LECTURE SIX

HIV TESTING SERVICES AND LINKAGE TO TREATMENT &

PREVENTION

Expected Learning Outcomes

At the end of this lecture the learner should be able to:
1. Explain the process of HIV testing and counselling
2. Identify various HIV Tests available
3. Describe the process of linking HIV testing to care

HIV TESTING
The news about the percentage of people in our surrounding who are HIV positive
makes many become anxious about their own HIV status. Again news about the
death from AIDS complications of a neighbour, relation or friend, worries most
people as to whether or not they have HIV. In order to get those worries allayed, we
need to do a test for HIV.

Who should be tested?

Testing is recommended for those who:

1. Have multiple sexual partner (2 or more sexual partner in the last 12 months)
2. Have received a blood transfusion recently in a place where blood is not screened
before transfusion, or if a sexual partner received a transfusion and later tested
positive for HIV.
3. Are uncertain about their sexual partner’s risk behaviour.
4. Are homosexuals.
5. Have used street drugs by injection especially when sharing needles and/or other
equipment.
6. Have a sexually transmitted diseases (STD), including pelvic inflammatory
diseases (PID).
7. Are health care workers with direct exposure to blood on the job?
8. Want to make sure they are not infected with HIV before getting pregnant.
9. Are infected with tuberculosis.
Note: Even if one does not have risk factors for HIV infection, one may still want
to get tested to ease their own mind. Getting tested for HIV also encourages
everyone to be more responsible about HIV transmission.

HIV COUNSELLING & TESTING

What is HIV counseling?
HIV/AIDS counseling/education is a confidential dialogue between a client and a
counselor aimed at providing information on HIV/AIDS and bringing about
behavior change in the client. It is also aimed at enabling the client to take a
decision regarding HIV testing and to understand the implications of the test
results and in any case must observe the “five C’s” • Consent,
Confidentiality, Counselling, Correct results and Connection (linkage) can be
assured

Components of voluntary counseling & testing (VCT):

1. Knowledge of status is voluntary
2. Pre-Test Counselling is offered either through one or more sessions with a
trained counsellor, after which the client may choose to test on the same or
different day
3. Informed Consent is obtained from the client by the service provider
4. HIV Test is performed using approved HIV test kits and testing protocols
5. Post Test Counselling (one or more sessions) that includes informing clients of
their HIV test results takes place on the same or different day

HIV TESTING
Since HIV was first identified as the cause of AIDS in 1983, a variety of tests have
been developed for diagnosing HIV infection as well as determine how far the
infection has progressed. Doctors determine if HIV is present in the body by
identifying HIV antibodies. The presence of the antibodies indicates HIV infection
because these antibodies form in the body only when HIV is present.

HIV antibodies form anywhere from five weeks to three months after HIV infection
occurs depending upon the individual’s immune system. The antibodies are
produced continually throughout the course of the infection. A variety of HIV
antibody tests are available. They are broadly classified into three groups: rapid tests,
Enzyme Linked Immunosorbent Assay (ELISA), and Western blot test. Most current
HIV antibody tests are capable of detecting antibodies to both HIV-1 and HIV-2.

Types of HIV Tests

Antibody Tests: The most common HIV tests look for HIV antibodies in your body,
rather than looking for HIV itself:

1. Enzyme-linked assay called an ELISA or EIA. (EIA) tests use blood, oral
fluid, or urine to detect HIV antibodies. Results for these tests can take up to
two weeks.
2. Rapid HIV antibody tests also use blood, oral fluid, or urine to detect HIV
antibodies. Results for these tests can take 10–20 minutes.

If you get a positive result from either of these tests, you will need to take another
test, called a Western blot test, to confirm that result. It can take up to two weeks to
confirm a positive result.

Antigen Tests
These tests are not as common as antibody tests, but they can be used to diagnose
HIV infection earlier from 1-3 weeks after you are first infected with HIV. Antigen
tests require a blood sample.

PCR Test (Polymerase chain reaction test)

This test detects the genetic material of HIV itself, and can identify HIV in the
blood within 2-3 weeks of infection.

Babies born to HIV-positive mothers are tested with a special PCR test, because their
blood contains their mother's HIV antibodies for several months. This means they
would test HIV-positive on a standard antibody test but a PCR test can determine
whether the babies have HIV themselves.

PCR tests are also used to measure viral loads for people who are HIV-positive.

HIV TESTING SERVICES AND LINKAGE TO TREATMENT &

PREVENTION
HIV testing services (HTS) provide the first critical link to comprehensive HIV
treatment and prevention. Additionally, this initial step provides opportunities to
offer other interventions such as sexual and reproductive health services, TB
screening and referral, substance abuse screening and referral, information and
referral for voluntary medical male circumcision, pre-exposure prophylaxis (PrEP),
post-exposure prophylaxis (PEP) and other combination HIV prevention services.

HIV testing should be voluntary and conducted ethically in an environment where

the five Cs of:
 Consent
 Confidentiality
 Counselling
 Correct results and
 Connection (linkage) can be assured

SETTINGS FOR HIV TESTING

To optimize access to testing services, HIV testing can be conducted in 3 different

settings:
(1) Facility-based (2) Community-based (3) Self-testing

Facility-based testing:
 Routine opt-out provider initiated HIV testing and counselling (PITC)
should be offered to ALL clients (including infants, children, adolescents
and adults) visiting health facilities regardless of the reasons for contact
with the health facility.
 As much as possible, provider initiated HIV testing and counselling
(PITC) is integrated into care pathways at all service delivery points.
 Patients starting HIV care should receive disclosure counselling and
support followed by family testing.

Community-based testing:
 Targeted community based HIV testing services (HTS) offers additional
opportunities to identify and link to treatment and prevention, people living
with HIV (PLHIV) of unknown HIV status.
 This setting is especially important for testing children and partners of index
clients through family-based testing and counselling; outreach to key
populations as well as orphans and vulnerable children (OVCs), and;
adolescents.

HIV self-testing (HIVST):

  HIVST allows individuals to collect their own specimen, perform the test,
and interpret the results on their own.
 If positive, a confirmatory test must be performed by a trained HTS provider
(facility-based or community-based) following the national testing algorithm
 Uptake of HIVST is improved with availability of easy-to-use testing
methods such as oral/ saliva-based tests
 These can be issued from health facilities and pharmacies or through
outreach programs
 HIVST may have the greatest benefit in reaching specific populations such
as key populations; partners of pregnant women attending antenatal clinic
(ANC); contacts of patients treated for sexually transmitted infections
(STIs); highly stigmatized populations; healthcare workers; and frequent re-
testers

PARTNER NOTIFICATION AND FAMILY-BASED INDEX CASE

TESTING

What Is the Partner Notification?

Partner Notification: voluntary process where counsellors and/or health care
workers ask index clients to list all of their: (1) sexual or injecting drug use
partners within the past year, and (2) children.
Index client: an individual newly diagnosed as HIV-positive and/or an HIV-
positive individual who is enrolled in HIV treatment services
After obtaining consent from the index client, each listed partner and child is: (1)
contacted, (2) informed that they have been exposed to HIV, and (3) offered
voluntary HIV testing services (HTS).
Goal of partner notification is to break the chain of HIV transmission by offering
HTS to persons who have been exposed to HIV and linking them to: HIV
treatment, if positive, or
Prevention services (e.g. VMMC, PrEP, condoms), if negative.
OPTIONS FOR NOTIFYING YOUR PARTNER ABOUT HIV
1. Client Referral = You tell your partner about your HIV and encourage him
or her to come to the health facility for an HIV test.
2. Provider Referral = A counsellor or other health care provider will call or
visit your partner and inform them that they need to test for HIV.
3. Contract Referral = You and the counsellor will work together to notify
your partner. You will have 30 days to tell your partner. After which, the
counsellor will contact your partner after getting your permission.

PRINCIPLES OF PARTNER NOTIFICATION SERVICES

 Client centered = partner notification services should be focused on the
needs and safety of the index client and his or her partner(s) and child(ren)
 Client chooses the best option for his/her circumstances
 Delivered in a non-judgmental manner.
 Confidential = both the confidentiality of the index client and all named
partners and children should be maintained at all times. The identity of the
index client should not be revealed and no information about partners should
be conveyed back to the index client (unless explicit consent from all parties
is obtained).
 Voluntary and non-coercive = participation should be voluntary for both the
index client and his or her partner(s) and child(ren)
 Accessible and available to all = partner notification should be available to
all index clients regardless of where they are diagnosed (e.g. in a health
facility or community setting).
  Comprehensive and integrative = partner notification services should include
strong referral and linkages to HIV treatment and prevention services

PACKAGE OF HIV TESTING SERVICES

Pre-test counselling/Pre-test information

 Client-initiated HT (CITC)
 Introduction and orientation to session
 Risk assessment
 Consent for the test
 Provider Initiated HT (PITC) in health facility setting
 Introduction and information on importance of testing for HIV
 Consent for the test
 Test preparation

Post-test counselling for negative results

 Risk reduction plan
 Linkage to other HIV prevention services
 Re-testing where applicable

Post-test counselling for positive results

 Enrolment into treatment and prevention
 Risk reduction and positive living counselling
 Partner/family testing

Assessment of other health-related conditions or needs

 HTS provider should assess all clients for other health related
conditions/issues, e.g.:
• Tuberculosis • STIs and cancer screening • eMTCT
• Family planning • Alcoholism •
Psychosocial issues
• Gender-based violence (GBV) • Voluntary medical male circumcision
(VMMC) • Non-communicable diseases

Clients who test HIV negative should have a risk assessment and be
offered/referred to appropriate combination prevention services including:
 TB screening, STI screening and treatment, family planning, provision of
condoms, VMMC, cervical cancer screening, gender based violence
recovery services, alcohol and substance abuse services, pre-exposure
 prophylaxis (PrEP), post exposure prophylaxis (PEP), mental health and
psychological support, and couples counselling and testing

Post-test counselling should, at a minimum, include three key messages that

begin the ART treatment preparation process for all PLHIV:
 Treatment (called antiretroviral therapy or ART) is available and is
recommended for everyone with HIV
 Starting treatment as soon as possible (preferably within two weeks of
testing positive for HIV) reduces the chance of your illness getting worse or
of passing HIV to others
 If you take your ART properly and do not miss pills you can expect to live a
long and productive life

Linkage from HIV Testing to Treatment and Prevention

 Patients with confirmed HIV infection are linked to treatment and
prevention expeditiously this includes:
 Providing information, disclosure, addressing barriers to linkage,
establishing systems to facilitate linkage, care coordination and integration,
and using a linkage register.

 Information
 Quality post-test counselling includes information about the nature and
availability of additional HIV-related services, description of the next steps
in treatment and prevention including entire treatment plan and follow-up
visits and schedule
 The benefits of immediate assessment and early initiation of ART
 Patient involvement in the decision making process regarding treatment and
prevention (especially where and when to start ART)

 Disclosure
 Disclosure to a trusted ‘significant other’ promotes linkage and adherence to
treatment
 Encourage and help the patient to discuss HIV status with a trusted friend or
close relative
 Encourage adolescents to identify and invite a supportive adult or friend to
support them

 Barriers to Linkage
 During post-test counselling, barriers to linkage are identified and addressed
  System to Facilitate Linkage
 The HTS provider is responsible for linkage into care
 Linkage is done to on-site treatment and prevention services through patient
escorts
 Where this is not possible (due to patient preference or the services are not
available), the testing facility the books the appointment with the receiving
facility and follow-up to ensure the patient registers at the receiving facility
 Retention and loss-to-follow up tracking systems are used to ensure linkage
is successful. These include enlisting the help of peer or buddy systems,
SMS reminders, phone calls and community outreach workers to escort HIV
positive clients to enrolment

 Care Coordination and Integration

 Coordinated and treatment PLHIV include: mother-baby pairs, partners and
families together
 Integrate common services offered to PLHIV include: TB diagnosis and
treatment, family planning, cervical screening, nutrition etc.

SUMMARY
In this lecture we have learnt the process of HIV testing and counselling. We
were able to identify various HIV Tests available and described the process of
linking HIV testing to care.

Further reading
Refer to the ART Guidelines (2016) Section 2.2.3: Diagnosis of HIV Infection in
the Older Child (>18 months), Adolescents and Adults

Activity
Jay is a 2o-year-old college student. She has been in a relationship with Mar for
the last two semester and Mar does not know his HIV status. She develops
nausea and vomiting for 3 days, and goes to the university clinic with the above
history. Her last menstrual period was 6 weeks ago and she has not been using
contraception.
Based on their history, which tests do Jay and Mar require to take?