persons.

This will contribute to reduction of new HIV infections


and improve the quality of life by ensuring HIV positive
individuals are identified early and linked to care,
treatment and support services while HIV negative
persons at risk are linked to prevention services.

2.2 Objectives

I. To provide guidance for provision of high quality and


non-discriminatory HTS to all persons in Uganda.

II. To provide guidance for HTS demand creation and


adoption of positive behavior.

III. To strengthen health systems for delivery of integrated


and targeted HTS in facility and community settings
to increase access, coverage and utilization of HTS
by all.

IV. To provide guidance for monitoring and evaluation


of HIV Testing Services

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National Implementation guidelines for HTS in Uganda, October 2016
3.0. Priority Populations
Populations with increased risks of HIV infection and
transmission; yet have limited access to HTS shall be
prioritized. Broadly, the policy provides guidance for
reaching Infants and children, adolescents and Youths,
pregnant women, couples and partners, men, key and
other vulnerable populations. This will ensure effective
identification of HIV positive individuals and their linkage
into care.

Policy Objective: To ensure that HTS address the specific


needs and concerns of priority populations.

Policy Statements:
a) HIV Testing Services shall be designed to address
the unique needs of persons categorized as priority
populations

Priority populations include;


i. Key Populations (also known as High burden /
high risk populations): These are persons among
whom prevalence of HIV is higher than the average
national prevalence. In Uganda, these include; sex
workers and their clients, long distance truck drivers,
men who have sex with men, fisher folks, boda-boda
riders, and uniformed forces.

ii. Vulnerable populations: These are persons that are


highly susceptible to or unable to protect themselves
from significant harm or exploitation linked with HIV

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National Implementation guidelines for HTS in Uganda, October 2016
infection. These include; couples and sexual partners
especially discordant couples, infants and young
children, sexually abused persons, adolescents and
Youth especially girls, young women, emancipated
minors, orphans and Vulnerable Children (OVC),
out of school children, persons with mental illness,
persons with disabilities (PWDs), health workers,
internally displaced persons, refugees, prison
inmates and migrant workers.

iii. Populations with limited access to HTS: These


are populations who by their nature do not easily
access HTS despite service availability. The limited
accessibility is due to barriers including ways of life,
economic reasons, development stage and stigma.
These include men, Adolescents, Children, Key
Populations, and fisher folk

All HTS and related IEC/SBCC shall be designed to


address the unique needs of these sub-populations

All HIV Testing Services shall be designed to address


the unique needs of the persons categorized as priority
populations

HIV/AIDS programs should be designed to ensure that


priority populations have equitable access to HTS services.
Where appropriate and relevant, these persons shall be
encouraged to be tested with their sexual partners.

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National Implementation guidelines for HTS in Uganda, October 2016
3.1 Couples and sexual partners
In Uganda 60% of new infections occur among married
people and discordant couples may account for up to 50%
of these infections. HTS coverage for couples in Uganda
is low and many people do not know their partner’s HIV
status. Couples and partner HTS have a number of benefits
including adoption of prevention strategies (condom
use, immediate ART initiation, PrEP); safer conception;
improved uptake of and adherence to ART and ART for
PMTCT and increases men’s uptake for HTS14.
HTS for Couples and Sexual partners will be enhanced
through targeting couples and sexual partners with HTS
information and setting up testing points in areas such as:
• Antenatal care settings
• Post natal and Family planning clinics
• HIV care and treatment clinics
• Home-based HTS for index partners
• Religious premarital preparations
• Couple testing campaigns

The privacy and autonomy of the couple and individual


must be respected during the HTS process.

HTS providers should encourage Couple counseling


and testing. In situations where a partner has tested
alone, partner testing and mutual disclosure should be
encouraged.

Where the index client gives permission and consent for


Partner(s) Notification, HTS Providers should ensure
protection of the client.
14 MoH 2011, Uganda AIDS Indicator Survey 2010/2011

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National Implementation guidelines for HTS in Uganda, October 2016
HTS providers must assess for potential gender-based
violence(GBV)during individual partner counseling
sessions. If this is identified early, HTS providers should
support people’s decisions not to test with their partners
until they are ready. HTS Providers should refer clients to
programs that address gender based violence.In addition
couples will be informed about and be supported to join
support groups, including discordant couple groups,
where applicable.

All HTS providers are encouraged to use the nationally


approved couples HTS protocol. Include annex to this
protocol?

3.2. Infants, Children and Adolescents

3.2.1. Infants and children below 18 months

Eighty percent (80%) of children infected with HIV


will die before their 5th birthday if not initiated on
treatment.15Diagnosing HIV infection among infants
should be done at 6 WEEKS or at the earliest opportunity
thereafter. All infants diagnosed with HIV should be
initiated on ART immediately to reduce morbidity and
mortality.

All pregnant women should be encouraged to attend


Antenatal Care and be tested for HIV. HIV positive
pregnant and breastfeeding women should be enrolled at
the Mother-baby Care Point where Early Infant Diagnosis
(EID) for their babies will be done through virological
15 WHO, 2015, Consolidated guidelines on HIV testing Services

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DNA/PCR.Other entry points for identifying HIV Exposed
Infants (HEIs) include; the Out Patient Department (OPD),
In Patient Department (IPD), Immunization/Young Child
Clinic (YCC), and PostNatal Care (PNC). Identification of
HIV Exposed Infants (HEIs) will be done through checking
PMTCT codes on the maternal passport and child health
cards to identify infants eligible for EID. In the absence of
PMTCT codes on the maternal passport and child health
cards; an HIV antibody rapid test of the mother should be
done to ascertain the HIV exposure status of the infant.

All HEIs should be offered DNA/PCR to confirm HIV


diagnosis.

3.2.2 Children 18 months to below 10 years


HTS should be provided to children aged 18 months and
less than 10 years to identify HIV infected children who
were missed by the EID program. HTS for this age-group
should be provided at the following entry points;
• Inpatient department
• Outpatient department
• Young Child Clinics
• TB Clinics
• HIV care and Treatment Clinics as part of index
testing
• Nutrition Clinics
• OVC Programs

Within OPD settings, HIV testing should be guided by


a Screening tool to identify children who are most likely
to be HIV positive so as to reduce the workload, cost of
testing and improve the yield (See annex III).

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3.2.3. Adolescents (10-19 years)
Globally 2.1million people of the 34 million estimated
to be living with HIV are Adolescents16. In 2013, 115,330
Adolescents in Uganda accessed HIV Testing services,
with a positivity rate of 2.5%17. However, adolescence is
a period characterized with vulnerabilities which increase
risk to HIV infection amongst this age group. Yet only 17%
of Ugandan Health Facilities offered Adolescent friendly
services18. In Uganda adolescent girls are generally at
higher risk of acquiring HIV than their male counter parts.
Adolescents from key population groups are at especially
higher risk for HIV infection.

HTS programs should involve adolescents in the design,


delivery, monitoring and evaluation of services to ensure
that their needs are addressed.

HTS providers should offer adolescent-friendly HTS. This


includes;
• A peer-led approach where adolescent peers are
involved in provision of services,
• Services should be offered at the convenience of
adolescents through flexible opening hours, walk-ins
or same-day appointments
• Services should be offered in a place that ensures
privacy and confidentiality
• The messaging should be age-appropriate

Special events exclusively for adolescents may help


overcome adolescents’ concerns of being seen attending
16 UNAIDS 2013; Global HIV and AIDS Report
17 MOH 2013, Baseline Survey for Adolescent HIV Care, Treatment and Support
18 ibid

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HTS services by older relatives, neighbors or family friends.
HTS providers should support adolescents to disclose their
HIV status to significant others for psychosocial support.
The providers must assess and ensure that disclosure does
not result in stigma and discrimination of the adolescents.

HTS should be provided to adolescents in the following


settings;
• IPD
• OPD
• ANC
• Sexual and Reproductive Health (SRH) Clinics (FP,
STI clinics)
• OVC Programs
• Special campaigns
• Mobile outreaches especially for adolescents from
Key Populations
• Youth centers
• Institutions of higher learning

In health care facilities settings, providers of HTS should


physically escort the adolescents to the next point of care to
ensure successful linkage to appropriate HIV prevention,
treatment, and care and support services.

Adolescents from key populations and vulnerable


adolescents (those living on the streets, orphans, in child-
headed households, girls engaged in sex with older men or
in multiple or concurrent sexual partnerships, adolescents
who are sexually exploited) should be prioritized. HTS
programs should ensure these are effectively linked to
other social services to improve their welfare.

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3.3. Youths
HIV prevalence increased from 1.5% in 2005 to 2.4% in
2011 in the 15-19 age-groups and from 4.7% to 5.4% in the
20-24 age groups with young women bearing the largest
burden. Sixty percent (60%) of women and 42% of men
aged 15-24 years had had sex by the age of 18 years. Only
42% and 46% respectively used a condom on their last
sex encounter in 2011; a reducing trend from 54% in 2005.
There was also an increasing trend in premarital sex from
22.5% in 2005 to 31% in 2011. Key risk factors accountable
for this are: low risk perception, need to experiment with
sex and therefore engaging in high risk sexual behavior19.

HTS programs should involve young people in the design,


delivery, monitoring and evaluation of the services to
ensure that their needs are addressed.

HTS providers should offer Youth-friendly HTS. This


should include;
• A peer-led approach where Youth peers are involved
in provision of services,
• Services will be offered at the convenience of the youth
through flexible opening hours, walk-in or same-day
appointments
• Services should be offered in a place that ensures
privacy and confidentiality

Special events exclusively for young people may help


overcome their concerns.

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National Implementation guidelines for HTS in Uganda, October 2016
Providers of HTS should ensure successful linkage to
appropriate HIV prevention, treatment, care and support
services through a functional linkage system.

3.4. Persons with Disability (PWDs)


People with disability (physical, mental or sensory) and
women in particular, are likely to be victims of sexual
abuse and rape than their able-bodied peers. At the same
time PWDs may have lower literacy rates, and depending
on the type of disability, communication of HIV and
AIDS messages and negotiating for safe sex may be more
difficult. HIV Testing Services may also be physically
inaccessible to PWDs20.

Modifications should be made for PWDs to access HTS in


a manner that meets their specific needs.

HTS Providers should be trained to be sensitive to


the needs of PWDs. All HTS service providers should
integrate disability within the HTS cascade. Strategies
for this integration should include orientation of service
providers to be disability-sensitive; training of service
providers in sign language, assessing capacity of the
PWDs to consent to HIV testing and receive results, and
providing appropriate referrals. HTS facilities should be
remodelled according to disability accessibility standards
to allow access to HTS for people with physical disability.

HTS providers should work with Disability People’s


Organisations (DPOs) to mainstream HTS within their

20 UNAIDS. (2009). Disability and HIV Policy Brief, UNAIDS/WHO and OHCHR.

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National Implementation guidelines for HTS in Uganda, October 2016
organisations so as to increase access and coverage of HTS
amongst PWDs.

3.5. Health workers


Health workers are at an increased risk of contracting
HIV as an occupational hazard. Several studies conducted
confirm increased exposure to HIV infection by Health
workers. In a study conducted in Northern region, 46% of
health workers were exposed to infectious fluids, 27% to
needle stick injury, 19.1% to mucosal exposure and 5.5% to
broken skin21. Health workers living with HIV and AIDS
may face discrimination and stigma at their workplaces
which affects access to HIV services.

HTS for health workers should be provided in a


manner that addresses issues of stigma, discrimination,
confidentiality and privacy. Privacy should be ensured by
having separate space, time dedicated to providers and
choice of providers if required.

Post-Exposure Prophylaxis (PEP) services should be


available at all times in all HTS accredited health facilities.

Health workers should be encouraged to access HTS and


other related services for their own benefit and that of their
clients/patients. Health workers should receive a full HTS
package like all other clients.

21 Odongkara BM. Et al 2012; Prevalence of occupational exposure to HIV among health


workers in Northern Uganda; Int. J Risk Saf Med. 2012; 24(2):103-13. doi: 10.3233/JRS-2012-
0563

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3.6. HTS for Key populations (KPs)
There is still a big unmet need for HTS among key
populations due to limited access to health services in
Uganda, yet HIV incidence and prevalence is high amongst
this population22. The Uganda HIV and AIDS Strategic
Plan 2015/16-2019/20 highlights Key Populations to
include: Sex workers, Fisher-folk, Men who have ex with
Men (MSM), long distance truck drivers, boda-boda/taxi
drivers and uniformed personnel. In Uganda sex work and
homosexuality are criminalized and therefore people from
these sub-populations may not seek health care services.
Stigma, discrimination, lack of confidentiality, coercion,
fear of repercussions, and lack of appropriate health
services, resources and supplies prevent such populations
from testing. For the same reasons, key populations may
find it difficult to easily accept linkage to care.

HTS for key populations should be offered through


innovative community and facility based approaches.
Community-based approaches may include; mobile
outreaches; moonlight clinics; and special events in safe
environments.

Peer-led strategies should be prioritized for key


populations.

At facility level, HTS should be friendly, confidential, non-


judgmental and convenient for Key Populations.

22 UAC 2016, KYE, KYR Modes of Transmission Synthesis study 2015

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National Implementation guidelines for HTS in Uganda, October 2016
Key strategies for reaching KPs should include;
• A peer-led approach where Key Population peers
are involved in provision of services
• Services should be offered at the convenience of Key
Populations through flexible opening hours, walk-
ins or same-day appointments
• Services should be offered in a place that ensures
privacy, confidentiality and safety
• Use of snowball and peers to reach their contacts

To improve access to and uptake of HIV testing, targeted


community-based HTS should be made available in
locations and settings acceptable and convenient to people
from Key populations.

PITC in Health facility settings should be offered to key


populations but should not be compulsory or coercive.

In addition to HTS, testing and screening for STIs, TB and


viral hepatitis should be offered to key populations as part
of the integrated HTS package. Key populations in prisons
and closed settings should be offered VCT.

People from key populations testing HIV negative should


be retested every three months.

3.7. Pregnant and breastfeeding women


HIV Testing done as early as possible during pregnancy
enables pregnant women with HIV to obtain and benefit
most from prevention, treatment and care services and
to reduce the risk of HIV transmission to their infants.

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Therefore, all pregnant women and their partners should
be offered HTS through a PITC model.

PITC should be prioritized in ANC as a key component


for eliminating Mother-To-Child Transmission of HIV
(eMTCT). It is strongly recommended that pregnant
women be tested as couples or together with their partners.

All HIV pregnant women who test HIV positive should be


linked to lifelong ART regardless of CD4 count.

3.8. Men
There are fewer men than women who have taken an
HIV test in Uganda23 and men usually have taken an HIV
test when they are already symptomatic with AIDS. As
a consequence, men are more likely to start ART at later
stages of HIV infection and experience higher morbidity
and mortality after starting ART. This low uptake
compromises the impact of proven HIV prevention
interventions, including SMC and treatment for prevention
among men24. The reasons for the low uptake of HTS
among men may include fear, stigma, the perception that
health facilities are “female” spaces and both the direct
costs and the opportunity costs of accessing services.

HTS providers should implement innovative strategies


aimed at reaching men. These may be facility and
community based.

Specifically, men should be targeted at work places to


increase their accessibility to HTS. This is because men
23 MoH 2011, Uganda AIDS Indicator survey 2010/2011
24 WHO 2015, Consolidated guidelines for HIV testing services

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National Implementation guidelines for HTS in Uganda, October 2016
spend most of their time at the work place and hence are
unable to seek conventional HTS in health facilities. HTS
providers should adhere to the 5Cs while providing HTS
at the work place.

In the facility, men should be targeted at ANC through


couple counseling, encouraging disclosure, and partner
notification where deemed necessary.

Approaches to reach men should be focused on; these may


include;

• Testing men in homes of Index clients

• Testing all men admitted in Male Wards


• Mobile HTS for mobile populations especially
Fishermen, long distance truck drivers
• Integration of HTS in male specific health programmes
e.g. SMC clinics and Reproductive health clinics
• Conducting Men specific HTS events e.g. integrating
HTS with sporting
• Religious organizations and others that bring men
and couples together e.g. Fathers Union, Mothers
Union, Christian Men and Women, Rotary club

3.9. Refugees, Internally Displaced Persons


(IDPs) and other Persons of concern to
the United Nations High Commission for
Refugees (UNHCR)
Emergency affected populations have more difficulty
accessing quality HIV services and may be more
susceptible to discrimination, violence and abandonment
upon disclosure of an HIV positive result. HTS for these

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National Implementation guidelines for HTS in Uganda, October 2016
vulnerable populations should always be voluntary
and additional effort must be taken to ensure informed
consent25.

Provision of HTS to refugees and IDPs must be accompanied


by ensuring access to HIV prevention, care and treatment
services and referrals to supportive social, policy and legal
environments for those testing HIV-positive and those at
most risk of acquiring HIV.

4.0. Ethical-legal Issues in HTS


This section addresses issues of ethics and legal provisions
that should guide HTS implementation. It addresses
human rights, non-discriminatory and stigma-free service
provision of HTS. It provides guidance on provision of
high quality and non-discriminatory HTS to all persons
in Uganda based on the 5Cs (Consent, Counselling,
Confidentiality, Correct results and Connection to care) as
recommended by WHO.

HTS programming and implementation shall take into


consideration the provisions of the national and regional
legal frameworks as well as human rights based approach
as laid down in international and national human rights
instruments.

25 UNHCR. (2009). Policy Statement on HIV Testing and Counselling in Health Facilities for
Refugees, Internally Displaced Persons and other Persons of Concern to UNHCR. UNHCR/WHO/
UNDP.

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National Implementation guidelines for HTS in Uganda, October 2016
Policy Objective:
To ensure that HTS are provided in a respectful, non-
discriminatory and ethical manner reflecting professional
integrity of the provider and respecting the human rights
of the person being tested.

Policy Statements:
a) All persons shall have the right to access quality HTS
irrespective of race, gender, ethnicity, disability, socio-
economic and political status.
b) All persons should consent to HTS. In situations where
consent cannot be obtained from the client, the next of
kin, guardian/parent or other authorised persons shall
provide consent on behalf of the client.
c) Clear and accurate information, education and
communication shall be provided to all persons
seeking HTS through pre and post-test counselling to
enable one make appropriate decisions related to HIV
testing.
d) Confidentiality shall be maintained in the process of
providing HTS services. Confidentiality may only be
broken with the CONSENT of and in the best interest
of the individual.
e) Disclosure of a client’s HIV status shall follow the
standard guidelines
f) HTS providers MUST ensure that the test results
provided to the client are correct
g) All persons accessing HIV counselling and testing
shall have the right to be linked to appropriate health
services

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National Implementation guidelines for HTS in Uganda, October 2016
4.1. Human Rights

All persons shall have the right to access quality HTS


irrespective of race, gender, ethnicity, disability, socio-
economic and political status.

Providers of HTS should ensure that all HIV testing


services respect human rights of clients irrespective of their
age, race, ethnicity, sex/gender, colour, disability, socio-
economic, political status, nationality or other grounds.

HTS services in Uganda will be accessible and non-


discriminatory to all persons in Uganda.

Access to HTS
HTS should be designed to address the unique needs of
all persons including priority populations. HIV testing
services should be designed to minimize barriers which
make them inaccessible to some population groups.

All persons will have the right to information, education


and communication on HTS adapted to their respective
special needs.

Non-discriminatory and Stigma free HTS


HTS should be made accessible to all persons in Uganda
irrespective of race, age, religious or political affiliation,
ethnicity, disability, gender, economic or social status, or
sexual orientation as declared under the MINISTERIAL
DECLARATION ON ACCESS TO HEALTH SERVICES,
2014.

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National Implementation guidelines for HTS in Uganda, October 2016
HTS providers should ensure no stigma and discrimination
during delivery of HIV testing services. Service providers
should ensure privacy and protection of clients from
discrimination due to perceived or confirmed HIV status.
Persons who test HIV positive shall not be discriminated
against directly or indirectly on the basis of their HIV
positive test results. For instance, HIV testing shall not
be required at the time of recruitment, as a condition for
continued employment or for insurance purposes unless
authorized by a legal body or justified as part of ethical or
professional standards

Providers of HTS services should put in place initiatives to


enforce protection of persons living with HIV.
HTS providers should treat clients with dignity, respect
and should observe the principles of equity, client
participation, and respect for autonomy. HTS providers
should ensure that PLHIV are meaningfully involved in
all HTS activities, including mobilization, behavioural
change education and communication, HTS provision,
linkage facilitation, documentation, care and support,
follow-up, monitoring and evaluation, and research.

Community and home-based HTS should address stigma


and discrimination so as to promote care and support of
persons infected and affected by HIV following an HIV
diagnosis.

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4.2. Consent for HTS

All persons should consent to HTS. In situations where


consent cannot be obtained from the client, the next of
kin, guardian/parent or other authorised persons should
provide consent on behalf of the client.

Informed consent is the voluntary agreement between a


client and a service provider for the client to take HTS. It
arises from the client having received adequate information
and education that enables them to understand the benefits
and need for testing and the implications of testing. In
Uganda the legal age of consent is 18 years. For HTS, the
age of consent shall be the age at which the individual is
able to understand the results, that is 12 years.

Consent for HIV testing shall be obtained and documented


in the appropriate patient records and evidence of this
indicated through signing or a thumbprint. This shall be
done for both adults and children and will also include;
o Persons who are unable to make a decision such as
the mentally disabled
o Persons who are illiterate or unable to write or read
o Infants and children aged below 12 years
o Persons participating in a research as subjects

For purposes of preventing transmission, informed


consent may not be required for the following categories
of persons;-
o Pregnant and breastfeeding women
o Spouses or partners of pregnant/breastfeeding
women

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o Persons who have committed sexual offences
o Individuals to be initiated on Post Exposure
Prophylaxis
o Donors of blood, body tissue and organs
However, service providers MUST ensure that the
individuals under this category understand the purpose
of their testing.

Consent for HTS in Children


Persons aged 12 years and above shall consent to HTS and
shall have a right to opt out of testing.

For adolescents aged 12 years to below 18 years, approval


of the parent or guardian shall not be a requirement for
HIV testing. However, the provider shall encourage
and support disclosure of test results by the adolescent
to significant persons for support. The lack of parental
approval/permission should not deter access to HTS by
the adolescent.

HIV testing for children less than 12 years of age shall


be done with the knowledge and consent of parents
or guardians and the testing must be done in the best
interest of the child. For those children without a parent
or guardian, an authorized person such as head of the
institution, health centre, hospital, clinic or any other
responsible person may consent for them.

Where a parent/guardian unreasonably withholds


consent to HTS for a child; the Service Provider should
use discretion to offer HTS ONLY if it is in the best interest
of the Child. Such situations may include: when a child is

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symptomatic and when the child’s history relates to HIV
exposure.

HTS will be appropriately adjusted to cater for special


situations such as:-people with physical, mental and
sensory disability, blood and other tissue donation,
occupational and non-occupational exposure, unconscious
patients, persons with temporary mental impairment as
detailed in table 1 below;

Table 1:HTS in special Situations


Special Guidance
Situation
Unconscious • Consent should be obtained from the
patients next of kin, guardian or authorized
person
• The service provider should offer
adequate counseling and support to the
authorized person.
• If the next of kin asks the service
provider to test the patient, he /she
must use their own discretion and in
the interest of the patient.

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Special Guidance
Situation
Mental • Since mental health patients have
health cognitive disability, consent should be
patients obtained from the next of kin, guardian
or authorized person.
• Patients/clients with temporary mental
impairment e.g. under influence of drugs
or alcohol are unable to give informed
consent. Therefore the service provider
should not offer the test. HIV testing is
not an emergency. However where the
service provider deems it necessary,
he/she should make a decision to test
for HIV at their discretion for the benefit
of the patient.
Persons with • The health facility should provide
hearing/ for sign language services through
speech appropriate training of staff or
disability collaboration and referral for sign
language services.

• For persons with speech disabilities, the


health facility should provide means of
communication that are appropriate.
Persons • HTS providers should be sensitive to
with visual and provide verbal explanations to
disability clients with visual disability.
or reading
difficulties

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Special Guidance
Situation
Post-exposure • In case of occupational and non-
prophylaxis occupational exposure, the source
person shall be tested without requiring
consent
• For the exposed person, HIV testing
for post exposure prophylaxis shall be
done using the HTS protocol
Blood and HIV testing should be done as part of the
other tissue donation process. Donors however shall be
donors given an opportunity to know their results.

4.3. Counselling

Clear and accurate information, education and


communication on HTS shall be provided to all persons
seeking HTS through pre-test and post-test counselling
to enable one make appropriate decisions related to HIV
testing.

All persons accessing HTS should be provided with


quality counselling. Counselling will include pre-test and
post-test counselling. Quality counselling should be non-
judgemental, accessible and client centred26.

Pre-test counselling will include:


o Information pertaining to the nature of HIV
transmission
o The importance of having an HIV test
o An explanation of the informed consent form
26

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National Implementation guidelines for HTS in Uganda, October 2016
o Client-centered information tailored to the
behavior, circumstances and special needs of
the person to be tested
o Personalized risk assessment
o Possible results and how to handle the situation to
reduce transmission; and
o Benefits of HIV testing
o The services available in case of an HIV-positive
diagnosis, including where ART is provided
o A brief description of prevention options and
encouragement of partner testing for sexually active
individuals
o The fact that the test result and any information
shared by the client is confidential
o The fact that the client has the right to refuse to be
tested and that declining to test will not affect the
client’s access to HIV-related services or general
medical care
o Potential risks of testing to the client in settings
where there are legal implications for those who
test positive and/or for those whose sexual or other
behavior is stigmatized
o Such other relevant information as the counselor
may deem necessary

• Post test counseling will include:


For people who test HIV Negative;
o An explanation of the test result and reported HIV
status
o The test results and the implications
o Importance of further testing where there is recent
exposure

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National Implementation guidelines for HTS in Uganda, October 2016
o Continuing necessity of taking protective measures
to avoid contracting HIV
o People with significant ongoing risk may need
more active support and linkage to HIV prevention
services.
o Emphasis on the importance of knowing the status
of the sexual partner(s) and information about the
availability of partner and couples testing services;
• Referral and linkage to relevant HIV prevention
services, including voluntary male circumcision
o SMC for HIV-negative men, PEP, PrEP for people at
substantial ongoing HIV risk;
o The need for retesting based on the client’s level of
recent exposure and/or ongoing risk of exposure
(see next section);
o Opportunity for the client to ask questions and
request counseling

• For people who test HIV Positive;


o Test results and the implications;
o The infectious nature of the virus and measures to
prevent transmission
o Referral to medical and social services
o The importance of notifying persons inclose or
continuous contact especially his or her partner
posing danger of infection
o Continued necessity of taking protective measures
to avoid contracting other types of infections such
as other STIs; including information of the reduced
transmission risk when virally suppressed on ART;
provide male or female condoms and lubricants and
guidance on their use.

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National Implementation guidelines for HTS in Uganda, October 2016
o Such other information as the counselor may deem
necessary.

Counselling for HIV testing should be provided in


accordance with approved and relevant HTS protocols.
There should however be variation in the content and
emphasis of the counselling sessions depending on the
HTS approach.

Counselling for children should be age appropriate.


o For children aged below 12 years: Counselling should be
offered to the parent/guardian. The child should only
attend the counselling session if the parent/guardian
finds it appropriate for him/her to participate.

o For children aged 12 years and above: Individual


counselling should be offered to the child unless the
child prefers to have the parent/guardian to participate
in the counselling session.

4.4 Confidentiality

Confidentiality shall be maintained in the process of


providing HTS services. Confidentiality may only be
breached with the CONSENT of and in the best interest
of the individual.

HTS providers should ensure privacy during provision


of HTS services. This should include privacy of verbal
communication, storage of HTS records and test results.

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All information discussed with the client during the
process of providing HIV Testing Services should not be
disclosed to anyone else without the CONSENT of the
client.

While maintaining confidentiality, HTS service providers


should support clients to disclose to their significant
others. This is intended to promote HIV prevention and
address issues of stigma, secrecy, shame and adherence to
care/treatment and other prevention services.

Shared confidentiality may be acceptable where it is


done in the best interest of the client to support clinical
management. This may be intra-facility or inter-facility
referral among service providers. In all cases, the client
should be informed and he/she should consent to the
need for shared confidentiality.

Disclosure of Test Results

Disclosure of a client’s HIV status shall follow standard


guidelines.

Disclosure of a client’s HIV status should ONLY be


done with the client’s informed consent except in special
circumstances such as defilement and rape. However,
health workers should remind individuals about their
responsibility including informing their sexual partners if
they are infected with an STI including HIV. Ethical and
legal issues related to disclosure include;

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National Implementation guidelines for HTS in Uganda, October 2016
Disclosure of a Client’s test results to other persons.
The results of an HIV test may be disclosed to;
• Parent or guardian of a minor
• Parent or guardian of a person of unsound mind
• A legal administrator or guardian with written consent
of the person tested
• A qualified /certified medical practitioner and
counsellor of the individual, where the HIV status is
clinically relevant
• A person authorized by the HIV prevention and
Control Act or any other law; or any other person as
may be authorized by a court e.g. in the context of
defilement or rape
• Any person exposed to blood or body fluids of a person
tested.

Disclosure of HIV Status among Children


Disclosure of HIV positive status to a child should be
done incrementally using age-appropriate language to
accommodate their cognitive skills and emotional maturity
in preparation for full disclosure by 12 years of age. This
should be done upon the assessment by the provider and
consent of the parent/guardian.

Disclosure to a child should be done by the parent or


guardian with support from the health worker.

Children may be told the HIV status of their parents or


guardians where applicable.

In cases where a parent/guardian notices that the child is


not ready for disclosure of the HIV positive status by 12

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National Implementation guidelines for HTS in Uganda, October 2016
years, the health worker should provide on-going support
to the process until the child is ready to be disclosed to.

Though children 12 years and above shall consent for


HTS on their own, the provider should encourage them to
disclose their test results to significant persons for support.

Adolescents with HIV should be counselled and


empowered to disclose their HIV status to significant
others to enhance their care.

Disclosure should be made to the person with whom the


child feels most comfortable.

Disclosure of an Individual’s HIV status to a sexual


partner
Service Providers should encourage disclosure of HIV
status to sexual partner(s) or any other significant other
for purposes of further support and prevention.

HTS providers should discuss with clients opportunities


for partner notification and where the client provides
documented consent, the provider may notify the sexual
partner.

HTS providers need to be sensitive to clients who may be


more susceptible to adverse outcomes of disclosure, such
as discrimination, violence, abandonment or incarceration.
Where the provider assesses and notices discomfort,
disclosure should be differed to a later date; and follow
up of the client should be done.

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4.5 Correct Results

HTS Providers MUST ensure that the test results


provided to clients are correct

HTS providers should provide high-quality testing


services using the recommended HIV testing algorithm
and adherence to the testing procedures. The following
strategies should be adopted to ensure correct HIV test
results:
• HIV testers should be supervised regularly by the
Laboratory team and certified.
• Routine internal and external quality assurance and
quality control for HIV testing should be performed
at all HTS sites and settings.
• Good storage of HIV test kits should always be
maintained.
• Expired HIV test kits should not be used.
• The right diluents for each HIV test kit should be
used.
DBS sample collection and dispatch for DNA/HIV PCR
testing should only be performed by trained laboratory
staff and medical staff such as nurses/midwives or,
clinical officers.

4.6 Linkage to care

All persons accessing HIV counselling and testing


shall have the right to be linked to appropriate health
services

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HIV Testing Services shall not be complete unless
individuals are appropriately linked to HIV Prevention,
care, treatment and support services. HTS providers
should ensure that all persons diagnosed with HIV are
effectively linked and referred to appropriate prevention,
treatment, care and support services.

All individuals who test HIV positive should be linked


to care and treatment immediately as per the ‘test and
treat’ strategy. However, where same-day linkage is not
possible, service providers must ensure that linkage is
done within 7 days (within the same facility) of within 30
days if referred to another facility.

Individuals who test HIV negative should be referred to


appropriate HIV prevention services including SMC.

HTS providers should put in place follow up mechanisms


for all HIV positive individuals linked within the same
facility and those referred to other facilities.
All referrals and linkages should be documented using
appropriate national data collection tools (Triplicate
referral form; Linkage Forms, Pre-ART and ART Registers).

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5.0 Social Behaviour Change
Communication (SBCC) for HTS
Social Behaviour Change Communication (SBCC) is a
process where communication is used to influence people’s
knowledge, attitudes, skills and practices (behaviour).
SBCC is conducted at individual, interpersonal,
community and national levels. SBCC involves providing
information to empower individuals and communities to
make desirable health decisions and practices. SBCC is
integral in the successful implementation of HTS. SBCC
supports identification of determinants of HTS uptake;
influences risk perception; and adoption of risk reduction
behaviours. The SBCC process includes: situational
analysis, design, implementation, monitoring, Evaluation
and learning

Policy Objective: To guide design, implementation,


monitoring and evaluation of SBCC interventions for
HTS based on the Comprehensive HIV Communication
Strategy and the Health Sector Development Plan

Policy statements
1. SBCC interventions shall be integrated into the HTS
programs for implementation and sustainability at
all levels
2. SBCC interventions shall be evidence-based so as
to target the right population and place
3. SBCC interventions shall empower the community
with knowledge and skills to take appropriate
action to seek and utilize HTS.

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5.1 SBCC Integration in HTS Cascade

SBCC interventions shall be integrated into HTS


programs for implementation and sustainability at all
levels

HTS providers should integrate SBCC at all levels of


the HTS cascade. The HTS cascade includes community
mobilisation, health education, pre-test counselling, testing,
post-test counselling and Linkage into care, treatment and
prevention. This will ensure continuity and consistency of
the messaging to the client and therefore give opportunity
to the client to obtain as much information as possible to
facilitate behaviour change. At every stage of the testing
process, the following key messages shouldbe reinforced;

HTS Relevant Messages to Responsible


Cascade be emphasized Human
Resource
Community Benefits of HIV testing, Community
mobilisation available testing mobilisers
facilities, referral for
testing, behaviour
change and HIV
prevention

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National Implementation guidelines for HTS in Uganda, October 2016
HTS Relevant Messages to Responsible
Cascade be emphasized Human
Resource
During The Flow/ process of Health
Health HTS. (Every site/point worker
Education offering HTS should have
a flow-chart indicating
the flow of HTS. Within
the facility as well as
community (during
the testing days) clear
signs/posters/printed
information that direct
clients to areas designated
for counselling and testing
should be visibly displayed.
Directions to designated
areas can also be provided
verbally during education
session).
During Benefits of testing, Counsellor/
Pre-test individual risk Lay provider
Counselling assessment, meaning
and and implications of
Information test results, available
giving support systems based
on test results and
preparing one to make
an informed decision to
test

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National Implementation guidelines for HTS in Uganda, October 2016
HTS Relevant Messages to Responsible
Cascade be emphasized Human
Resource
During How the testing will Tester
testing be done, how long it
will take and what will
happen after the results
are out.
During Test results and their Counsellor /
Post-test implications, risk Lay Provider
Counselling reduction options,
importance of
disclosure, available
services for the HIV
positive, coping
strategies, referral and
appropriate behaviour
change
Linkage into Importance of linkage, Counsellor
Prevention, available referral points / Lay
Care, and services and client Provider/
Treatment choice Linkage
and support Facilitator
services

Information, education and communication on HTS


should be focused so as to reach all Priority populations
with appropriate information based on their special needs.

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5.2 Communication and Mobilisation for
HTS

SBCC interventions shall be evidence-based so as to


target the right population and place

SBCC should start from situation analysis through various


ways such as literature review, research and stakeholder
consultations. Program data should be used to inform
SBCC interventions

Mobilization approaches should be tailored to the needs


and contexts of different population groups in different
places. Mass mobilization and HTS campaigns for HIV
testing should not be encouraged.

Interpersonal Communication should be used as the


primary vehicle for identifying and mobilizing clients
for HTS and to challenge norms and clarify myths and
misconceptions.

Mass media should be limited to general HIV education


and creation of a conducive environment for adoption of
risk reduction behaviour.

SBCC material development should follow the standard


process of situation analysis, design, testing and
production.

Implementers should be as innovative as possible in


designing and implementing SBCC interventions without
violating the established Standards and Ethics.

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Relevant stakeholders within the SBCC arena should
review SBCC materials and tools to ensure that they cater
for local contexts and target audiences.HTS Implementers
should submit SBCC materials and tools to the national
technical working group for review and approval by the
health promotion and Education Division of MOH before
implementation.

All HTS and related IEC should be designed to address


the unique needs of priority sub-populations.

All approved SBCC materials and tools should be made


available through a digital repository at MOH with specific
guidelines for use and reproduction. This will allow for
wide sharing and preservation of key SBCC materials and
tools.

All programs that implement HTS as part of their service


package should integrate SBCC according to the Health
sector HIV Comprehensive Communication Strategy and
the National Communication Implementation Plan.

HTS Implementers should regularly obtain updated SBCC


tools and guidelines from the Ministry of Health, Health
Promotion Department.

Partners should use MOH standardized documents at


planning and implementation of SBCC interventions.

MOH should continue to provide technical leadership


and guidance for SBCC interventions and will address
any emerging issues that require policy direction.

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5.3 Demand creation

SBCC interventions shall empower the community with


knowledge and skills to take appropriate action to seek
and utilize HTS.

SBCC implementers should involve the target populations


in the planning and implementation of SBCC interventions
to promote ownership and sustainability.

SBCC implementers should use existing community


structures and resources for mobilizing target populations.
Such structures include:
• The Local Council system
• Religious structures
• Informal groups including SACCOS
• Formal structures like schools and health facilities

5.4 Tracking and reporting SBCC


interventions for HTS

All HTS SBCC interventions shall have an M&E


framework to track the contribution of SBCC activities
in the achievement of the policy objective

MoH shall develop specific indicators for measuring


the progress and results of SBCC interventions. HTS
programs implementing SBCC activities should report
progress and results as per the National HTS SBCC
indicators.

In order to reach 90% of HIV positive individuals with

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HTS, SBCC partners should innovate, learn document and
share results for replication.

SBCC interventions should be guided by the monitoring


and evaluation agenda of the National HTS communication
implementation plan and the Monitoring and Evaluation
Framework for HIV and AIDS.

6.0 Delivery of HIV Testing Services


This policy and guidelines provide a framework to guide
the identification of 90% of individuals living with HIV and
link them to Care and treatment. Those who test negative
should be offered prevention services and empowered to
remain negative. This section therefore provides guidance
on the various HTS implementation approaches and
models that should be implemented to scale so as to realize
the outcome above.

Delivery of HTS should be guided by the 5Cs i.e.


Counseling, Consent, Confidentiality, Correct results
and Connection to care. To ensure universal access,
HTS should be provided in both community and health
facility settings and should employ both Client initiated
(Voluntary) and Provider Initiated HIV Counseling and
testing approaches.

Policy Objective:
• To standardize delivery of high quality and
population specific HTS at facility and community
settings.

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National Implementation guidelines for HTS in Uganda, October 2016
Policy Statements:
a) A mix of facility and community-based approaches
shall be used to provide HTS
b) Facility based HIV testing services shall be provided
at various service points within the facility as part of
routine service delivery.
c) HIV testing services in community settings shall be
offered following a targeted approach especially for
priority populations who are less likely to attend
facility based HTS.
d) HTS services shall be incorporated in all health
related plans and programs and therefore be an
integral component of all routine health care services
e) Voluntary HIV Counselling and Testing shall be
provided on a client’s request.
f) Provider Initiated HIV Counselling and Testing shall
be provided by a health worker as part of routine
preventive services, clinical management and care.
g) Mandatory and Diagnostic HIV testing shall be
considered under special circumstances.
h) HTS service providers shall adhere to the nationally
approved HTS protocol for adults and children as
per the various approaches and models.
i) All HTS delivery approaches and models shall
adhere to the principles of Consent, Confidentiality,
Counselling, Correct Test Results and Connection
j) The National recommended HTS algorithm shall be
used to guide the performance of HIV tests using
either rapid or DNA PCR tests in both public and
private sites.
k) MOH shall ensure periodic evaluations of HIV test
kits and test algorithms

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National Implementation guidelines for HTS in Uganda, October 2016
l) Repeat testing shall be conducted in specified
circumstances to rule out laboratory or transcription
error and either to rule in or rule out sero-conversion.
m) HIV re-testing shall be done based on client’s level of
recent exposure and or ongoing risk of exposure.
n) All individuals newly and previously diagnosed
with HIV shall be re-tested before ART initiation.

6.1 Settings and Approaches for HIV


Testing Services
•A mix of facility and community-based approaches
shall be used to provide HTS

•Voluntary HIV Counseling and Testing (VCT) shall be


provided on a client’s request.

•Provider Initiated HIV Counseling and Testing (PITC)


shall be provided by a health worker as part of routine
preventive services, clinical management and care for
patients in clinical settings.

•Routine and Diagnostic HIV testing shall be considered


under specific circumstances.

•All HTS delivery approaches shall adhere to the


principles of Consent, Confidentiality, Counseling,
Correct Test Results and Connection to care

HIV testing services shall be offered in facility and


community settings with an aim of achieving universal
access. To ensure provision of quality HTS, both new

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National Implementation guidelines for HTS in Uganda, October 2016
and existing facilities and testing points/sites where HTS
is carried out will be assessed to ensure they conform to
acceptable standards and thereby be certified (See section
11.7for details). The two main approaches to HTS delivery
shall remains voluntary counselling and testing (VCT)
sometimes called Client initiated counselling and testing
(CICT) and provider initiated Counselling and testing
(PITC). In Uganda, the HTS cascade shall follow the steps
depicted in the figure 2below;

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Figure 2: The HTS Process/Journey

Demand creation HTS Promotion


Creation

Facility
HTS Entry Point

Community

VCT/CICT
HTS Approach

PITC

Pre-test
Counselling/
Information
giving

HTS Protocol HIV Testing

Post test
Counselling

Prevention
Linkage & Services
Referral
Care, Treatment
& support

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6.1.1 HTS at health facilities

Within the decentralized health system, HTS shall be


offered up to HC II level. At HC IIsHTS should be offered
under supervision of higher level health facilities. Both
providers initiated testing and counselling (PITC) and
Voluntary Counselling and testing (VCT) shall be provided
in health facilities.

Voluntary Counselling and Testing (VCT)


VCT remains a key approach to HTS provision in Uganda.
In this approach, individuals and couples willingly seek
HTS either from the health facility or a community based
testing point/site.
VCT should be offered to individuals or couples at risk
seeking to know their HIV status.

It should be offered at both facility and community


settings in form of outreaches; community outreaches for
HTS should mainly target priority populations.

Provision of VCT should follow the approved HTS


protocol.

Provider Initiated testing and counselling (PITC)


Provider-Initiated Testing and Counselling should be
conducted in a health facility/ Clinical setting. Here, the
request to take an HIV test should be initiated by a health
worker.

Health workers should offer HTS as a standard of health


care to all patients attending high yield service points in

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health facilities regardless of the reasons for the clinic visit.
The health worker should provide adequate information
to the patients about the benefits of testing to enable them
make an informed decision to test.

PITC should be prioritized but not limited to high yielding


service delivery points. Such settings include; maternal
and child health services, adult and paediatric in-patient
wards, TB clinics, nutrition centres, family planning
clinics, STI clinics, nutrition rehabilitation units and clinics
managing survivors of sexual abuse. See section 6.2for
details about integration of HTS.

At low yielding points such as Outpatients departments


(OPD), patients should be screened for eligibility to test
using standard eligibility criteria; and those eligible
should be offered PITC. This will help to reduce on the
health worker-patient load for HTS.

In these settings, the ‘opt –out’ approach should be


applied where HIV testing is done with other relevant tests
unless the client declines. Opting out of testing should be
documented in the client’s clinical records.

PITC shall include diagnostic testing as well as routine


testing.

Diagnostic testing: This shall be carried out on individuals


as deemed necessary by the attending health care team
with the purpose of better patient management. Such
situations may include symptomatic, unconscious, very
sick and mentally impaired patients. Through PITC,

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the patient or attendant should be given an opportunity
to know his/her status to promote adherence; prevent
further transmission and enhance psychosocial support
for the patient.

Routine HIV testing: This shall be carried out for


individuals likely to pause a risk of HIV infection to others.
The following individuals shall be offered routine testing
in reference to the Uganda HIV prevention and Control
Act 2015;
• Pregnant and breastfeeding women
• Partners of pregnant and breastfeeding women
• Donors of blood, body tissue and organs.
• Sexual offenders and survivors

6.1.2 HTS at community settings


HIV testing services at communities will aim to serve
especially priority populations that otherwise would not
attend facility based HTS. The services should be offered
in homes, social gatherings,, education establishments
and at workplaces.

Programs offering HTS at community level shall ensure


that follow-up services for prevention, care and treatment
are adequate to ensure linkage to care, treatment and
prevention services.
HTS in community settings shall aim at offering an
integrated package of primary health care services,
including STD detection and treatment, child health
screening and other health promotion interventions. HTS
in community settings will utilise MOH HMIS tools.

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HTS at community level should be offered in various ways
as listed below:

Outreach HIV testing services


HTS outreaches shall be targeted to focus on priority
populations.

Outreach HTS can be offered by higher to lower level


health facilities or to communities through planned and
regular visits to the outreach sites or through community
camping where outreach sites are inaccessible.

Note: HTS outreaches for general populations as well as


during public campaigns are not encouraged.

Home based HIV Counselling and testing (HBHCT)


HBHCT shall follow two main models: (1) door-to-door
testing for all consenting individuals, couples or families
in a specified geographic area and (2) index client Contact
tracing and testing that is offered to households with a
consenting known HIV positive person or an active or
suspected TB patient(index client).Both approaches shall
be implemented in Uganda

Index-client contact tracing shall be prioritised for all


HIV positive individuals in care as well as confirmed and
presumptive TB patients and those newly diagnosed with
HIV. This shall target all household members of Index-
clients. Index-client HBHCT has been documented as an
effective approach to identifying HIV discordant couples
and children infected with HIV.

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Door-to-door testing may be implemented ONLY in
high HIV prevalence settings or communities for key
populations such as the fisher folk, hotspots for Sex work
or through the snow-ball approach to Sex workers and
Men who have sex with Men.

HBHCT should be arranged in collaboration with existing


health facilities and community support groups to ensure
on-going care for persons who are offered HTS.
It is anticipated that HBHCT should offer the benefits of
supported disclosure and adherence to ART and other
medications.

HTS at the work place


Workplace HTS seek to provide formally employed
men and women access to testing. This population may
have limited access to clinical services due to their work
schedules that do not allow them to leave their workplaces
in search for health care. Workplace testing has been
implemented with high levels of uptake and linkage to
HIV and TB services, particularly in high burden settings.
Confidentiality, coercion and weak linkages to services
have been documented as the main concerns with this
approach resulting in adverse outcomes for those testing
HIV-positive.

Workplace testing should be confidential and not be


promoted where it is likely to be abused. Employers
should ensure a safe environment for workers to access
HTS services.

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HTS at the work place should majorly aim to reach more
men.

Employers in Uganda should mainstream the provision of


HTS to employees and their families in the work place as
an integral component of staff welfare. As part of corporate
social responsibility, employers should support provision
of high quality HTS to the surrounding communities. .

HIV testing services at work places should be offered


within the workplace, health facilities or as outreach
services in collaboration with public health facilities and
private HTS providers.

HTS in Educational Institutions


HTS in educational establishments should address sexually
active youth in the context of sexual health education and
behaviour change interventions.
Provision of HTS in education institutions in Uganda
should be done according to the National School Health
Policy.

HIV testing should not be conducted for pupils or students


while at school. Where the provider deems it necessary,
the child should be linked to the nearest Health facility to
access HTS.

Test for triage


Test for triage is an approach to support community-
based HTS provided by lay providers. In this approach,
trained and supported lay providers conduct a single
HIV RDT. If this single RDT is reactive, the individual is

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promptly linked to a facility for further HIV testing, where
the validated national testing algorithm is performed. See
figure 3 below;

Figure 3: The ‘test for triage’ Algorithm

Adopted from WHO

This approach is recommended in Uganda under pilot


programmes ONLY. Further guidance shall be provided
when results of the pilots are obtained.

6.2 Integration, decentralisation and Task-


Sharing of HTS
• Facility based HIV testing services shall be provided
at various service points within the facility as part
of routine service delivery or as stand-alone services.
• HTS services shall be incorporated in all health related
plans and programs and therefore be an integral
component of all routine health care services

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Integration of HTS into other health programs is critical
for sustainability, minimizing missed opportunities for
HTS, reducing HIV-related stigma and discrimination,
improving utilization of services and enhancing
convenience for clients. It also enhances program
effectiveness and efficiency.
HTS should continue to be integrated into the health
services delivery systems in a manner that facilitates
access and increases impact. Effective HTS programming
practices can improve the quality and efficiency of HTS in
some settings and these include:
• Integration of HTS into other health services
• Decentralization of HTS to primary health-care
facilities and outside the traditional health care system
(for example, workplaces, places of worship)
• Task sharing of HTS responsibilities to increase the
role of trained lay providers

6.2.1 Integration of HTS in other health services


Integration involves not only providing related services
in a single setting, but also strengthening linkage,
documentation, reporting, monitoring and evaluation
systems to share information on referrals and feedback
between settings and providers.

The primary purpose of integration is to make HTS more


convenient for people coming to health facilities largely for
other reasons other than HTS. This will increase the uptake
of HIV testing. For the health system, integration may
reduce duplication of services and improve coordination
– for example, in stock management.

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HTS services should be an integral component of all
routine health care services. For sustainability, HTS
interventions shall be incorporated in all health related
plans and programs.

All service points such as TB, Family Planning, STD, ART,


PMTCT, Safe Male Circumcision (SMC), in-patient wards,
malnutrition and other child health and adolescent centres
and Outpatients department should have HTS integrated.

Integration with tuberculosis services


All HTS clients should be screened for TB symptoms
during pre-test counseling.

All patients with active or presumptive TB should be


tested for HIV using the PITC approach.

All clients diagnosed with TB should be promptly


registered with the national TB program and started on
anti-TB treatment.

HIV-positive clients diagnosed with active TB should


be urgently started on ART, regardless of CD4 count,
while those not having TB should be considered for TB
preventive therapy using isoniazid as per Figure 4 below;

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Figure 4: HIV/TB testing and Screening Algorithm in
HTS

Clients attending HTS (facility &


community settings)

Pre-test information and counselling

HIV testing and TB Screening

HIV Positive HIV Negative

TB Positive TB Negative TB Positive TB Negative

Initiate Consider
Provide
TB TB Link to Post-test
treatment preventive TB counselling
and ART therapy & Treatment
ART

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Key approaches for TB/HTS integration should include
the following:
• Active promotion of HTS among TB clients through
the distribution of information materials and health
education talks by HTS counsellors at the OPD and
in the waiting rooms of the TB clinic.
• Health workers should routinely offer HTS to all TB
patients, their family members and other contacts as
standard of care during individual consultations.
• On site HTS should be introduced at TB clinics and
routine screening of all clients with presumptive and
diagnosed TB should be done. Partners of known
HIV-positive TB patients should be offered voluntary
HTS with support for mutual disclosure.
• Clinical assessments for TB among HTS clients who
test HIV positive should be conducted.
• Suspected TB patients should be referred to the TB
clinic for additional assessments.
• Health workers and community service providers
should be trained onthe integrated approach.
• Clients with presumptive and diagnosed TB should
be encouraged to refer their partners for HTS.

Integration with services for sexually transmitted


Infections (STIs)
Given their common mode of sexual transmission, HIV
and syphilis co-infection is common. Syphilis infection is a
recognized co-factor for HIV transmission and acquisition,
and maternal syphilis infection has been associated with
increased risk of mother-to-child transmission of HIV.

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Therefore all women attending ANC should be routinely
screened for both syphilis and HIV.

All clients diagnosed with other STIs should be offered


HIV testing. New STI infections such as gonorrhea and
syphilis may indicate recent engagement in unprotected
sex and thus a heightened risk of HIV acquisition.

People receiving STI treatment may also have primary HIV


infection and therefore, a high HIV viral load. Diagnosing
individuals with HIV/STI co-infection is important both
as a prevention strategy and to improve the quality of care
for people with HIV.

HTS providers should routinely assess HTS clients for


STDs. It is highly recommended that STD screening be
offered to all HTS clients and when possible, syphilis
testing should be performed on the same blood sample
as that used for HIV testing and results provided on the
same day.

If possible, on-site syphilis treatment should be offered


immediately to any HTS client testing positive for syphilis.

During the visit, HTS clients should be informed about


STD services available on site and the importance of
syphilis testing. If STD services are not available on site,
clients should be referred to the nearest facility or service
point where STD treatment can be obtained.

Integration with family planning services


Basic family planning (FP) information should be
incorporated into all HTS counselling sessions for both

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HIV-positive and HIV-negative clients; HTS information
should also be offered at all FP settings.

Especially for HIV-positive clients, the risks of mother-


to-child transmission and the benefits of family planning
should be clearly explained.

‘Dual protection,’ which is use of condoms for HIV and


STD prevention and hormonal contraceptives for family
planning, should be emphasized during counselling
sessions.

HTS should be provided at all FP settings and where


possible family-planning services should be provided at
the HTS site. In the event that family-planning services are
not available, clients should be counselled and referred for
family planning at the nearest FP service delivery point.

Integration with maternal, neonatal and child health


(MNCH) services
All women should have access to HIV testing services
including information before they conceive so that they
make informed decisions about pregnancy and family
planning. Pre-pregnancy couple HIV and syphilis
screening and testing should be provided and couples
treated or linked to services as appropriate.

In the context of dual elimination of mother-to-child


transmission of HIV and syphilis, all pregnant and
breastfeeding women should have access to integrated
HIV and syphilis testing services. For couples infected with
HIV, importance of eMTCT should be clearly explained.

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PITC should be offered as part of the MNCH care package
to all pregnant and breastfeeding women.

HTS should be offered alongside other routine ANC


laboratory tests at the first ANC visit or earliest contact.

In the Young Child Clinics (YCC), all HIV exposed and


suspected children must be offered HTS including their
mothers.

Children with HIV-like symptoms or suspected exposure


identified during immunization or other service points
should be offered HTS and related services.

All HIV-positive children identified in HTS should be


checked to ascertain if they received all immunizations
and if not, they should be referred for immunization.

Integration with safe male circumcision (SMC) Services


SMC reduces chances of heterosexual HIV transmission.
Men and their partners should have access to HTS services
as an integral component of SMC services in order to make
an informed decision to undergo the procedure. This
will also inform future HIV risk reduction plans27.SMC
providers should offer HTS to all clients seeking SMC and
encourage them to receive the service together with their
partners.

6.2.2 Decentralization of services

Decentralization in this context refers to providing HTS in


peripheral health facilities, community based settings and
27 MOH. (2010). Safe Male Circumcision Policy . MOH.

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other locations. Providing HIV testing in places closer to
people’s homes reduces transportation costs and waiting
time experienced in health facilities hence increase uptake
of HTS. Decentralization of services, however, may not
always be appropriate or acceptable to potential users.
In some settings centralized HIV testing services may
provide greater anonymity than neighborhood HTS
especially for key populations or others who fear stigma
and discrimination. In some low prevalence settings,
decentralizing HTS may be inefficient and costly.

For facility-based interventions, HTS should be provided


up to the HCII and community levels. Where HTS is
provided up to HC II and community, HTS implementers
should ensure provision of quality of services through
regular support supervision.

At community level, the context, needs, service gaps and


overall costs and benefits should be weighed to decide
where HTS should be decentralized.

6.2.3 Task sharing of HTS


Uganda continues to face shortages of trained health
workers. Task sharing which refers to the rational re-
distribution of tasks between cadres of health-care
providers and is a pragmatic response to health workforce
shortages. Task sharing to trained Lay providers seeks
to enable the existing workforce to provide HTS to more
people; hence facilitating efforts to decentralize HTS. Task
sharing to community based health care workers may
help to address the needs of key populations and other

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priority groups. It is not simply a means to save resources
but rather one valuable tool to improve access to, coverage
and quality of services.

The following criteria should guide the selection of lay


HTS providers: should be trustworthy, with ethical and
professional conduct, knowledgeable about what they are
doing, polite, proficient in dealing with sensitive issues,
able to listen and with basic required qualifications. See
section 11.5 of this policy and guidelines for details.

Like other health-care providers and laboratory technicians,


lay providers should be trained, mentored and supervised
by on-site supervisors, ideally including someone trained
in laboratory procedures. They should perform their duties
as per the accepted competency standards to ensure that
they offer high quality HTS. They should be trained using
standard training curriculum which details complete HTS
procedures, including collecting specimens, performing
RDTs following the validated national testing algorithm
and testing strategy, providing counseling and issuing
test results as well as recording, keeping and reporting on
the appropriate HIMS tools.

Lay providers shall also be trained in medical ethics so that


they are fully aware of their duties to obtain consent and
to maintain confidentiality regarding the client and the
HIV status. As with any other health workers providing
HTS, ongoing supportive supervision and mentoring of
lay providers shall cover both the testing and counseling
aspects of their work, provide up-to-date job aides

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and SOPs, and be involved in regular external quality
assessment (EQA).

6.3 Differentiated models for HTS

HIV testing services in community settings shall be


offered following a targeted approach especially for
priority populations who are less likely to attend
facility based HTS.

A mix of client and provider initiated approaches shall


be differentiated to increase HTS uptake by different
population categories. Individuals will be free to request
for an HIV test on their own at either a facility or
community testing point. Health care providers should
also inform their patients about the need to know their
HIV status. The proposed HTS approaches are informed
by evidence from international, regional and national
good practices. They are aimed at increasing access to
as well as uptake of HTS by priority population groups.
HTS approaches should be modified and tailored to target
particular priority populations that may not be easily be
reached by conventional approaches.

Priority populations that are less likely to attend facility-


based HTS include Key Populations, Men and Adolescents
and Youth. HTS providers should adopt and scale up
strategies that have worked to reach these populations.

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Good Practices in HTS Programming
This policy and guidelines adopts good practices identified
and documented globally, regionally and nationally to ensure
effective HTS programming and delivery. These include
initiatives and innovations that prove relevant, efficient, cost-
effective, and sustainable and add value to the realization
of the goals and objectives of this policy. Identified good
practices include;
 Integration of HTS with other health services especially
MNCH, STI, TB and general medical care
 Expansion/scale-up of HTS to public and private health
facilities under the Public-Private Partnership (PPP)
and outside the health facility (for example, workplaces,
educational establishments like schools, places of worship)
 Task shifting and task sharing to trained and supervised
lay providers, counselors, social and development
workers, and teachers
 Targeting individuals and couples in most need of HTS
classified as priority populations
 Target setting for the HTS program
 Using data to improve HTS programming.
 Use of peer-led HTS innovations for HTS delivery in
adolescent/youth, PWDs and Key Populations
 Capacity strengthening for HTS providers through Pre-
service training and in-service training, mentorships and
Coaching, and peer and group supportive supervision

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Key Populations
Access to HTS for key populations should be prioritized.
Key populations continue to be disproportionately affected
by HIV in all settings. In 2013 there were an estimated
2 million new HIV infections worldwide. Of these, an
estimated 40% occurred among key populations. Within
key populations, adolescents (10–19 years old) and young
people (15–24 years old) are at greater risk for acquiring
HIV. The estimated HIV testing coverage among key
populations in Uganda remains low and data on HIV
testing coverage collected for key populations is based
on small samples from a limited number of settings. In all
settings people from key populations are less likely than
the general population to link to HIV services in a timely
manner because their behaviour is criminalized and they
experience stigma and discrimination.

HTS providers should therefore prioritize and focus on


tailored HTS approaches and strategies so as to reach key
populations in all settings. These include;

A Peer-led approach- Peers leaders from amongst the Key


population groups are identified and trained to reach their
peers with HIV prevention information, link them to HTS,
prevention, care, treatment and support programs and
offer Peer support.

Moon-light clinics: HTS is offered in the evening or at


night within the communities where KPs live or conduct
their business.

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Mobile clinics: HTS is offered in mobile Vans at hotspots
for Key populations especially Sex Workers and men who
have sex with men (MSMs)

Camping: HTS outreach camps targeting hard to reach


populations especially the fisher folk in the Islands.

Special Clinics in safe places: These are stand-alone clinics


established to offer specialised care to Key populations
within hot spots. Members of the general population
should not be denied services at these clinics however;
this will prevent stigma and discrimination for Key
populations.

Targeted outreaches: These should target Key populations


and the mobilization should be done by their Peer leaders.
The general population should not be denied services at
these outreaches to prevent stigma. In order to identify the
Key population, unique identification cards or numbers
should be given to the KP and presented at the outreach.

Snowball contact tracing: This should target populations


such as MSM and SWs whose sexual behaviour is highly
stigmatised in Uganda.

Strategies for other priority populations are detailed in


section 3.0 of this policy and guidelines.

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6.4 The HIV Testing Services Protocol

HTS service providers shall adhere to the nationally approved


HTS protocol for adults and children as per the various
approaches and models.

Regardless of the HTS approach, HTS providers shall


adhere to the recommended counselling and testing
procedures/protocols as detailed in each approach.
The HTS protocol describes the minimum steps that shall
be followed in order to provide quality and effective HTS
services. For HTS services to be complete, the following
key steps must be undertaken:
• Pre-test counseling/ information giving
• Testing for HIV
• Post-test Counseling
• Linkage into Prevention, Treatment, Care and
support services

The protocol starts with client registration followed by


pre-test counselling and consent for testing. Pre-test
counselling prepares clients for the HIV test and also
enables those who decline the test to receive counselling
without necessarily testing for HIV. A specimen is then
collected from clients who consent to testing and the
testing procedure is conducted.

Depending on the type of test (rapid, PCR etc.) and the


testing algorithm, the results of the test may be available
within an hour or a few days. When the results are ready
the client is provided with post-test counselling, during

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which the test results are given. Clients are then linked
to care, treatment and prevention services as appropriate
depending on the test result. Follow-up support is then
provided which may be available at the HTS site in the
form of post-test clubs or on-going counselling. Clients
should be referred elsewhere for further care and support
where these services are not available.(Figure 5 below).

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Figure 5: The HTS Protocol

Client registration

Health education/Pre-test session for all clients

All clients initiated All self-referred clients


by service provider (VCT)
(PITC)

Individual, couple, group counselling/information giving

Clients who decide to rest Clients who decide not to rest

Consent obtained
Provide counselling
and encourage testing
Obtain sample and carryout the test

Results giving and post-test


counselling regardless of test
result

Appropriate referral and linkage


to prevent, treatment, care and
support

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Client registration
Clients should register with their names to enable
appropriate referral and linkage to services. All HTS sites
must ensure confidentiality of client information. Where
HTS is provided in health facilities, HTS clients may
register like other patients at the outpatient department to
avoid being stigmatized.

Pre-test counselling and information giving


With the widespread use of HIV Rapid Diagnostic Test
kits, most people receive their HIV test results (at least
results of the first test) and often a diagnosis on the same
day. Therefore, intensive pre-test counseling is no longer
strongly recommended and may create barriers to HIV
testing services delivery. Individual risk assessment and
individualized counseling during the pre-test information
session is also kept at a minimum.

Depending on local conditions and resources, programs


may provide pre-test information through individual or
group information sessions and through media such as
posters, brochures, websites and short video clips shown
in waiting rooms. When children and adolescents are
receiving HTS, information should be presented in an age-
appropriate way to ensure comprehension.

Where group counselling is provided, individuals need to


be provided with the opportunity to ask questions, receive
personalised information and provide consent for HIV
testing.

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During pre-test counselling of a couple, the counsellor
should ensure that the couple understands the importance
of receiving results together. Similarly, people in
polygamous marriages/relationships should be given
options to bring their partners for HTS. Pre-test counselling
should include;
• Benefits of knowing one’s HIV status
• Benefits of couple HIV counselling and testing
• An explanation of the HIV testing process
• The meaning of an HIV-positive and an HIV-
negative diagnosis
• The need for consent for an HIV test
• A summarised version of HIV risk assessment and
risk reduction
• A brief description of prevention options and
encouragement of partner testing
• Importance of disclosure including mutual
disclosure
• The need for referral and linkage to prevention,
treatment, care and support
• The services available in the case of an HIV-positive
diagnosis, including where ART is provided
• The potential for incorrect results if a person already
on ART is tested
• The fact that the test result and any information
shared by the client is confidential
• The fact that the client has the right to opt out of the
testing and that declining testing will not affect the
client’s access to HIV-related services or general
medical care

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• The potential risks of testing to the client in settings
where there are legal implications for those whose
sexual or other behavior is stigmatized
• An opportunity to ask the provider questions.

Special considerations for pregnant and post partum


women
Pre-test information or health education for women who
are or may become pregnant or are postpartum should
also include:
• The potential risk of transmitting HIV to the infant
• Measures that can be taken to reduce mother-to-
child transmission, including the provision of ART
to benefit the mother and prevent HIV transmission
to the infant
• Counseling on infant feeding practices to reduce
the risk of HIV transmission
• The benefits of early HIV diagnosis for mothers
and infants
• Encouragement for partner testing.

Special considerations for couples or partners who ask


to be tested together
Couples counseling and partner testing promote mutual
disclosure of HIV status and increases adoption of
prevention measures, especially in the case of discordant
couples (one HIV-positive partner and one HIV-negative
partner).
The pre-test information session for couples should avoid
as much as possible to dwell on past sexual behavior or
risks, as this is unnecessary and may create tension for
the couple. The person conducting a pre-test information

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session should make it clear that both testing and post-test
counseling can be provided individually, if either partner
prefers it that way, and then the couple is supported to
disclose to each other.

Special considerations for key populations


In some instances, key populations are discriminated and
stigmatized. Like all individuals coming for HTS, key
populations shouldbe offered the general information.
All facilities should train health workers so that they
better understand the needs of key populations, available
support and prevention services, and be able to provide
acceptable and appropriate pre-test counselingforthem.

Post-test counselling
Post-test counselling will be offered as a discussion
between a provider and a client(s) with the aim of
informing the client of their HIV results and assisting
them to cope with the results. The results of the HIV test
will determine the counselling messages to be given to
the client. Confidentiality and privacy should be observed
during result giving. Under no circumstances should
results be given in a group and the results should be given
to clients in written form.
For PITC, if the client is too ill or unconscious; the
provider should to wait until it is appropriate to give the
results or consider giving them to the next of kin who is
appropriately identified.

Couples should be offered post-test counselling as agreed


between the couple and counsellor during the pre-test
session. Where individual members of a couple receive

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pre-test counselling and testing separately, the service
provider should reinforce the benefits of and support the
disclosure of test results to the spouse or sexual partner.
The minimum package for post-test counselling should
include;
• Assessing the client’s readiness to receive test result
• Giving the test results clearly, without ambiguity
• Assessing the client’s understanding of the test
result and its implications
• Making on-going plans for risk reduction, partner
notification and testing
• Making arrangement for follow-up support
• Making plans for involving significant others and
disclosure
• Referral and linkage to prevention, treatment, care
and support

Post-test Counselling for those who test positive


A diagnosis of HIV infection is a life-changing event and
before giving positive HIV test results, the provider should
keep in mind the 5 Cs of HTS.
Post-test counseling should be “client-centered”, which
means avoiding formulaic messages that are the same
for everyone regardless of their personal needs and
circumstances. Instead, counseling should always be
responsive to and tailored to the unique situation of each
individual or couple.

It is important to give the client time to consider the results


and help the client cope with emotions arising from the
diagnosis of HIV infection due to the psychological

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readjustment caused by the shock of knowing their HIV
positive status.

Counseling for HIV positive clients should include:


• Explanation of the test results and diagnosis.
• Discussing the immediate concerns of the client and
helping him/her decide who in her or his social network
may be available to provide immediate support
• Provision of clear information on ART and its benefits
for maintaining health and reducing the risk of HIV
transmission, as well as where and how to obtain it
• Making an active referral for a specific time and date.
• Discuss barriers to linkage to care, same-day enrolment
and ART initiation.
• Arrange for follow-up of clients who are unable to
enroll in HIV care on the day of diagnosis.
• Provide information on how to prevent transmission of
HIV, including information of the reduced transmission
risk when virally suppressed on ART; provide male or
female condoms and lubricants and guidance on their
use.
• Discuss possible disclosure of the result and the risks
and benefits of disclosure, particularly among couples
and partners.
• Encourage and offer HIV testing for sexual partners,
children and other family members of the client. This
can be done individually, through couples testing,
index testing or partner notification.
• Assess the risk of intimate partner violence and discuss
possible steps to ensure the physical safety of clients,
particularly women, who are diagnosed HIV-positive.

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• Assess the risk of suicide, depression and other mental
health consequences of a diagnosis of HIV infection.
• Provide additional referrals for prevention, counseling,
support and other services as appropriate (for
example, TB diagnosis and treatment, prophylaxis for
opportunistic infections, STI screening and treatment,
contraception, ANC, risk reduction plans, and sexuality
counseling.
• Encourage and provide time for the client to ask
additional questions.

Post-test counseling for special populations

Key populations: These will be given intense post-test


counseling combined with follow-up counseling by Peer
Leaders. Those who test positive need to be enrolled in
HIV care and initiated on treatment immediately. Those
who test negative should be supported to adopt risk
reduction behaviors/practices.

Individuals from key populations who test HIV-positive


may lack social networks and/or a supportive family
to help them deal with their diagnosis. These people
may need additional counseling as well as peer support
services to cope with this diagnosis. A peer counselor may
particularly help this client understand and cope with the
diagnosis and support linkage to care and treatment by
serving as a “Linkage Facilitator “to assist them to find,
choose and obtain a full range of services.

Couples and partners: Post-test counseling for sero-


discordant couples may be especially challenging as these

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results may be difficult for the provider to explain and
for the couple to accept. There may be need to engage
an experienced counselor and clinician and be attached
to discordant couples’ support groups. HTS providers
should, as much as possible adhere to the protocol for
discordance counseling.

Pregnant and post-partum women: Post-test counseling


for pregnant and post-partum women who are diagnosed
with an HIV infection should include the following, in
addition to the standard messages described above for all
people diagnosed with HIV infection:
• Childbirth plans to ensure they deliver under a
qualified health worker
• Initiate lifelong ART for their own health and PMTCT
• Partner testing for support and involvement in the
PMTCT interventions
• Screening for co-infections especially TB and syphilis
• Counseling on adequate maternal nutrition, including
iron and folic acid
• Infant feeding counseling to avert malnutrition and
HIV transmission in their babies
• Giving ARVs to their babies for PMTCT
• HIV testing and follow up for the infant for early
diagnosis and enrollment into care

Adolescents: Along with standard messages for all those


diagnosed with an HIV infection, post-test counseling for
adolescents with HIV should include:
• Tailored help with linkage to HIV care and treatment
• Counseling, referral and linkage to specific psychosocial
and mental health services tailored to both the situation

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in which infection happened and the developmental
age of the individual
• Information on adolescents’ rights and responsibilities,
especially their right to confidentiality and health care
• An opportunity to ask questions and discuss issues
related to sexuality and the challenges they may
encounter in relationships, marriage and childbearing
• Individualized planning on how, when and to whom
to disclose HIV status and engage families and peers in
providing support
• Referral for small-group counseling and structured
peer support groups, which may particularly benefit
adolescents with HIV

Post-test counselling for those who test negative


Counseling for those who test HIV-negative should
include the following:
• An explanation of the test result and reported HIV
status
• Education on methods to prevent HIV acquisition
• Provision of male or female condoms, lubricant and
guidance on their use
• Emphasis on the importance of knowing the HIV
status of their sexual partner(s) and information about
the availability of partner and couples testing services
• Referral and linkage to relevant HIV prevention
services, including SMC for HIV-negative men, PEP,
PrEP for people at substantial on-going HIV risk
• A recommendation on retesting based on the client’s
level of recent exposure and/or ongoing risk of
exposure

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• An opportunity for the client to ask questions and
request for further counseling

Services for adolescents who test HIV-negative:


Adolescents who test HIV-negative need information
and education about healthy behaviors. Such behaviors
include correct and consistent condom use, reduction
of risk-associated behaviors and prevention of HIV and
unwanted pregnancy and about the need for retesting if
they have new sexual partners. They also need referral
to appropriate prevention services, such as SMC,
contraception and harm reduction.

Services for partners who both test HIV-negative:


Couples and partners who are both diagnosed HIV-
negative can benefit from the standard health information
and prevention education given to individuals who test
negative. In addition, the counselor or health worker
may offer further counseling at the couple’s or a partner’s
request.

Inconclusive HIV test results or test results not yet


confirmed
An HIV-inconclusive result means that the first reactive
test results were not confirmed by additional testing
using subsequent HIV assays. All clients with an HIV-
inconclusive status should be encouraged to return after
14 days for additional testing to confirm their diagnosis
(Ref. Serial testing Algorithm).

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6.5 Counselling in HTS
Counselling is a core principle in the provision of HTS.
Counselling is central in ensuring that HTS adheres to the
human rights; is provided with utmost privacy and respect
to ensure confidentiality; testing processes are monitored
for quality to ensure correct test results are given and
referral and linkage is done to ensure clients are linked to
further care as per their HIV test results. This sub-section
describes how counselling should be provided across the
HTS continuum.

6.5.1 Consenting procedure for HTS


In Uganda the legal age for consent is 18 years. For HTS,
the age of consent to take an HIV test shall be 12 years.
However, all young people 12-18 years of age will be
encouraged to disclose their HIV status to their parents
and guardians for purposes of obtaining on-going support.

For children below 12 years the parent or guardian should


consent. For children without a parent or guardian, the
head of the institution, health centre, hospital, clinic or
any other responsible person should consent for them. If
a child below the age of 12 requests for an HIV test, their
parents or guardians should be fully be involved.

If the parent or guardian proposes the test, the counsellor


should assess if the parent or guardian is requesting for
it in the best interest of the child. Children should not be
tested simply for the parents or guardians to know their
own status but for the benefit of the child.

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As far as possible, the child should be involved in the
decision, along with the parent or guardian. For children
who cannot clearly understand the results, the parent or
guardian should be fully involved and should sign the
consent.

6.5.2 Counselling for Disclosure of test results


HTS providers shall protect the client’s privacy and guard
against unlawful disclosure of clients’ HIV status without
compromising efforts for enhancing care and support
for the client and prevention of further transmission
of HIV. Service providers shall also ensure privacy and
protection of clients from discrimination due to perceived
or confirmed HIV status.

Several approaches may be used to support client


disclosure of HIV status as outlined below;

• Client self-disclosure: Service Providers empower


the client to disclose by her/himself
• Counselor supported disclosure: Service provider
discloses a client’s status to a significant other in
the presence of the client. This allows the provider
an opportunity to provide more information about
HIV and AIDS. For couples and sexual partners,
supported disclosure promotes dialogue, respect
and mutual support.
• Re-testing for Partners as Couples: The service provider
invites the sexual partner of the index client to the
facility and conducts couple counseling and testing
without necessarily disclosing client’s status.

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Counselling Children for disclosure

During post-test counselling for children and minors,


counsellors should carefully assess to whom they should
give the child’s results. Disclosure is a process that should
be done at the judgment of the counsellor and parent/
guardian.
Before disclosing results for children less than 12 years,
the counsellor should assess if the parent or guardian is
willing to discuss HIV and the test results with the child
openly. If this is the case, disclosure should be done. If
otherwise, the counsellor should support the parent or
guardian to disclose.

Counsellors should aim at disclosing to children their HIV


status by the age of 12 years. The counsellor should work
with the parent or guardian to plan for the child’s future
care if the child is positive.

Children aged 12 years and above (Adolescents) should


be given results after counselling. If the child sought HIV
testing alone, the counsellor should discuss involvement
of the parents or guardians to provide additional support
for the child.

In all age groups mentioned above, on-going counselling


and support should be provided by parents or guardians
and the counsellor. Never should anyone lie to a child of
any age about their HIV results.

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Disclosure of HIV Status amongst Couples & sexual
partner(s)

Service Providers should encourage disclosure of HIV


status to sexual partner(s) or any other significant other
for purposes of further support and prevention.

During counselling, HTS providers should screen couples


and partners for GBV using a standard screening tool.
Where GBV is present, disclosure may be differed to a
later date; and follow up of the client should be done. Such
clients should be linked to other services including legal,
Violence mitigation and psychosocial support.

Service providers should prioritize additional counselling


both before and after testing including after disclosure of
the client’s HIV status to the sexual Partner.

Couples and partners should be offered HIV testing


services with support for mutual disclosure.

Partners of known HIV positive TB patients shall be


offered HTS and support provided for mutual disclosure.

6.6 HIV Testing


The Nationally recommended HTS algorithm shall be used to
guide the performance of HIV tests using either rapid or DNA
PCR tests in both public and private sites.

HIV testing should be performed by a health worker


trained in HIV testing using the approved HIV test kits
and will follow the approved HIV testing algorithms.

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6.6.1 Diagnostics for HIV
All HIV testing should be performed in accordance
with the assay manufacturer’s instructions. In addition,
SOPs and job aids should be developed that help testing
providers to minimize testing and reporting errors and
improving the quality of the testing results.

It is recommended that any reactive HIV test result using


a screening test must be confirmed with a second assay or
with both a second and third assay.
There is generally a trade-off that favors sensitivity over
specificity for the first-line HIV assay so as not to miss
true positive specimens. Additional testing is required to
resolve cases of false reactivity (that is, to rule out false
positives) and to verify reactivity (that is, to rule in true
positives).

Performance characteristics of assays


The following performance characteristics should be
considered when selecting assays to validate as testing
algorithms;
• First-line assay – should have the highest sensitivity
• Second and third-line assays – should have the highest
specificity and lowest invalid rates
• All assays should have very low inter-reader variability

Specimens for HIV testing


Currently, the recommended specimens for use in HIV
testing remain limited to whole venous blood, plasma,
serum or dry blood spots. These specimens can either
be drawn by using vein-puncture or finger prick. Other
specimens like urine and saliva may be used after NHRL
validates them.

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Venous whole blood: Whole blood freshly collected by
vein-puncture. The specimen should be subjected to
testing immediately.

Serum: Collect fresh whole blood in a container without


an anticoagulant, mix by hand 4–5 times immediately and
let it stand for the clot to form. Remove the serum within
30 minutes of collection of the blood sample. The serum
can be stored at 2–8 °C and used for testing within 5 days
or as specified by the instructions for the assay to be used.

Plasma: Collect whole fresh blood in a container with


a recommended anticoagulant validated by the assay
manufacturer, such as EDTA, heparin or citrate. Mix it
by hand 8–10 times immediately, and centrifuge for up to
10 minutes. After centrifugation, the plasma is separated.
Remove the plasma within 6 hours of collection. The
plasma can be stored at 2–8 °C, and used for testing within
5 days or as specified by the instructions for the assay to
be used.

Capillary whole blood: Capillary (finger-stick) whole


blood is collected using a lancet and a specimen transfer
device recommended by the instructions for use. The
specimen should be used immediately. Note that the
specimen transfer device may or may not include an
anticoagulant. An anticoagulant contributes to accuracy.

The hanging drop method, whereby blood is dropped


directly from the fingertip onto the test device, is not
recommended, as it does not ensure that the specimen
volume is accurately added.

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Dried blood spot (DBS): Venous or capillary whole
blood is applied to a filter paper by hanging drop or
microcapillary. Whole blood is later eluted from the filter
paper and used for the test procedure.
The collected blood sample on the DBS can be store at 4 °C
for up to 3 months, at –20 °C for longer.
The use of specific assays with DBS should be validated
by the manufacturer. When the manufacturer has not
validated their assay for DBS, the use of DBS is considered
“off-label”, or unauthorized for returning medical results.

Handling specimens
Universal precautions should be observed during specimen
handling. Standard operating procedures should be
followed to ensure that accurate test results are obtained.
Guidelines for sample referral and transportation should
be followed.

HIV testing algorithms


An algorithm is a combination and sequence of HIV tests
that have been tested and agreed by a reference laboratory
to represent HIV testing for a given purpose.

HIV Testing Algorithm for testing persons aged 18


months and above in Uganda

HIV testing for programming in Uganda will be conducted


using rapid diagnostic antibody tests following the
approved Serial testing Algorithm

The Nationally approved Algorithm for HIV testing in


Uganda is as follows:

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A. Screening test: Alere Determine HIV 1/2
B. Confirmatory test: Stat-Pak
C. Tie-Breaker: SD Bio line

Figure 6 below shows Uganda’s serial testing Algorithm.

• Note that in Uganda the breaks lest will no longer


be used to provide a definite HIV positive diagnosis
but to rule out negatives that are discrepant on
screening and confirmation
• Individuals whose samples react on the lie break
shall be retested after weeks (14 days)as per WHO
recommendation

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The Nationally approved Algorithm for HIV testing in Uganda is as follows:
A. Screening test: Alere Determine HIV 1/2
B. Confirmatory test: Stat-Pak
C. Tie-Breaker: SD Bio line
Figure Figure
6 below shows Uganda’s
6: Serial HIVserial testing
Testing Algorithm. for testing
Algorithm
persons above 18 months of age in Uganda, 2016
Figure 6: Serial HIV Testing Algorithm for testing persons above 18 months of age in
Uganda, 2016
Screening Test
Screening Test
DETERMINE

Non-Reactive
Non-Reactive Reactive
Reactive

Report HIV Confirmatory Test


Report HIV Negative Confirmatory Test
Negative STAT-PAK

Non-Reactive Reactive

Non-Reactive Reactive
Tie-Breaker Test Report HIV
SD BIOLINE Positive

Tie-Breaker Test Report HIV Positive


Non-Reactive Reactive

Report HIV
Non-Reactive Report as Reactive
Negative Inconclusive
Re- test at 14 days

66 | P a g e Report HIV Negative Record as Inconclusive


Re- test at 14 days

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Algorithm for testing infants below 18 months of age
Serological tests: Serological tests (Antibody tests) do not
determine HIV status in this age group. This is because the
test may detect antibodies that might have been passed
from the mother through the placenta to the infant.
Therefore a positive serological test may only tell you that
the child has been exposed to HIV, rather than that the
child is HIV-infected. These babies should be enrolled at
the Mother – baby care point (MBCP) and should undergo
the Virological HIV testing process for HIV exposed
infants.

If a serological test (antibody test) is performed among


infants, it will just determine the HIV exposure status of
the baby.

A NEGATIVE antibody result means the child is not


infected, but could become infected if their mother gets
infected with HIV when they are still breastfeeding.

A POSITIVE antibody result means that the child is


exposed to HIV and the mother is infected.The HIV
antibody test is therefore used to establish HIV exposure
status of the infant.

Virological testing among children below 18 months of


age:
A virological test (DNA – PCR) is the only reliable method
to determine the HIV status of children below 18 months
of age. It detects the actual virus in the child’s blood.

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Virological testing using nucleic acid testing (NAT)
technologies should be conducted using dried blood spot
(DBS) specimens.
A POSITIVE virological test result for a child aged 6
weeks – under 18 months will confirm that the child is HIV
infected. The following procedures should be followed to
diagnose HIV in infants:
• The 1st DNA – PCR test should be done at 6 weeks of
age to diagnose HIV infection among infants infected
during pregnancy and delivery.
• A 2nd DNA – PCR test should be done 6 weeks after
cessation of breastfeeding to diagnose HIV infection
among infants who may not have been infected
during pregnancy and delivery but got infected
during breastfeeding.

A NEGATIVE 1st DNA – PCR test result means that child


is not infected, but could become infected if they are still
breastfeeding whereas a POSITIVE 1st DNA – PCR test
result means that the child is HIV infected.

A NEGATIVE 2nd DNA – PCR test result means that child


is not infected whereas a POSITIVE 2nd DNA – PCR test
result means that the child is HIV infected.
Regardless of the 1st or 2nd DNA – PCR test result, all
babies born to HIV positive mothers shall have to undergo
a rapid HIV antibody test at 18 months of age as shown in
Figure 7 below.

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Figure 7: HIV Testing Algorithm for children <18months

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Figure 7: HIV Testing Algorithm for children <18months
There is need to pro-actively look for infants whose mothers
never attended PMTCT services through the routine offer
of PITC in child health services, immunization clinics,
under-5 clinics, malnutrition services, well-child services
and services for hospitalized and all sick children, TB
clinics, and services for orphans and vulnerable children
and testing the family members of index clients to identify
HIV-exposed infants.

Choosing a child to be tested for HIV should be guided


by the HTS eligibility screening tool for children and
adolescents. However, in a high HIV prevalent setting like
Uganda, every child who is admitted should be tested for
HIV.

6.7 Re-Testing and Repeat Testing


• Repeat testing shall be conducted in specified
circumstances to rule out laboratory or
transcription error
• HIV re-testing shall be done based on client’s level
of recent exposure and or ongoing risk of exposure
to rule in or rule out sero-conversion.
• All individuals newly and previously diagnosed
with HIV shall be re-tested before ART initiation. .

6.7.1 Re-testing
Most persons do not require a re-testing to validate an
HIV negative result. However, it is important to identify
individuals who truly require retesting. Retesting should
be done on a second specimen from the same individual

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using the same testing algorithm after a specified period
or in case of observed exposure.

Re-testing for individuals who test HIV NEGATIVE

Retesting for individuals thought to be in the window


period is needed ONLY for those who report specific
recent risk. Table 2 below shows the categories of people
to re-test at specified time-points.

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Table 2: Populations eligible for re-testing

S/no Population category When to re-test


Individuals exposed 4 weeks after testing
to HIV within the last
4 weeks prior to HIV
testing
Key Populations Every 3 Months
HIV negative Every 3 months
Partners in
discordant couples
Pregnant women 1st trimester/1st ANC Visit,
then in the 3rd Trimester/
during labour and
delivery
Breastfeeding Every 3 months until 3
Women months after cessation of
breastfeeding
Confirmed and After 4 weeks
presumptive TB
Patients
Patients treated for After 4 weeks
STI
PEP clients At 1 Month, 3 months and
6 months
PrEP clients As per guidelines.
Individuals with After 14 days
inconclusive results

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Retesting before initiating ART

Retesting for individuals starting ART refers to the testing


of a new specimen for each HIV positive individual
conducted by a different provider using the same testing
algorithm prior to initiation of ART.

In 2016, Uganda adopted the ‘test and treat’ strategy for all
HIV positive individuals.
Re-testing for individuals starting ART is thus critical in
ensuring that HTS reduces the risk of misdiagnosis of
HIV status and ensure that individuals are not needlessly
placed on life-long ART with potential side-effects, waste
of resources, and made to suffer psychological impact of
misdiagnosis.

Retesting should be conducted by a different tester, at


the site where the decision on ART initiation will be
made. Retesting according to this procedure aims to rule
out possible technical or clerical errors. Such errors may
include specimen mix-up through miss- labeling and
transcription errors, as well as random error either by the
provider or of the test device.

Retesting people on ART

Retesting people on ART is not recommended in Uganda.

The effect of ART in suppressing viral replication may


extend to suppression of the immune response and, thus,
of antibody production. Therefore, non-reactive test results
particularly on assays using oral fluid must be interpreted
cautiously.
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Individuals undergoing HIV testing must be made aware
of the risk of incorrect diagnosis if they do not disclose
that they are on ART.

All individuals receiving HIV testing should be asked if


they have been tested previously and told they are HIV-
infected and/or if they are now on ART or have ever
received ART.

6.7.2 Repeat Testing


Repeat testing should be conducted in specified
circumstances to rule out laboratory or transcription error
and either to rule in or rule out sero-conversion. This could
be followed by supplemental testing where additional
assay(s) not used in the first testing algorithm may be used
on the same specimens to obtain more information about
the HIV test result.

6.7.3 HIV Self- testing (HIVST)


HIV self-testing is a process in which an individual collects
his or her specimen, performs a test and interprets his or
her own test result in private. HIVST transcends barriers
such as stigma, lack of time and distance to health facilities
or HTS centers. HIVST aims to make HIV testing more
accessible to several under-served populations such as
men, key populations including MSM and sex workers,
and hence facilitates knowledge of HIV status. Several
research studies have found HIVST to be highly acceptable
across diverse populations and settings, including the
general population, men who have sex with men (MSM),
sex workers, among others. In addition, evidence from
other sub-Saharan African countries suggests that HIVST
can; empower users, be cost-effective, and has potential

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to increase access to and uptake of HIV testing services,
particularly among individuals who may not otherwise
test. In Uganda, however, the degree of acceptability
for HIVST is not yet known since such studies are still
ongoing. Evidence from these will inform scale-up and the
HTS program in general.

Several possible models for availing HIV rapid tests for


HIVST implementation have been recommended. These
models vary in the amount of support that is provided
(supervised or unsupervised), level of access (clinically
restricted, semi-restricted, or open access) and how and
where HIV rapid tests are distributed or performed
(facility-based, community-based, or other settings
following the HTS approaches.

In Uganda, HIVST should be performed under controlled


settings such as Research or demonstration projects using
approved HIV rapid diagnostic tests that use either finger
stick whole blood or oral fluid (mouth swab) under close
supervision of the Ministry of Health until the MOH
provides further guidelines.

HIVST does not provide a diagnosis. All reactive (positive)


self-test results should be confirmed using the approved
National HIV testing algorithm.

HIVST pilot projects should provide adequate information


to individuals who test HIV-positive to ensure linkage to
confirmatory testing, HIV care, and support
The Ministry of Health, upon availability of evidence will
develop guidelines for delivery of HIVST

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7.0 Linkage to Prevention, Care,
Treatment and Support Services
The second 90’ in the UNAIDS fast-track targets of 90-
90-90 by the year 2020 is “linkage of 90% of HIV positive
individuals to treatment’. Without effective strategies that
ensure linkage and enrolment in care, the effect of HTS
in reducing HIV transmission, morbidity and mortality
cannot be fully realized.It is therefore the mandate of
the HTS program to ensure identification and linkage
of HIV positive individuals to care, treatment, support
and prevention services. The success of linkage shall be
measured by enrolment into care and not by intermediary
process indicators such as the number of referral cards
issued. This section therefore provides guidance to HTS
providers to ensure successful linkage of all HIV positive
individuals identified. It emphasizes the critical role of
Linkage Facilitators as well as strategies to track intra-
facility, inter-facility and community to facility linkages.

Specific Objective: To guide HTS providers to implement


effective referral and linkage mechanisms to achieve
90% linkage into care for all identified HIV positive
individuals to achieve epidemic control

Policy Statements
a) Inter and intra facility networking and collaborations
should be promoted for effective linkages of clients.
b) All HTS service points should have a regularly updated
referral directory of community and institutional
prevention, care and support services.
c) HTS providers should link all HIV positive individuals

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to prevention, treatment, care and support.
d) HTS providers should refer HIV Negative persons to
appropriate HIV prevention services
e) All HTS providers should designate personnel to work
as Linkage Facilitators

7.1 Intra and Inter-facility linkages

Inter and intra facility networking and collaborations


shall be promoted for effective linkages of clients.

Linkage as opposed to referral refers to the act of


connecting an individual from one point of care to
another. Intra-facility linkage refers to connecting a client
from one point of care to another within the same facility;
while inter-facility linkage means connecting a client from
a point of care in one facility to another facility. Linkage
is considered successful if client is able to reach and get
enrolled into care.

HTS providers should facilitate and ensure complete


linkage of HTS clients both within and across facilities.

Intra-facility linkage should be encouraged for facilities


that are accredited to offer HIV treatment. However,
clients should be given an opportunity to choose the most
appropriate facility to receive care, treatment or prevention
services from.

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Steps involved in linking an HIV positive client to care
• Provide client with adequate information about HIV
and AIDS care and treatment services available.
Provide the client with a number of facilities to choose
from as his/her preferred choice.
• Discuss the Pros and cons for each option for the client
to make an informed decision. Remember the journey
to good treatment adherence starts with proper and
appropriate linkage to care
• After the client has chosen the facility, complete the
HCT Client result slip and the triplicate referral form
indicating the facility the client has been referred to.
• Remember to record the clients’ contact information on
the triplicate referral form for easy tracking and follow
up.
• Record in the HCT register column 20 where the client
has been referred.
• Tell the client the exact location of the care clinic in the
facility of referral as well as the clinic days.
• If the client prefers to receive care from your facility,
hand over the client to the Linkage Facilitator who
should escort and hand over the client to the service
provider in the care clinic. Clients should be handed
over to care and prevention points together with the
linkage and referral documentation forms

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Figure 8: Intra-Facility Linkage- How does an HIV+
client travel through the facility?

ENTRY POINT
Registration
Group Education
Pre-test Counseling
HCT Register/ HCT
Card

Testing Point/
Laboratory
HCT Log

Post - test
Counseling
Client Results Slip

Is there care at
Home this Facility?

Refer to another Facility


Linkage to care Use triplicate Referral
Forms

Confirm Enrollment Follow up to confirm


into care enrollment into care
Compare HCT Use the Follow
Register & Pre-ART up/tracking schedule
Register

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Table 3: Description of Flow Chart
1. Client arrives 2. The Client is 3. The test
at the facility counselled is performed
with unknown by the service and results
status. provider at sent back to the
the entry Counselling
point. The point
service
provider
performs the
HIV test or
sends client
to the testing
point (Lab).
Activities for the Activities for Activities for the
HCW: the HCW: HCW:
─ Provide ─ Fill out HTS ─ Perform HIV
pre-test client card test correctly
information ─ Record in daily
giving through consumption
health talk log for test kits
─ As part of ─ Record result
history taking, on HTS card
establish
Client’s HIV
status

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4. The Service 5.The HIV 6. Further
provider positive client Counselling,
provides post- is escorted to appointment
testcounselling the HIV clinic giving and
for the positive with the referral treatment is
client and forms in the given at the
provides referral facility and ART clinic
and linkage enrolled in care
information on the same day
Activities for the Activities for Activities for the
HCW: the HCW: HCW:
─ Provide results ─ Linkage ─ Completing
accurately Facilitator pre-ART
─ Provide should escort register
information client to ART ─ Opening client
oncare clinic file
available at ─ Hand ─ Pre-ART
the facility client to Counselling
and elsewhere responsible ─ Baseline
inthe staff investigations
catchment area ─ Ensure client ─ Appointment
─ Complete the is enrolled setting
client card and on the
include referral same day
notes of linkage/
─ Complete referral
the triplicate
referral form
7. Use the linkage data to review and monitor the
indicator performance periodically

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7.2 Tracking Inter-Facility Linkage after
Referral
Follow up should begin one week after referral has been
done. A client should have reached and been enrolled in
care within 30 days of referral. The purpose of tracking
(follow up) is therefore to establish which clients have
been linked and which ones have not. Follow up using
phones or home visits should be done for those not linked.
Follow up should check for the following;
• If the client reached the facility/clinic
• If the client received the services
• If the services provided served the purpose for
which the referral was made

Effort should be made to assist the client to reach/receive


the services for which they were linked. Table 4below gives
guidance on how facilities and providers shouldtrack
linkage of referred HIV positive individuals.

Table 4: Follow-Up/ Tracking schedule

Timeline Action
Day of Client diagnosed HIV positive and
Linkage referred to preferred facility
Linkage Facilitator documents clients
contacts
Linkage facilitator obtains clients consent
for home visiting Linkage facilitator
introduces client to Community Health
worker

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Week 1 Linkage Facilitator calls Client or Facility
X contact where the client was referred.
If client reached, document complete
linkage.
Week 2 If the client didn’t reach the facility by
week 1, the Community Health Worker
(VHT) visits Client’s home to remind
him/her about the referral
Week 3 Linkage Facilitator calls Client or Facility
X contact. This helps to confirm if the
VHT visit to client’s home made any
impact. If client reached, document
complete linkage.
If client didn’t reach, Linkage Facilitator
visits client’s home to discuss reasons
for the clients failure to reach the referral
point
Week 4 Linkage Facilitator calls Client or Facility
X to confirm if client reached. If yes,
document linkage as complete. If no,
document as Lost

Means of follow up shall include;


1. Using phone calls: call the facility where the client
was linked
2. Periodic physical checking of records: crosscheck
in the Pre-Art register where the client was linked
3. Client report back: should be done by phone call or
physical reporting. Encourage client to report back
after reaching the referred to facility. Provide your
facility contacts to the clients and the exact point to
return to in case they physically comeback.

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4. Physical home visits by both Community health
workers (VHT) and Facility based health workers
(Linkage Facilitator).

7.3 Referral Directory


All HTS service points shall have a regularly updated
referral directory of community and institutional
prevention, care and support services

All HTS service points should have a regularly updated


referral directory of existing community and institutional
prevention, care and support services within their
catchment area.

The referral directory should be district-specific and


should show the scope and nature of services provided at
various sites. The directory should be regularly updated
in consultation with the DHO and implementing partners
within the district and should have provision for linkage
to community structures, including village health teams.

Within the health facility, linkage meetings should be held


to track and document linkage between different service
points and ensure clients not linked are tracked and
brought into care.

Systems to monitor and evaluate the success of linkage


approaches and identify areas for improvement should be
established. Implementing and documenting Continuous

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Quality Improvement (CQI) should be done.
Appropriate information about services to which the
client is referred for and linked to should be provided;
mechanisms for documentation, feedback and monitoring
should be established.

HTS providers should address barriers to linkage in order


to ease the process. Barriers may include;
• Client factors such as feeling healthy, depression,
lack of social or family support and fear of disclosure
• Social or cultural factors such as stigma and
discrimination
• Structural or economic factors; including legal issues
and lack of transportation Health system barriers;
such as poor referrals, stigmatizing or unfriendly
services and long waiting times in facilities

Figure 8: Referral and Linkage Services

SMC
Home- ART
based care PMTCT

Blood
donation
Family Planning

Nutrition HTS
Psycho-social
support

STI management

OI
Paediatric Management
care OVC
TB/HIV
services
care

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7.4 Good practices to increase linkage to HIV
care
Uganda has adopted the ‘test and treat’ strategy for all
individuals testing HIV positive. Hence, same day linkage
to HIV care and treatment should be prioritized. It is noted
that some people may not be linked to care and treatment
immediately due to social, psychological and clinical
reasons. Often, people need time to accept the diagnosis
and seek support from partners and families before being
linked to care. ;

Strategies to improve linkage to care and treatment


services
• Sensitize the community to reduce stigma and
increase community based support for treatment
adherence and retention
• Improve service delivery, reporting and feedback
mechanisms
• Reduce barriers to care, such as lengthy processes
and unnecessary requirements for enrolment into
care.
• Monitor linkage between HIV testing, treatment
and prevention services.

Practices which may increase Linkage to ART Initiation


• Integrated services where HIV testing, prevention,
treatment and care, TB and STI screening and other
relevant services are provided together at a single
facility or site
• Providing on-site or immediate CD4 testing with same-
day results as well as Viral load testing

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• Support and involvement of trained lay providers
who are peers and act as Linkage Facilitators, expert
patients/clients and community outreach workers
to provide support and find people who are lost to
follow-up.
• Intensified post-test counseling by both facility and
community health workers
• Provision of brief strengths-based case management
which emphasizes people’s self-determination and
strengths, is client-led and focuses on future outcomes,
helps clients set and accomplish goals, establishes good
working relationships among the client, and the health
worker and other sources of support in the community,
and provides services outside of office settings
• Using communication technologies, such as mobile
phones and text messaging, which may help with
disclosure, adherence and retention particularly for
adolescents and young people
• Promoting partner testing may increase rates of HIV
testing and linkage to care, as may approaches in
PMTCT settings that encourage male involvement
• Intimate partner notification by the provider, with
permission, is feasible in some settings; it identifies
more HIV-positive people and promotes their early
linkage to care
• Decentralized and community-based distribution of
ART

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7.5 Linkage for HIV Positive individuals

HTS providers should link all HIV positive individuals


to prevention, treatment, care and support

With the test and treat strategy, all individuals who test
HIV positive should immediately be initiated on treatment.
Where this is not possible, linkage should be effected
within 7 days after diagnosis for intra-facility linkage. For
linkage across facilities (inter-facility), a client should be
followed up within 30 days of HIV diagnosis for linkage
to be successful.

Children below 15 years and Adolescents should be


prioritised for linkage and follow up due to their increased
vulnerabilities.

The Linkage Facilitator should actively track linkage of


adolescents and offer additional support because they are
more likely to drop out of care. Referral for HIV Negative
individuals

7.6 Linkage for HIV Negative individuals

HT S providers should refer HIV Negative persons to


appropriate HIV prevention services

A range of HIV prevention services should be available


for those who are HIV-negative.
It is important to support linkage to prevention services
for those with the greatest ongoing risk such as people

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in settings of high HIV incidence, key populations and
negative partners in sero-discordant couples.

Linkage of men and boys eligible for SMC from HIV


testing should be prioritized.

7.7 Linkage Facilitators

All HTS providers should designate personnel to work


as Linkage Facilitators

Linkage Facilitators should be established in health


service delivery to minimize loss to follow up and ensure
effective linkage of clients into HIV services within and
across programs. Currently, various HTS providers have
institutionalised this cadre either as designated full time
paid staff or volunteer personnel. This guidance provides
a framework to effectively plan and efficiently manage
volunteer lay providers, streamline and harmonize their
roles, incentives and supervisory structures.

Linkage facilitators should operate at two levels; at the


Health facility and within the communities. At facility
level, Linkage Facilitators s may include designated
staff or Volunteer s with a defined scope of work and
supervised by the HTS focal person. These should
include expert clients at the HIV Clinic and Mentor
Couples at the eMTCT clinic. Key functions of facility
based Linkage Facilitators should include:
• Supporting health workers in service delivery e.g.
registration and weight taking, client file retrieval
etc.

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• Linking HIV positive individuals to care and
treatment both within and across facilities
• Peer to peer education and counselling
• Follow up of clients referred to other facilities
• Client follow up in the community
• Drug adherence counselling and monitoring
• Reporting

Facility Linkage Facilitators should be aged 25 years and


above and be able to read and write at least in both English
and a local language.
At community level, all resource persons working within
the community and linking individuals to HIV services
should be linkage facilitators. These include VHTs, Expert
Clients, Mentor mothers, and Peer educators.
They will be titled ‘Community Linkage Facilitators’
(CLFs) and will be selected at Parish level. They should
coordinate with other Community –based health Workers
facility-based linkage facilitators to minimise missed
opportunities for HTS.
Parish VHT coordinators should be supported to take on
the role of CLFs. Key functions of CLFs shall include;
• Mobilizing community members for services (
outreach services and health education talks)
• Sensitizing the community on benefits of HTS and
seeking care
• Linking clients to appropriate service providers –i.e.
walk clients to service points
• Providing information to clients on different

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providers and the services provided
• Keeping a record of clients to follow up and potential
clients in catchment area
• Keeping a record of other linkage facilitators in the
catchment area
• Actively following up clients in the community
• Gathering client’s concerns and preferences and
giving feedback to providers
• Preparing monthly reports

7.8 Monitoring Linkage


Intra-facility linkage should be monitored routinely to
ensure that no HIV positive individual falls out of the
cascade. The Linkage Facilitator should verify successful
linkages on a weekly basis by comparing the HTS Register
with the Pre-ART Register. Any individual identified in
the HTS Register but not recorded in the Pre-ART register
should be followed up and status documented.

MOH standard referral forms should be utilized by all


HTS service providers. The triplicate Referral form should
be used to track both intra and inter-facility linkages. MoH
should develop and provide tools to document follow up
of referrals.

HTS providers should use data on linkage to identify


challenges and apply QI principles to improve linkage to
care.

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8.0 HTS Health Systems
requirements
In order to increase access, meet the 5 Cs, and ensure
quality, HTS should be offered within a functional health
system. The following elements will especially be critical
in achieving this; committed leadership and governance,
qualified Human Resources for Health, clear financing
mechanisms, infrastructure, a functional procurement and
supply chain management system and a clear Monitoring
and Evaluation plan.

Specific Objective: To provide guidance on maintenance


of a functional health system that ensures quality and
equitable HIV testing services

Policy Statements:
a. Governance and coordination of HTS under the multi-
sectoral approach remains the responsibility of the
Uganda AIDS Commission (UAC)
b. Overall technical leadership for HTS shall be the
mandate of MOH with delegated functions along the
decentralized health system.
c. HTS shall be offered under infrastructure which
ensures privacy and confidentiality during counselling;
physical accessibility for all; safety of the provider,
client and community and appropriate storage of HTS
supplies and commodities.
d. MoH shall maintain a functional procurement and
supply chain management system to ensure a
sustained delivery of HIV testing services through
forecasting, quantification, monitoring stocks, and

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timely ordering of adequate and quality HTS supplies
and commodities at all levels
e. It shall be the mandate of the MoH to mobilize resources
to finance HTS and ensure universal access to quality
HTS through provision of affordable services by both
public and private health facilities.
f. HTS shall be offered by trained and certified providers
including Lay Providers, counsellors, laboratory
personnel, medical workers, data managers and
logistics managers.
g. Training of HTS providers shall be conducted by
accredited HTS Training Institutions using MOH
approved curricula
h. Monitoring and evaluation of HTS will be conducted
in line with the National Monitoring and Evaluation
Framework for HIV/AIDS in the health sector.
i. The MoH shall ensure availability of a functional HIMS
for HTS and all HTS implementers shall adhere to
standardised mechanisms for data collection, storage,
analysis, and reporting
j. Quality Assurance shall be an in-built component of
the HTS cascade. All facilities will offer HTS as per
the set standards, implement quality improvement
activities and carry out quality control activities to
ensure quality HTS
k. MOH shall guide HTS research to evaluate feasibility,
acceptability, quality and effectiveness of interventions
for evidence-based programming

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8.1 Leadership and Governance of HTS
Governance and coordination of HTS under the multi-
sectoral approach remains the responsibility of the
Uganda AIDS Commission (UAC)

Overall leadership and governance for HTS shall be the


mandate of MOH with delegated functions along the
decentralized health system.

Leadership and governance functions for HTS should be


carried out along the entire cascade of the decentralized
health service delivery system as mandated by the MoH.
Organizations delegated to perform these functions
will ensure that strategic policy frameworks exist and
are combined with effective coordination, oversight,
regulations, functional systems and accountability.

8.1.1 Coordination and oversight


Coordination and oversight for the HTS implementation
shall be done at National, district and service delivery
level.
Coordination and oversight for HTS at national level will
be carried out by the Uganda AIDS Commission (UAC)
and the AIDS Control Program (ACP) of the MoH. The
UAC will provide overall coordination of the multi-
sectoral response to HIV/AIDS including provision of
leadership for planning, implementation and monitoring
of HTS by different stakeholders.

The ACP of the MoH will coordinate the technical


assistance for implementation, monitoring and evaluation

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of HIV Testing Services. The ACP will fulfil this mandate
through a National HIV Testing Services Committee
(NHTSC) comprising of representation from key HTS
organisations and development partners who will advise
on the technical aspects of the HTS program.

At district level, the District Health Officer (DHO) through


the district HTS Focal Person shall coordinate and ensure
effective implementation, supervision and monitoring of
HTS within the district.

At health facility level, the In-charge through a designated


health facility HTS Focal Person shall coordinate and
ensure effective implementation of HTS within the health
facility.

The roles and responsibilities of the different stakeholders


at all levels are described in section 12.0 of this policy and
guidelines.

8.1.2 Accountability
Accountability should focus on tracking how financial
resources and other inputs for provision of HTS translate
into service provision, uptake and impact on identifying
individuals living with HIV as per the triple 90 strategy.
The accountability mechanisms should engage key
stakeholders who finance HTS the beneficiaries and HTS
providers.

The following should be done for accountability at all


levels;
• Implementing partners and political leaders should

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be engaged to witness arrival of stocks as they are
delivered.
• Annual financial audits for HTS resources should be
conducted.
• Financial reports for HTS resources should be compiled
quarterly. Funds spent on salaries and motivation
of HTS providers should be included in financial
expenditures.

At National level, MoH should ensure that funds for


procuring HTS supplies and commodities are well
accounted for MoH should ensure that mechanisms
for procurement and management of HTS supplies and
commodities have clear accounting procedures to track
flow and utilization of resources.

At District level, the DHO and Chief Administrative


Officer (CAO) should ensure availability of clear
accounting procedures to track flow and utilization of
HTS resources.
HTS data and other relevant information to monitor and
evaluate performance should be utilised. Districts should
undertake bi-annual financial audits on all HTS related
logistics.

At Health facility level, the Health unit in-charge should


be responsible for tracking performance around the actual
uptake of services in relationship to the resources availed
to the health facility.

Use of HTS data capture tools, including the HTS register


and the HIV testing daily activity registers should be used

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to track utilization of HIV test kits and compilation of
monthly reports.

8.2 Infrastructure for HTS


HTS shall be offered under infrastructure which
ensures privacy and confidentiality during counselling;
physical accessibility for all; safety of provider, client
and community during the HIV testing process and
appropriate storage of HTS supplies and commodities.

Appropriate infrastructure is essential for delivery of


accessible, quality and safe HIV Testing Services. This
includes availability of adequate physical space and a
conducive environment for HIV counselling and testing
and equipment to run HIV tests.

8.2.1 Physical accessibility


HTS providers should ensure physical accessibility to HTS
services to all persons by remodelling facilities as per the
accessibility standards28. People affected by accessibility
barriers include People; who use wheelchairs, with limited
walking/movement abilities; with visual impairment or
low vision; with hearing impairment, with intellectual
disabilities, with psychosocial disabilities, Elderly persons,
pregnant women, and people with temporary disabilities29.
Accessibility modifications may include ramps, stairs,
barrier-free entrances, parking space, latrines, toilets,
pathways, handles and grips.

28 MoGLSD/UNAPD 2013, Accessibility Standards: A practical guide to create a barrier-free


physical environment in Uganda.
29 ibid

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8.2.2 Counselling space
HTS should be provided in designated, clean, well
ventilated areas with sufficient lighting and adequate
space for both the service provider and client. The
designated areas should be private to allow for confidential
discussions and sitting space for both the counsellor and
the client. At outreach sites, counselling may be conducted
in an open space such as under the tree but confidentiality
should be observed.

8.2.3 Testing space


At facility level, HIV testing should be conducted both in
the laboratory and at other designated points within the
facility. HIV testing should also be done in community
settings such as homes, churches, work places or market
places.

Any area designated for performing HIV tests should


have adequate space to allow for all the testing materials/
tools to be comfortably used to facilitate quality testing.

During testing, universal precautions and standard waste


management procedures MUST be adhered to so as to
ensure safety of the provider, client and community.

8.2.4 Storage space for HTS supplies and


commodities
Health facilities should designate adequate space with the
manufacture’s recommended temperatures to store HTS
test-kits and associated commodities. In addition health
facilities should design and/or implement systems for

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management and distribution of HTS commodities within
the facility to avoid stock-out of test-kits at different testing
points.

8.2.5 Records storage rooms


All sites offering HTS should store HTS records including
laboratory records in a designated secure place. This
should ensure confidentiality of clients’ records as well as
easy retrieval.

8.3 HTS Logistics Supply Chain Management


MoH shall maintain a functional procurement and
supply chain management system to ensure a sustained
delivery of HIV testing services through forecasting,
quantification, monitoring stocks, and timely ordering
of adequate and quality HTS supplies and commodities
at all levels

An effective supply chain management system is critical


for maintenance of adequate stocks of quality HIV testing
supplies and commodities for sustained and un-interrupted
service delivery. It guides processes of monitoring stocks,
forecasting, quantification and requesting/ordering for
HTS supplies and commodities and ensures adequate
levels of quality and essential HIV testing supplies and
commodities. This section also guides the processes of
storing HTS supplies and commodities to maintain their
potency.

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8.3.1 Stock monitoring and management of test
supplies
MoH shall ensure HTS commodity availability at all HTS
sites by utilizing the approved national warehousing
and commodity management systems. MoH approved
tools for stock management of laboratory reagents and
HIMS records shall be used by HTS programs to track
stock levels and consumption patterns of HTS supplies
and commodities. The use of both electronic and paper
based tools such as the stock cards should be enhanced.
Information generated shall be used for improvement of
HTS services delivery and ensuring that facilities always
have adequate stock of HTS supplies and commodities
within the required expiry dates.

8.3.2 Forecasting and Quantification


MoH shall ensure availability of quality and adequate
stocks of essential HTS supplies and commodities at all
levels. The MoH approved Logistics management systems
at National and district levels shall be utilized and adhered
to during monitoring of stocks, forecasting, quantification
and requisitioning/ordering for HTS supplies and
commodities at all levels.

The National Quantification Planning and Procurement


unit (QPPU) together with Uganda National Health
Reference Laboratory (UNHRL) and the NCTC shall
forecast, and quantify the national need in consultation
with key national stake holders. Forecasting assumptions
required for HTS supplies and commodities shall be
discussed and harmonised through the NCTC and availed
to UNHRL to guide the QPPU.

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HTS supplies and commodities should be availed through
the approved National warehouses which shall distribute
to facilities through the district mechanisms.

All facilities should use consumption data and stock


at hand to forecast the need for HTS supplies and
commodities. The forecast should factor in the expected
volume of clients to be served at the facility.

Quantification of HTS commodities and supplies and


assessment of the operation of the laboratory credit line
shall be conducted annually. Analysis of consumption
data for HTS commodities shall be conducted by
MOH personnel at all levels, in collaboration with HTS
implementing partners.

When estimating the number of persons to be tested for


HIV, the following should be considered:
• The projected increase in demand for HTS services
• Increasing demand from the targeted community
HTS
• Planned HTS activities like VMMC
• The shelf life of the test kits available in the
warehouse in relationship to consumption rates
• Testing guidelines from the National Health
Reference Laboratory (NHRL)
• Facility based trainings, internal and external
quality testing procedures using HIV test kits.

8.3.3 Procurement and distribution


MoH shall define specifications and procure all HTS
supplies and commodities and other medical supplies and

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commodities. All HTS supplies and commodities should be
purchased centrally through approved MoH Warehouses
as stipulated in the supply chain rationalization of the time.
Each warehouse should ensure that the commodities are
stored and distributed to all facilities in accordance with
good manufacturing practice.

8.3.4 Storage of HTS supplies and commodities at


district and Facility
All HTS sites should be supported to have proper storage of
HTS supplies and commodities as per the manufacturer’s
recommendations to ensure potency hence quality of the
HIV tests. However, the basic minimum storage standards
for medical and laboratory supplies should be maintained
at both district and facility levels.

8.3.5 Training in logistics management


In order to ensure a functional logistics supply chain
system, all Stores Assistants at the district and facility levels
should be trained in logistics and stock management. Key
training content should include;
• Quantification of the requirements for essential
reagents and other supplies for HTS
• Collecting and using accurate supply chain
information,
• Storage, management and distribution of HTS
commodities.

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8.4 Financing for HTS

It shall be the mandate of the MoH to mobilize resources


to finance HTS and ensure universal access to quality
HTS through provision of affordable services by both
public and private health facilities.

In order to guide and regulate the costing of HIV testing


services to increase affordability and access, MoH will be
responsible for mobilizing resources to support delivery
of quality HTS. The MoH will work within the existing
development mechanisms including budget allocations
from government and support from development partners
such as Global fund, PEPFAR, and others to raise funds to
offer HTS. The AIDS Trust Fund when regularised shall
be another source of financing for HTS and allocated HTS
resources will be ring fenced and utilised for implementing
planned activities.

MoH shall provide free HTS supplies and commodities to


accredited public and private not for profit health facilities.
Therefore HTS services should be offered free of charge to
all clients at the accredited facilities.
In Private for profit health facilities (PFPs) where a fee may
be charged for HTS to enhance sustainability, it should be
affordable and not be a barrier to access of service and
should be approved by the facility management. The fee
should be clearly displayed and receipts should be issued.
Clients who fail to afford it should be considered for a
waiver or referred to an accredited public or private not
for profit (PNFP) health facility.

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The site manager should determine whose fees should be
waived based on recommendation from the counsellor.
Free days may also be considered as a way of attracting
clients for whom a fee would represent a barrier to using
HTS.

Funding priorities for HTS should include;


• Human resources,
• Supplies and commodities,
• Capacity building,
• Supportive supervision,
• Coordination,
• Research and
• Service delivery
• Quality assurance

On an annual basis the HTS programme should determine


priorities for funding. These should inform resource
allocation and resource mobilisation efforts.

All private facilities should be expected to seek accreditation


and certification from MOH and the certifying authority to
assure the quality of HIV testing offered by such facilities.
Such facilities are encouraged to provide free HTS as part
of their corporate social responsibility.

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8.5 Human Resources for HTS
•HTS shall be offered by trained and certified providers
including Lay Providers, counselors, laboratory
personnel, medical workers, data managers and logistics
managers
•Training of HTS providers shall be conducted by
accredited HTS Training Institutions using MOH
approved curricula

Delivery of effective HTS depends largely on the


knowledge, skills, motivation, equitable and appropriate
deployment of personnel responsible for organizing,
delivering and monitoring health services. Human
resources for HTS delivery include direct service providers
(medical workers, counselors, Lay providers, M&E staff,
logistics staff and Laboratory staff), trainers/mentors and
supervisors.

8.5.1 HTS service providers


HTS must be performed by qualified personnel, who
include direct service providers (medical workers,
counsellors, Lay providers, M&E staff, logistics and
Laboratory staff, trainers/mentors and supervisors.

All HTS providers must be trained using the nationally


approved curricula for the different HTS models. An HTS
provider must be competent and proficient in providing
pre- and post-test information or counselling including
HIV testing.

When staff is limited, Lay Providers, who are appropriately

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trained should provide these services under supervision
of a qualified and competent HTS provider.

HTS sites should ensure that all HTS providers have


sufficient knowledge, skills and attitudes to offer
comprehensive HTS as per the different models available
in the country.

8.5.2 Use of Lay Providers


Task-sharing through the use of trained and well
supervised Lay providers is highly recommended to
increase access to and reduce missed opportunities for
HTS. Lay providers shall include expert Clients, mentor
mothers, RCT Volunteers, Village Health team members
and Community Health Extension Workers. MOH should
standardize the training and supervision of Lay providers
to ensure they deliver quality HTS. The Lay provider
scope of work in relation to HTS shall include:
• Community mobilization
• Health Education
• Pre-test Counseling and information giving
• Conducting rapid HIV tests (under supervision of a
Laboratory staff)
• Post-test counseling
• Linkage to Prevention, care, treatment and support
services
• Follow-up of clients including tracing those lost to
follow-up

Lay providers should be engaged at community or health


facility level where task sharing is applied to complement
the health workers.

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8.5.3 HTS Provider qualifications
HTS providers should have a minimum educational
background of at least ‘Ordinary level or its equivalent.
This applies equally to those with or without a medical
background.

8.5.4 Performing an HIV test


HIV testing using the rapid test kits should be conducted
by trained and certified laboratory technicians, other
medical and non-medical professionals as well as Lay
providers. Non-laboratory personnel MUST be supervised
by a qualified medical laboratory technician.

Other HIV tests including ELISA and virological tests


must be performed by qualified Medical Laboratory
technologists.

8.5.5 Training in HIV counselling and testing


All HTS providers must undergo the foundational HTS
training using standardized National HTS training
curricula. This training should not be less than two weeks
of classroom instruction and one week practical experience
followed by three months supervised practice in a real
work setting. All HTS training curricula should include
HIV rapid testing module as part of the content.

All HTS training must be conducted by trainers certified


by MOH.

All HTS providers MUST:


• Meet the minimum educational qualifications required
to perform specific tasks
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• Demonstrate mastery of content of an MOH approved
HTS curriculum
• Complete a period of supervised practice (as specified
by the specific training curriculum) with endorsement
by a counselor supervisor, and
• Pass a final assessment

After earning the basic certificate to provide HTS, providers


can then be oriented in the different models of providing
HTS depending on their organization’s or institution’s
mandate and settings.

HTS providers should regularly update their knowledge


through refresher and in- service training. Health workers
are required to earn 24 hours of Continuing Medical
Education (CME) per year as per national guidelines.
Non-medical HTS providers should participate in an
equivalent number of hours of refresher training per year
in order to be certified and hence assure highest- quality
HTS services.

8.5.6 Qualification of HTS Counsellor Trainers


An HTS Trainer should have a minimum qualification
of a University degree in a medical field, education or
humanities. In addition, he/she should possess the
following requirements:
• Strong background knowledge in HIV/AIDS
Counseling skills
• Experience of not less than 6 months providing HTS
services
• Training of trainers (TOT) skills from a recognized
institution.

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• Be oriented in the use of standardized HIV counselor
training courses approved by MOH.

HTS trainers should regularly update their Knowledge


and skills through personal reading, seminars, refresher
training, conferences and further training so as to remain
relevant.

8.5.7 HTS Provider Support Supervision and


Mentorship
HTS providers need support to: prevent burnout, share
experiences and learn from each other, receive technical
updates and enhance quality of services.

HTS providers should also receive support and learn


through Quarterly debriefing meetings with their
supervisors. Supervisors should be professionally
competent and be able to provide personal and professional
support during supervision meetings.

Individuals to provide HIV counsellor supervision should


be well trained using a curriculum approved by the
Ministry of Health.

HTS implementing programs should institutionalize


counsellor support supervision activities to provide
regular support to HTS providers. MoH shall develop
standardised supervision guidelines, tools and checklists
to guide supervisors to provide quality supervision of
HTS providers.

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HTS providers shall be supervised on a quarterly basis
and the outcomes of supervision documented for follow
through.

Supervisors of HTS providers shall include HTS provider


Trainers, HTS supervisors, HTS focal persons and Senior
Counsellors. These shall be trained in the use of the
standardised supervision guidelines and checklists to
ensure appropriate supervision and mentorship.

8.5.8 Composition of HTS Providers


The following persons shall offer HTS;
• Laboratory staff
• All qualified/certified and registered medical
practitioners who have undergone the Foundational
three –week’s comprehensive HTS course.
• Professionals such as Teachers, Social workers,
Development workers who have undergone the
Foundational three –week’s comprehensive HTS
course
• Professional counselors who have had a pre-service
HIV counseling training from a recognized training/
education institution. These shall undergo Rapid HIV
testing training unless there is evidence of this module
as part of the pre-service training
• Health professionals and social workers/counselors
who have undergone in-service training modules in
HTS and have been certified by MoH. Such training
modules include HBHCT, PITC, PMTCT, couples HTS
and pediatric and adolescent HTC, or/and HTS for
Key populations.

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• Lay providers who have undergone a tailor-made three
weeks comprehensive HTS training using approved
curricula and certified by MoH.
• All the above should be regularly mentored and
supervised.

Table 5: Summary Roles and Responsibilities of HTS


Providers

Cadre Roles and Responsibilities


HTS Provider • Create demand for HTS through health
(health worker/ talks
counselor) • Utilize relevant SOPs and job aids to
provide high quality HTS
o Conduct risk assessment and
reduction counseling.
o Utilize approved adult and infant
HIV testing algorithms.
o Conduct pre-test and post-test
counseling
o Conduct HIV tests and give correct
results.
o Facilitate evidence based behavioral
interventions (EBIs).
o Provide and appropriately document
referrals and linkages.
• Manage HTS supplies and commodities
• Utilize approved HMIS tools
• Participate in HTS supportive
supervision, and mentorships for Lay
providers
• Conduct continuous quality
improvement for HTS

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Lay provider • Mobilize HTS clients and conduct
health talks.
• Conduct pre and posttest counseling
sessions.
• Perform rapid tests( under the
supervision)
• Support linkage of clients diagnosed
with HIV to care, treatment, prevention
and support services.
• Distribute condoms and IEC materials
to clients.
• Mobilize and sensitize, educate and
refer communities for HTS.
Facility • Oversee planning, staff deployment,
In-charge/ monitoring and evaluation of HTS
manager services.
• Ensure adequacy of supplies and
commodities for HTS.
• Ensure availability& use of the HTS
policy, SOPs and HMIS tools.
• Participate in supportive supervision.
• Work with the HTS focal person to
ensure quality HTS delivery.
• Communicate and monitor the HTS
performance targets
• Ensure availability of conducive space
for providing HTS
• Facilitate timely reporting for HTS and
commodities to the relevant offices.
• Provide regular feedback to staff on
HTS.
• File records of all HTS trained and
supervised/mentored staff.
HTS Focal See roles under section 12.0
person

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Laboratory in- • Ensure internal quality controls and
charge external quality assurance (QA) for HIV
testing, and perform QA audits and
Proficiency Testing corrective actions.
• Supervise HIV rapid testing at all
testing points and ensure accurate
documentation of HIV test results in the
log book
• Ensure availability and correct use of
HIV testing SOPs(testing algorithms
adult and infant, EID dispatch
books, HIV testing log book, waste
management and safety precautions)
• Conduct mentorship of HTS providers
on quality testing
• Ensure accountability for HTS
commodities (test kits, DBS
commodities, PT panels) management
• Liaise with the HTS focal person
to ensure timely reporting for
commodities consumption, and
accurate projection
• Ensure proper storage and management
of testing commodities in accordance
with the SOPs.
• Perform HIV ELISA tests
• Re-test all HIV positive samples before
clients are initiated on ART
• File all records for EQA-PT, QA audits,
internal quality controls, and HTS lab-
related training

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HTS • Ensure that HTS providers receive
supervisors/ regular debrief sessions to mitigate burn
Mentors and out in order to maintain quality HTS
trainers provision.
• Identify performance gaps and provide
mentorship and/or supervision to HTS
providers through one to one or group
sessions in the service delivery points.
• Build capacities for self and peer
supportive supervision among HTS
providers.
• Perform observed sit in sessions to
ensure adherence to HTS SOPs.
• Provide timely feedback to the HTS
providers on their performance
• Support continuous quality
improvement, and trainings
• Coach and health workers
• Provide technical support supervision
• Train HTS providers
• Participate in research related activities
Logistics • Accurately forecast the requirements for
management HTS supplies
officer • Collecting and using accurate supply
chain information,
• Storage, management and distribution
of HTS commodities.

8.5.9 HTS staff-client ratio

MoH and districts should ensure adequate staffing


levels/norms for HTS delivery to ensure provision of
quality HTS. It is recommended that each HTS provider
should serve a maximum of 20 clients per day to prevent
burn-out and provision of poor quality services. Group

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education pre-test information giving, task-sharing, work
scheduling and improved work habits should reduce on
felt workload.

8.6 Health Information Management system


for HTS
The MoH shall ensure availability of a functional HMIS
for HTS and all HTS implementers shall adhere to
standardised mechanisms for data collection, storage,
analysis, and reporting

FunctionalHealth Management Information System


(HMIS) shall be required for generation of quality data
to guide planning and overall programme management
and improvement. The HTS program therefore needs to
haveappropriate primary data collection and reporting
tools; trained and skilled personnel to offer the services
and collect, manage and store data; efficient and robust
mechanisms for data processing, analysis, reporting and
monitoring and evaluation team to track performance
through use of a selected input, process, output, outcome,
and impact indicators.

8.6.1 HTS data collection


HTS data should be collected during counselling using the
National HTS client card (HMIS 055B). This card should
be filled for every client who undertakes testing. Data
on the HTS client card shall be summarised in the HTS
Register (HMIS 055A). The HTS register shall serve as the
main source of data about HTS in the facility. However,
these may be revised as MOH moves towards electronic
data management systems

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Information about HIV testing should be collected using
the Daily Activity register for recording HIV Test Kits
(HMIS 055A4)

8.6.2 Data Management


Health facility data aggregation: All HIV testing data
should be aggregated in the health unit HTS register
(HMIS 055). Each health facility should have one HTS
register where all information from the HTS client cards
(generated from different testing points) should be entered.

8.6.3 Reporting
At Facility level: On a monthly basis, each health facility
should compile an HTS report which is part of the monthly
health facility report. The data should be summarized on
the monthly health unit report form (HMIS 105) and a
copy sent to the DHO and another copy retained at the
health facility. The monthly report is generated from the
HCT register.

District level: In each district, all HTS sites (public,


PNFP, PFP) should submit their data to the health sub-
district (HSD). Each HSD should then submit their data
on a monthly basis to the DHO’s office. At the district,
a trained HMIS officer usually the Bio-statistician shall
analyze facility data and provide feedback to the HSD and
HTS sites.

Data from all health facilities within the district offering


HTS should be uploaded into the web based District
Health Information System (DHIS-2) to form the district
report and uploaded onto the MoH National platform.
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National level: HTS data should be consolidated into the
HMIS from submissions from DHIS-2.MoHshould keep
an inventory of all facilities offering HTS which must
be uploading monthly reports. National data should
be aggregated and shared with the UAC and other
stakeholders through the national stake holder review
meetings (Joint AIDS review and Health sector review
meetings). National and sub-national Country reports and
fact sheets should be shared with the districts.

HTS data should be collected, handled, stored and


processed/analyzed by personnel trained in the use of the
standard HTS HIMS tools

The figure below shows the flow of data from the


community/facility to National level.

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Figure 9: HTS data flow chart

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8.7 Quality Assurance and control for HTS

Quality Assurance shall be an in-built component


of the HTS cascade. All facilities should offer HTS as
per the set standards, implement quality improvement
activities and carry out quality control activities to
ensure quality HTS

Quality Assurance (QA) in the context of HTS refers to


adherence to the HTS set standards; conducting quality
control and Continuous quality improvement (CQI) to
offer quality HTS. Quality assurance should be achieved
through training, mentorship, certification, data quality
assessment and implementation of process control
mechanisms. Routinely collected HTS data should be
used to track performance, identify any gaps and use CQI
approaches to improve performance.

8.7.1 Adherence to standards and policies


HIV testing services shall be provided according to
the provisions of this policy and guidelines. Therefore,
HTS supervisors and managers should ensure that HTS
providers adhere to the set standards.

Non-adherence to the set standards such as protocols,


approved algorithms and guidelines by HTS programs,
facilities and testing points shall warrant withdraw of
certification and hence, barred from providing HIV testing
services.

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8.7.2 Certification of HTS Providers and Site
accreditation
MOH in collaboration with other certifying and licensing
bodies shall establish and implement a certification and
accreditation system for HTS training institutions, HIV
testing sites/points (both public and private facilities) and
HTS providers. Sites that meet the accreditation criteria
shall be allowed to provide HIV testing training and
services. Sites which do not meet the minimum standards
required shall be supported to attain accreditation status
before they are allowed to provide HTS.

Setting up an HTS point/site


Prior to certification/accreditation of a site to offer HTS,
the facility/site should be assessed to determine the
suitability of provision of quality HTS using a standard
audit score sheet.

This process will be subjected to both public and private


health facilities.

Assessment should be conducted for both new and


existing HTS Facilities/sites/service points. The following
parameters should be measured;
• Availability of human resources in terms of
numbers, knowledge and skills
• Presence of a logistics information management
system
• Availability of infrastructure – counselling rooms,
laboratory space, records storage
• Appropriate laboratory services
• Availability of a functional HMIS

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• Availability of a functional Linkage system for both
HIV care and prevention services
• Current (External Quality Assurance) EQA
assessment (for existing sites)
The initial assessment should be used to plan for setting
up or improving provision of HTS.

As a minimum standard, for a facility to offer HTS, it


should have trained personnel, adequate infrastructure
for counselling, conducting HIV tests, secure storage of
records and commodities as prescribed in this policy.
The facility should have EITHER capacity to offer on-
going care and support for HIV/AIDS patients OR should
have an established referral and linkage system or links
with other HIV/AIDS services for both HIV care and
prevention.

All facilities (public and private) should adhere to the


national HIV testing algorithm and other SOPS, use
national HMIS tools for data collection and reporting and
participate in External quality control with established
reference laboratories.

All trained and practising HTS providers shall be assessed


and certified annually using a standardized competency
assessment checklist.

The quality of counselling should be evaluated through


regular support supervision, self-evaluation, mystery
clients, sit-in sessions, counsellors’ meetings, fellowships,
exit interviews, suggestion boxes, and community
assessments at designated intervals.

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8.7.3 Quality assurance for Laboratory reagents and
test kits
Proactive post market surveillance must be conducted (to
identify any problems before use) through in country lot/
batch verification testing, before and after distribution of
test kits to testing sites according to set National guidelines.

Reactive post Market surveillance of all test kits must be


conducted through reporting and evaluation of complaint,
including reports of adverse events, and any required
actions to correct the problem and prevent re-occurrence

MOH shall conduct periodic evaluations of HIV test kits


and laboratory reagents for potency. This shall be done
every 5 years.

All HIV test kits to be used in the country for various


purposes including research shall be validated before they
are imported, on their arrival and during their use, as a
quality control process. A new batch of test kits should be
tested alongside the existing batch (lot to lot validation),
using retained samples of known HIV status.

Testing materials and supplies should be well stored,


should not expire and should be handled by trained HTS
service providers.

8.7.4 Quality assurance for Laboratory processes


and procedures
All HIV testing service points shall undergo certification
before they start performing HIV testing

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All testing sites shall be assessed bi annually using SPI-
RT checklist and certification awarded to those that meet
the desired criteria. Sites that do not meet certification
criteria shall be supported to bridge gaps identified during
assessment.

HIV testing Standard Operating Procedures should be


available on site, displayed, read, understood, signed by
users and adhered to.

All testing standard operating procedures should


provide detailed instructions on all aspects of the testing
including test requesting, environmental requirements,
test performance, a stepwise process for conducting
the test, quality control instructions, test interpretation,
reporting and recording results, appropriate use of the
testing algorithm, storage, inventory information and any
internal and external quality assurance requirements.

Manufacturer instructions shall be periodically reviewed


for any new information on the test kits as deemed
necessary.

All HIV testing and safety related SOPs should be reviewed


at least annually.
Quality control specimens from a National Reference
Laboratory (NRL) or Public Health Laboratory (PHL)
accredited to perform the production of such materials
should be used to evaluate quality of test kits and to check
whether the person testing performs it correctly (ensures
test system is performing properly).

External quality assessment shall be conducted through


proficiency testing, retesting a subset of specimens or all
positives by another qualified tester, facility or laboratory.

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Figure 10: Steps for post Market surveillance of WHO
prequalified Diagnostic kits

WHO Prequalified IVD

Proactive PMS Reactive PMS

Lot Verification Evaluation of Complaint


EQA/QC

Pre-distribution Post-distribution Possible field safety


corrective action

Possible issuance of Field Safety Notice

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8.7.5 Evaluation of test kits and other laboratory
reagents
MoH should conduct periodic evaluations and quality
assurance of HIV testing kits and reagents. Protocols for
quality standards for reagents should be developed, printed
and distributed regularly to all the facilities performing
HIV testing as per the manufacturer’s specifications for
the HIV test kits or reagents in use.

The quality of laboratory diagnosis of HIV should


continuously be monitored. Poor performing laboratories
should be identified and supported through mentorship,
training and corrective actions.
Modes of monitoring quality of laboratory diagnostics
• Internal controls
• Periodic site audits
• Tester competency assessments
• Periodic Proficiency Testing participation of testers
• Routine observation of lay testers by the laboratory
supervisor

8.7.6 Quality assurance/control measures for


monitoring and evaluation
• All HTS sites shall use the approved and standard
HTS HMIS tools.
• All HTS points shall conduct quarterly data quality
assessment (DQAs) meetings to ensure correctness
in reporting. Standard guidance of conducting DQAs
shall be developed by MoH and facilities oriented
about the process.

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• All sites offering HTS shall have well displayed SOPs
showing HTS indicators to be collected, indicator
definitions and sources of data.
• All sites offering HTS shall have well displayed SOPs
showing data flow from the point of collection to the
national level and stakeholders
• All sites offering HTS shall have secure storage of HTS
records. Access to patient records by unauthorized
persons shall not be encouraged so as to ensure
confidentiality of client information.

8.8 Research
MOH shall guide HTS research to evaluate feasibility,
acceptability, quality and effectiveness of interventions
for evidence-based programming

Research shall be an integral part of HTS implementation


in Uganda. MoH shall set a priority research agenda for
the HTS program based on emerging needs. MOH shall
collaborate with Research Institutions to conduct both
surveillance-based research as well as population-based
studies in HTS.
HTS related studies shall be done with the knowledge and
in consultation with the MoH.

Operations research for innovative HTS models should be


prioritised by HTS implementers. Findings from such shall
be disseminated to all stakeholders to promote learning
and adaptation.

Research results shall be utilized to inform policy


development, HTS programming and implementation

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All HTS research shall conform to the relevant legislation
and ethical standards of practice set by appropriate
research ethical committees and bodies of government at
various levels

Documentation, sharing of lessons learned, and adoption


and/or adaptation of good practices shall be promoted.

8.8.1 HIV testing in surveillance settings


Unlinked surveillance or anonymous epidemiological
testing, whether to assess HIV infection trends and impact,
may be undertaken provided it complies with ethical
principles of scientific research, professional ethics and
protection of individual rights and confidentiality and
safeguards anonymity.

All testing conducted in research settings should be pre-


approved by the relevant ethical review boards.

Whenever possible, individuals who are tested for


surveillance purposes should be given an opportunity to
know their HIV results.

Key populations and vulnerable groups should be


prioritized in HIV surveillance activities.

In Uganda where there is a generalized epidemic


additional periodic national population-based surveys are
recommended.

Surveillance systems shall use the same testing strategy and


the validated national testing algorithm recommended for

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HIV diagnosis. This is particularly critical when test results
and an HIV status are reported back to an individual

HIV surveillance systems should use programmatic


data whenever possible, particularly data from PMTCT
programmes and HIV diagnosis.HIV surveillance activities
are encouraged to collaborate with biological surveillance
activities for other, overlapping epidemics such as TB, STIs
and viral hepatitis. This collaboration expands monitoring
and enhances the efficiency of the HIV response.

Providers of HTS are encouraged to participate in HIV


case reporting, which should be part of the national HIV
surveillance system. Case reporting data are used to assess
the number of people in need of treatment and care and to
inform the planning and allocation of resources.

9.0 Monitoring and Evaluation for HTS


Monitoring and evaluation of HTS should be conducted
in line with the National Monitoring and Evaluation
Framework for HIV/AIDS in the health sector.

Monitoring and Evaluation of HTS services shall be done


in line with the National HIV and AIDS Monitoring
and Evaluation Plan for the health sector. Information
generated shall be made available to responsible officers at
the facility, district and national levels and it should be used
in the planning cycle of HTS programs. This information
should also be vital on a day-to-day basis in forecasting
and planning for HTS supplies and commodities.

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9.1 Collection and reporting systems for
periodic assessments
The MOH should conduct periodic assessments of HTS
in form of surveys or operations research or programme
evaluation. The protocol including structured and
standardized data collection tools for collecting and
analysing the information for this assessment shall be
developed by MoH.

9.2 Process indicators


At process level, the following shall be tracked;
Proportion of;
1. Facilities offering HTS,
2. Facilities with HTS policy and implementation
guidelines and HTS standards of care guidelines
3. HTS providers trained and certified by type and
number
4. HTS providers trained and certified in HIV testing and
Quality assurance and control
5. Facilities with tracer HTS commodities and supplies in
stock
6. Counseling and laboratory personnel who have
received refresher training
7. Facilities offering HTS visited by technical support
supervision and mentorship teams at least 4 times
every 12 months.
The MoH aims at achieving 90% in each of the above
indicators

9.3 Quality of care indicators


Proportion of Facilities offering HTS;

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1. In accordance with the counselling guidelines for the
different populations and ages
2. As per the national HIV testing algorithms
3. Following the HIV testing SOPs
4. And accurately filing the HTS client card
5. And accurately filing the Daily HIV Testing Activity
register
6. And accurately filing the HTS register
7. Passing the QC tests
8. Passing the proficiency test
The MoH aims at achieving 90% in each of the above
indicators

9.4 Outcome indicators


1. Proportion of individuals classified as priority
populations offered HTS
2. Proportion of individuals identified HIV positive
3. Proportion of individuals testing positive who are
linked to HIV treatment, care and support services

10.0 Desired Policy Outcomes


By 2020, the following are the desired outcomes of this
policy and implementation guidelines;
• HTS Standards adhered to and quality HTS offered
• Equitable HTS services available in Uganda
• 90% of Priority populations reached with HTS
• 90% of estimated HIV infected persons identified
• 90% of identified HIV positive persons linked into
care

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11.0 Policy Performance Indicators
The following Key HTS indicators shall be monitored to
ensure that the desired outcomes of the policy are realised;
At input level;
1. 90% of HTS providers trained and certified to offer
HTS
2. 90% of HTS points/sites certified annually to offer
HTS
3. Lay Providers trained and certified to offer HTS
At Process,

1. 100% of Regional referral Hospitals, General


district hospitals, Health Centre IVs, Health Centre
IIIs offering quality HIV Testing Services

2. 50% of Health Centre IIs offering HIV testing


services

At Output/outcome indicators
1. 90% of HIV positive individuals identified
2. 90 % of HIV positive individuals identified linked
into care
3. Increased knowledge of HIV and AIDS
4. Increased adoption of safer sex behaviours
(reduction in multiple sexual partners, age at first
sex- using the UPHIA as baseline)

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12.0 Policy Implementation Framework
This section highlights the proposed framework for
ensuring implementation of the policy guidelines to
improve HIV testing services.

At National Level, the Uganda AIDS Commission (UAC)


shall provide the overall coordination of the multi-
sectoral response to HIV and AIDS in Uganda including
provision of leadership for planning, implementation and
monitoring of HTS by different stakeholders.

The Ministry of Health (MOH), through the STD/AIDS


Control Programme (ACP) shall coordinate the technical
aspects of implementation, monitoring and evaluation of
HIV testing services in Uganda. The ACP shall fulfill this
mandate through a National HIV Counseling and Testing
Committee (NCTC) comprising of representation from
key HTS organizations and development partners.

The NCTC is constituted into sub-committees which


provide oversight technical support to ACP in key areas
of the HTS cascade. These technical areas are handled by
the different sub committees namely;
• Policy and Research
• Laboratory services and supply chain
• Quality Assurance, Monitoring and Evaluation
• Capacity building
• Social mobilisation and Communication

Through ACP, MOH is responsible for:


• Developing a Priority Action plan for HTS

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• Coordination of ADPs funding to support HTS
priority areas
• Coordination of HTS partners
• Planning, policy formulation and setting standards
• Capacity building
• Advocacy and resource mobilisation
• Equitable distribution of HTS services across the
country
• Supplies and logistics management
• Quality assurance, monitoring and evaluation
• Research

At District level;
The District Health Officer (DHO) through the district
HTS Focal Person shall coordinate and ensure effective
implementation, supervision and monitoring of HTS
within the district.

The district HTS Focal Person should be responsible for:


• Profiling HTS partners in the district and developing
a directory
• Coordination of HTS partners at district level
• Coordinating joint planning, implementation,
monitoring and supervision of HTS activities within
the district.
• Advocacy and resource mobilisation to implement
district based HTS
• Conduct demand creation for HTS services
• Conducting community assessments and identify
priority areas and populations for HTS
• Supervising HTS delivery at district Level

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• Managing HTS supplies and logistics
• Data management and reporting about HTS in the
district
• Quality Assurance of HTS
• Ensure adequate supply of HTS supplies and
commodities

At Health Facility level


The health facility In-charge through a designated health
facility HTS Focal Person shall coordinate and ensure
effective implementation of HTS within the health facility.
The health facility HTS Focal Person should be responsible
for:
• Internal support supervision and mentoring of
service providers
• Timely and accurate ordering of HTS supplies and
commodities.
• Effective referral and linkage for prevention, care
and treatment services
• Good data management and timely reporting
• Demand creation for HTS including community
mobilisation
• Coordinate implementation of targeted community
HTS services

The role of Implementing Partners


Implementing Partners remain a critical partner in the
provision of HTS in Uganda. They should support the
districts to;
• Disseminate and distribute the HTS policy and
implementation guidelinesalong the decentralized
district health systems.

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• Reinforce adherence to and use of the HTS policy
and implementation guidelines during provision
of HTS
• Build capacity of HTS providers through training,
mentorship, and assessment for certification
• Implement, monitor and report HIV testing services
• Ensure HTS sites participate in EQA for HIV testing
through working with UVRI. IP should make sure
HIV testers and not just sites participate in EQA,
and feedback from UVRI to sites is prompt.
• Ensure sites are using all nationally approved data
collection tools and conduct quarterly DQA
• Ensure sites receive adequate support supervision
for both HIV testing and HIV counseling.

The role of ADPs


Over 90% of Uganda’s HIV and AIDS response is
financed by AIDS Development Partners (ADPs), thus
key stakeholders for HTS implementation. Specific roles
for ADPs should include;
• Provide technical assistance to the HTS program
in planning, implementation, monitoring, quality
assurance and evaluation
• Build local capacities for technical assistance in
HTS programming
• Finance HTS activities
• Provide technical Assistance and finance research
for HTS
Figure 11 below shows the coordination structure for HTS
in Uganda.

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National Implementation guidelines for HTS in Uganda, October 2016
Figure 11: National HTS Coordination structure

UAC NCTC

Lab &
MOH Top Logistics
Management
SBCC
National
STD/ACP Level
Cap.
Building
HTS Unit
Policy &
Research

QA & M&E

District Health
Office District
Level
District DLFP
HTS FP
HUB
Coordinator
HF I/C HTS
Delivery
Point
HF HTS FP

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13.0 Policy Review Plan
The National HTS Policy shall be reviewed every 5 years.
This is in alignment with the National HIV and AIDS
Strategic Planning process.

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14.0 References
1. MOH 2014, Minsterial Directive on Access to
Health Services without Discrimination
2. UAC 2015, 2014 Uganda HIV and AIDS Progress
Report
3. MOH 2012, Client Charter 2012/13-2014/15
4. MOH 2011, Monitoring and Evaluation Plan
for Heath Sector Strategic and Investment Plan
2010/11-2014/15
5. UAC 2015, The National HIV and AIDS
Monitoring and Evaluation Plan 2015/2016-
2019/2020
6. MOH 2011, Uganda HIV Counseling and Testing
Policy, 3rd Edition
7. UAC 2015, National HIV and AIDS Strategic Plan
2015/2016- 2019/2020
8. UAC 2015, National HIV and AIDS Priority
Action Plan 2015/2016-2017/2018
9. MOH 2010, National ABC Policy guidelines for
HIV/AIDS
10. MOH 2010, Safe Male Circumcision Policy
11. MOH 2011, Uganda Antiretroviral Therapy Policy
12. MOH 2011, Uganda National Malaria control
Policy
13. MOH 1999, National Health Policy
14. MOH 2011, The Integrated National Guidelines
on ART, PMTCT and Infant and Young Child
Feeding, 1st Edition
15. MOH 2013, Uganda National Infection Prevention
and Control Guidelines
16. UAC 2015, Lessons learned from the Uganda HIV

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National Implementation guidelines for HTS in Uganda, October 2016
and AIDS Country Response Progress Reporting ,
2015
17. MOH 2014, Addendum to the National
Antiretroviral Therapy Guidelines
18. MOH 2010, Health Sector Strategic and Investment
Plan 2010/11-2014/15
19. UAC 2015, Know your Epidemic, Know your
Response: Modes of HIV Transmission Study
20. MOH. (2006). Uganda HIV/AIDS Sero-
behavioural Survey, 2004-2005. MOH and ORC
Macro.
21. WHO 2015, Consolidated Guidelines on
HIV Testing: 5 Cs- Consent, Confidentiality,
Counseling, Correct Results and Connection
22. MOH 2016, Rapid Assessment Report of the
2010 HIV Counseling and Testing Policy and
Implementation Guidelines
23. UNHCR. (2009). Policy Statement on HIV Testing
and Counselling in Health Facilities for Refugees,
Internally Displaced Persons and other Persons of
Concern to UNHCR. UNHCR/WHO/UNDP.
24. WHO. (2010). Handbook for Improving HIV
Testing and Counselling Services. Field Test
Version. WHO.

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National Implementation guidelines for HTS in Uganda, October 2016
14.1 Annex 1. Policy Guidance for
development of HTS implementation
guidelines
These HTS implementation guidelines should operate
within the scope of the national, regional and international
polices; in alignment with national plans and harmony
with other MOH implementing guidelines.
International guidelines
• WHO Consolidated Guidelines for HIV Testing,
2015
• UNAIDS, 90*90*90 Fast Track Targets
• 65th UNGASS declaration to end the AIDS epidemic
as a public health threat by 2030
• The Sustainable Development Goals
Regional Guidelines
• The East African HIV Prevention and
Management Act 2012
National guidelines
• The Constitution of the Republic of Uganda
(3rdrevision, 15thFebruary 2006)
• The Penal Code, ACP 120.
• The Uganda HIV Prevention and Control Act(2014)
• The National Development Plan II(2016-2020)
• The National HIV and AIDS Strategic
Plan(2015/2016-2019/2020);
• The National HIV and AIDS Monitoring and
Evaluation Plan(2015/2016-2019/2020)
• The National HIV and AIDS Indicator
Handbook(2015/2016-2019/2020)
• The National HIV and AIDS Priority Action
Plan(2015/2016-201718)
• The National Health Policy(2010)

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• Uganda Adolescent Sexual Health and Development
Policy(2011)
• Ministerial Directive on Access to Health Services
without Discrimination (2014)
• The Uganda Patient’s Charter (2009)
• The National Integrated Antiretroviral Treatment
and Care Guidelines for Adults and Children 2009
• Addendum to the National Treatment Guidelines,
2014
• The National Policy Guidelines On Post Exposure
Prophylaxis For HIV, Hepatitis B And Hepatitis C,
2007
• The National Policy on Injection Safety and
Healthcare Waste Management
• Uganda Clinical Guidelines, 2003
• PMTCT Guidelines, September 2006
• National Infection Prevention and Control
Guidelines, 2004
• The Home based care policy guidelines
• The Uganda National Laboratory Policy, 2009
• Safe Male circumcision Policy, March 2010
• TB/HIV Collaboration policy

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14.2 Annex 2: Glossary of terms
Acute HIV Infection: Acute HIV infection is a highly
infectious phase of disease that lasts approximately
two months and is characterised by nonspecific
clinical symptoms. Acute HIV infection contributes
disproportionately to HIV transmission because it is
associated with a high viral load. HIV infection may not
be detected on antibody-based HIV tests only. Persons
who are in the phase of acute HIV infection often have flu-
like symptoms and may be core infectious than persons
with chronic HIV infection.

Attendant: A person who cares for someone who is ill.

Analytical sensitivity: This describes the smallest amount


of specimen containing (analyte) HIV-1/2 antibodies
and/or HIV-1 p24 antigen that an assay can accurately
measure/detect.

Analytical specificity: This referstothe ability of an assay


to identify a particular specimen (analyte) containing
HIV-1/2 antibodies and/or HIV p24 antigen, rather than
others, in a specimen and thus rule out false reactivity.

Antibody Rapid HIV Test: An antibody Test that


determines if an individual aged 18 months and above is
infected with HIV

An active referral: is one in which the tester makes an


appointment for the client or accompanies the client to the
appointment and enrolment into HIV clinical care.

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Care-giver: Any person other than a parent or guardian
who care for a child, including a foster parent; a person who
cares for a child with the implied or express permission
consent of a parent or guardian or a person who cares for
someone who is ill.

Client: An individual who seeks HIV counselling and/


or HIV testing and/or support for HIV/AIDS and related
conditions.

Client Initiated HIV testing and counselling: This is a type


of HIV testing and counselling in which persons actively
seek HTS, often at facilities that offer those services.

Couple counselling and testing: This is counselling


provided to sexual partners or intending sexual partners
to enable them take the test and receive results together.

Decentralization
Refers to the process of delegating or transferring
significant authority and resources from the central
ministry of health to other institutions or to field offices of
the ministry at other levels of the health system (regional,
district, health sub-district, primary health-care post and
the community)

Diagnostic sensitivity: This is defined as the percentage/
probability that an HIV test should correctly identify all
individuals who are infected with HIV as per used assay.

Diagnostic specificity: This is defined as the percentage/


probability that an HIV test assay should correctly identify

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all individuals that are not infected with HIV (true HIV-
negative).

Discordant couple: Sexual partners with one testing HIV


negative and the other testing HIV positive

Discordant test results: When one HIV test in an individual


is reactive and another test using a different HIV test in
the same individual, is non-reactive.

Disclosure: A process where a client the results of his


or her HIV test results with their partner, family, friend,
community members or care-givers, that is in the best
interest of the client and others for thepurpose of obtaining
their support from an emotional perspective as well as for
healthy life style choices that include active prevention
of the transmission of HIV to sexual partners or unborn
children.

Discrimination: Making an unjust distinction in dealing


with people on the basis of their revealed or assumed HIV
status, which results in them being denied opportunities,
benefits, care or services

Early infant diagnosis (EID): Testing of infants


todeterminetheir HIV sero-status,given that the infant
can be infected in utero, peripartum, postpartum or via
parental exposure

Free-standing sites: This is a site offering HTS services


that is not physically located in an existing health facility.
It may have limited care and support services for HIV/

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AIDS. It should therefore have a strong referral system
with other health services, and efforts should be made to
offer other related services such as AIDS care and support,
family planning and STD care in an integrated manner.

Generalized HIV epidemic: This is where HIV


is firmly established in the general population.
Although subpopulations at high risk may contribute
disproportionately to the spread of HIV, and sexual
networking in the general population is sufficient to sustain
the epidemic. In this case HIV prevalence is consistently
over 1% in pregnant women attending antenatal clinics.

Health-unit–based sites: These are sites located in an


existing health facility, preferably at a level IV health
centre and above, where capacity and associated HIV/
AIDS services are available. However, level III facilities
with adequate capacity should provide HTS. The health
facility may be either government or non-government.
HTS services at such a site should be integrated into
existing health services on a daily basis. However, if a
facility is short staffed, specialized HTS clinic days may
be established.

HIV testing algorithm: A combination and sequence of


HIV test assays that have been agreed upon b a reference
laboratory to represent HIV testing for a given purpose.

HIV Exposed Infant (HEI): Infants that are exposed to


HIV either during pregnancy, delivery, and through
breastfeeding or via maternal/parenteral exposure

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Index Testing or index case HIV testing: A focused
approach to HIV testing in which the household and
family members (including children) of people diagnosed
with HIV are offered HIV testing services.

Indeterminate Results: HIV indeterminate status is the


HIV status of an individual in whom the test results do
not lead to a definitive status (where HIV negative or HIV
positive).

Informed consent: A process by which a client voluntarily


confirms his or her willingness to provide written or verbal
consent to be tested for HIV or to provide information
about his or her HIV status to a health care provider or
researcher.

The agreement is obtained after the client has received


information about the HIV test and understands the
purpose of the procedure or after understanding the
purpose of the exchange of the information as being in the
best interest of his or her own health or that of the partner,
or in the case of a pregnant woman, the foetus or the baby
being breast fed.

Informed consent should be voluntary and conducted


according to the legal and ethical requirements outlined
in these guidelines.

Informed refusal: A process where a client with or


without clinical signs of opportunistic infections consults
a health care worker and is counselled and offered HIV
testing which the client refuses. Such a refusal should be

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recorded in the client’s file and signed by the client and
the health care worker.

Integration: Refers to the co-location and sharing of


services and resources across different disease areas In
the context of HIV, this may include the provision of
HIV testing, prevention, treatment and care services
alongside other health services, such as TB, STI, HBV and
HCV services, antenatal care, contraceptive and other
family planning services, and screening and care for other
conditions, including non-communicable diseases.

Integrated service delivery: This is a service delivery


approach that encourages and allows the health care
provider to review the client as whole, assessing needs
beyond the primary reason for the visit. This provides
the basis for providing additional services or referring the
client to receive services from another provider or facility.
Its aim is to increase the efficiency of service delivery and
reduce stigma associated with HIV/AIDS.

Internally Displaced Persons: People or groups of people


who have been forced to leave their homes or places of
habitual residence, in particular as a result, or in order to
avoid the effects of armed conflict, situations of generalized
violence, violation of human rights or natural-or human-
made disasters, and who have not crossed an international
border.

Key populations: Key populations are defined groups


who, due to specific higher-risk behaviours, are at increased
risk for HIV infection irrespective of the epidemic type or
local context. Key Populations in Uganda as specified by

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the National HIV Prevention strategy are: Sex Workers,
Fisher Folk, Long distance Truck drivers, men who have
sex with men (MSM), people in prisons and other closed
settings, boda-boda men and the Uniformed Personnel.

Persons at high risk: These include heterosexual persons


who have engaged in unprotected sex with someone of
unknown or known HIV negative status, or have had sex
with someone who has engaged in unprotected sex since
their most recent HIV test.

Priority Populations: Populations with increased risks


of HIV infection and transmission; yet have limited
access to HTS. They include Key Populations, Vulnerable
populations and populations with limited access.

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
to provide health–care delivery services.

Next of kin: Spouse or close blood relative

Non reactive: Refers to an HIV antibody or HIV antigen/


antibody test that does not show a reaction to indicate the
presence of HIV antibody and/or antigen.

Outreach sites: This refers to sites where HTS services


should be offered outside a health facility setting. This
could be in smaller health facilities such as levels II and III
and sites mentioned in the home based HTS models like

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workplaces, school establishments with a mechanism for
ongoing support services for HTS clients.

Persons of concern to UNHCR: Refers to refugees,


internally displaced persons, stateless persons and other
persons of concern to UNHCR

Pre-test information: A dialogue and the provision of


accurate information by a trained lay provider or health
worker before an HIV test is performed

Provider-initiated HIV testing and counselling: This


is HIV testing and counselling offered by health care
providers to persons attending health care facilities,
as a standard component of medical care. It offers an
opportunity to the client to opt in or opt out of the HIV
test.

Quality Assurance (QA): Is a part of quality management


focused on providing confidence that quality requirements
should be fulfilled. Any arrangement that safeguards
maintains or promotes the quality of HIV counselling
and testing services according to defined national and
international standards.

Quality control (QC):Is a material or mechanism which,


when used with or as part of a test system (assay), monitors
the analytical performance of that test system (assay). It
may monitor the entire test system (assay) or only one
aspect of it. Effective management and support to ensure
that standard operating procedures stipulated at each
service point are adhered to in order to ensure provision of

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quality HIV Testing services according to defined national
and international standards.

Quality improvement (QI): Isa part of quality


management focused on increasing the ability to fulfil
quality requirements

Reactive: Refers to an HIV antibody or HIV antigen/


antibody test, which shows a reaction to indicate the
presence of HIV antibody and/or antigen

Refugees: People who are outside their country of


nationality or habitual residence, and have a well-founded
fear of persecution due to their race, religion, nationality
membership of a particular social group or political
opinion

Repeat testing: Refers to a situation where additional


testing is performed on an individual immediately
following a first test during the same testing visit due to
inconclusive or discordant test results; the same assays are
used and, where possible, the same specimen.

Retesting: Refers to a situation where additional testing is


performed for an individual after a defined period of time
for explicit reasons, such as a specific incident of possible
HIV exposure, such as unprotected sexual intercourse.
Retesting is always performed on a new specimen and
may or may not use the same tests as the one at the initial
test visit.

Risk-reduction counselling: Counselling with a client


that focuses on HIV risk behaviour and the acquisition or

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transmission of HIV with the goal of getting the client to
assess their behaviour and reduce their risk of infection.

Shared confidentiality: Other health workers providing


direct care to ma access a client’s medical information
with the client’s consent and for the purpose of providing
the continuum of care to the client

Sensitivity: This is the probability that an HIV test should


correctly identify all individuals who are infected with
HIV.

Sero conversion: Refers to a period from HIV infection to


when sufficient quantity of HIV antibodies are produced
by an individual to become detectable on a given HIV
antibody and/or antigen test.

Sero-conversion sensitivity: This refers to the ability of


an HIV assay to detect HIV infection during or soon after
sero-conversion.

Service provider: Any person qualified to provide a


service for the benefit of the client.

Specificity: This is the probability that an HIV test should


correctly identify all individuals that are not infected with
HIV.

Stigma: These are negative attitudes or perceptions of


towards individuals who are known or perceived to be
infected or affected by a condition such as HIV/AIDS.

Task sharing: This refers to the rational redistribution of

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tasks between cadres of health-care providers with longer
training and other cadres with shorter training, such as
trained lay health services providers.

Trimester: Refers to three month intervals of a woman’s


pregnancy. The first trimester is the period of pregnancy
from the first day of the last menstrual period through
completion of 14 weeks. The second trimester is the period
between the 15th and 28th week and the third trimester the
period of pregnancy from the beginning of the 29th through
the 42nd completed week of gestation.

Voluntary HIV testing and counselling: A type of HIV


testing and counselling model in which persons actively
seek HIV Testing services out of their own initiative, often
at facilities that offer these services.

Vulnerable Populations: These are persons that are


highly susceptible to or unable to protect themselves from
significant harm or exploitation linked with HIV infection.

Window period: This refers to a period of time from


when a person is suspected to have been infected with
HIV to when HIV antibodies can be detected by a given
HIV test assay. The window period varies from person to
person and also depend on the HIV test assay used (1st,
2nd, 3rd and 4th generation tests assays). The mean time
from exposure to development of antibodies is about one
month. Most people should develop antibodies by 3-4
months.

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The policy and guidelines were developed with support from
the following partners:-

PEPFAR