A Giant Leap Toward the First 90: WHO Releases New HIV Testing Guidance at IAS 2015 in Vancouver

 

The UNAIDS 90-90-90 Treatment Target set a high bar for the HIV community, and on July 19, at the 8th International AIDS Society Conference in Vancouver, I attended the launch of new WHO guidelines designed to help countries vault toward the first of the three UNAIDS goals.

The 90-90-90 strategy specifies:

  • By 2020, 90% of all people living with HIV will know their HIV status.
  • By 2020, 90% of all people with diagnosed HIV infection will receive sustained antiretroviral therapy.
  • By 2020, 90% of all people receiving antiretroviral therapy will have viral suppression.

We know that the first target—ensuring that 90% of people living with HIV know their status—is arguably the hardest to achieve, as currently, nearly half of people living with HIV do not. In order to address this deficit, WHO has suggested that “countries need to improve the effectiveness of their HIV testing services and reach people with HIV who are undiagnosed so they can be linked to HIV prevention, care and treatment.”

In the release of the new guidelines, WHO emphasized quality, efficiency yield, and linkage to prevention, care, and treatment. Key takeaways and recommendations from the new guidelines include:

  1. The 5 C’s: Consent, Confidentiality, Counseling, Correct Results, & Connection
    All forms of HIV testing should adhere to the WHO 5 Cs. Clients must give informed consent to be tested and counseled. HIV testing must be confidential—what the provider and client discuss should not be disclosed to anyone else without the expressed consent of the person being tested. All HIV testing must be accompanied by appropriate post-test counseling and providers of HIV testing should provide high-quality services that ensure people receive a correct diagnosis. Linkage to prevention, treatment, and care services should include effective follow-up, including long-term prevention and treatment support.
  2. The Role of Lay Providers
    Lay providers who are trained can, using rapid diagnostic tests, independently conduct safe and effective HIV testing services—a crucial step forward if the ambitious 90-90-90 targets are to be met.
  3. Test for Triage
    In the new guidelines, WHO proposes a new approach for testing in community settings known as “test for triage.” In this approach, a single rapid diagnostic test (RDT) is offered with linkage to further testing in a facility to confirm an HIV-positive diagnosis and start clinical care (when needed).
  4. HIV Self-Testing
    WHO also emphasizes the role HIV self-testing (HIVST) can play as an entry point to appropriate health-seeking behavior, since care and treatment is now widely available. However, reactive HIVST results should be confirmed by a trained healthcare provider. The potential benefits of HIVST, related issues, and potential concerns should be weighed and considered carefully.

In the same session at the conference, WHO also shared its new plans to help countries achieve the second and third UNAIDS targets. The recommendation to follow the “test-and-treat” policy going forward will shape the upcoming December 2015 update to the consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV and the new 2015 consolidated strategic information guidelines for HIV in the health sector.

These are exciting times. With 15 million people already on treatment, the strong feeling is that the final chapter of the AIDS epidemic is currently being written—most remarkably in the very same city where, during the 1996 International Conference on AIDS, the modern highly-active combination ART era as we know it was launched under the prophetic theme of ‘One World, One Hope!’ It is my hope that the new WHO HIV testing guidelines will help us move toward achieving our goal of an AIDS-free generation.

The Strengthening High-Impact Interventions for an AIDS-free Generation (AIDSFree) project aims to improve the quality and effectiveness of high-impact, evidence-based HIV and AIDS interventions such as HIV testing services.