Session 3: Fundamentals of HIV Testing Services

HTS Delivery Approaches

In Zimbabwe, HTS is delivered in a variety of ways. In this section we will review the different models in HTS. We will then review the guiding principles of HTS and discuss linkage to different post-test services.

Learning Objectives

By the end of this session, you will be able to:

• Explain the different approaches used in HTS.
• Explain the guiding principles in HTS.
• Explain rapid HIV testing quality assurance and its importance.
• Link clients/patients to different post-test services.

Learning Activities

• HTS Delivery Models (5 min)

  The importance of early identification of people living with HIV (PLHIV) so that they access relevant HIV prevention, treatment, care and support services early necessitates that various approaches be used in reaching them. In Zimbabwe the two complimentary models that are utilized in the provision of HTS are the facility-based model and the community-based model. Tap on each model to read more.

  • Facility-based model
  • Community-based model

  Facility-based model

  HTS should be provided with other services being offered in health care facilities in the public, private, and NGO sectors. Provider initiated testing and counselling (PITC) services should be provided at all entry points to all clients (adults, adolescents, and children) attending all health facilities as the recommended “standard of care”. Examples of entry points include antenatal care (ANC), tuberculosis (TB), and outpatient clinics; inpatient wards SRH, and VMMC services. Services can be offered through PITC, client initiated HIV testing and counselling (CITC), index-case testing and self-testing.

  Community-based model

  Community-based HIV testing and counselling (CBHTS) refers to HTS provided in community settings. It contributes to reduction in stigma and discrimination by removing social barriers to HTS. Through increased access to services, more people can access HIV prevention, treatment, care, and support services. CBHTC increases access to HIV testing (reduced cost of transportation to CITC sites or health facilities; convenient for family members; enhances privacy; helps reduce stigma). It promotes behaviour change leading to the reduction of HIV transmission while increasing access for couple/partners HTS and enhances disclosure. It provides an opportunity to address HIV discordance among couples/partners. Different settings/approaches can be used to provide CBHTC as follows: home based, including index case testing; mobile and outreach, workplace, educational institutions, campaigns, and self-testing.

• HTS Approaches (10 min)

  Tap on each type of HIV test to read more about it.

  • Provider-initiated testing and counseling approach
  • Client-initiated testing and counseling
  • HIV self-testing
  • Facility and community index case testing
  • Mobile outreach and HTS campaigns

  Provider-initiated testing and counselling approach (PITC)

  PITC is mainly a facility-based approach. It refers to HTC recommended by health care providers to people attending health care facilities as a standard component of care. PITC is not mandatory HIV testing, neither is it HIV testing without an informed consent. The pre-test information giving approach is preferably a group education session, followed by an offer of rapid HIV testing where the client can choose to proceed or opt out. Those who opt out require individual pre-test counselling and continuous offer.

  Client-initiated testing and counselling (CITC)

  Client-initiated HIV testing and counselling is conducted in a wide variety of settings including health facilities, stand-alone facilities outside health institutions, through mobile services, in community-based settings, and even in people’s homes. Previously referred to as voluntary counselling and testing (VCT), in the CITC approach, the client voluntarily decides to learn about his or her HIV status. A provider gives pre-test information, then performs the HIV test, and gives post-test counselling. CITC identifies HIV-negative individuals and allows service providers to encourage behaviour change, help prevent primary or secondary HIV infection, and link people to post-test services (VMMC, RH, VIAC, etc.). This approach usually targets the “worried well.”

  HIV self-testing (HIVST)

  HIV self-testing refers to a process in which a person collects his or her own specimen (oral fluid or blood) and then performs a test and interprets the result, often in private or with someone he or she trusts. HIVST is offered as an additional approach to HIV testing services. It does not provide a definitive HIV-positive diagnosis, because a reactive (positive) self-test result always requires further testing from a trained testing provider using the relevant validated national testing algorithm. People who test positive during self-testing need to confirm the positive test at a health facility. If they test positive with confirmatory test they are then linked to treatment and care.

  HIVST is a promising and innovative model which may increase testing uptake.

  Watch the video to learn more about the process of HIV self-testing.

  Facility and community index case tsting

  Index case testing can be provided at the facility and in the community. The HIV-positive client is the index case. Family members and all sexual partners of an HIV positive client should be offered HTS. This may be offered at the facility (with community-based support to encourage testing) or through community-based index case testing by a counsellor, nurse, trained community health worker (CHW), or expert client (using HIV self-testing kits). You can also offer HIV self-testing kits to the index case.

  Mobile outreach and HTS campaigns

  HTS campaigns can take different forms including service provision through mobile or outreach services, creating awareness and directing clients to service provision sites, and as part of disease prevention campaigns (such as malaria campaigns). They can vary in duration and can target specific populations, such as couples or youths, or be in commemoration of specific events, such as World AIDS day.

• The HIV Testing Service Package (5 min)

  The components of the HIV testing service package includes:

  • Pre-test information giving
  • Conducting the HIV test
  • Post- test counselling
  • Follow up Counselling and referrals

  We will go more into the counselling sessions shortly.

  HTS services must also coordinate with laboratory services to support quality assurance and delivery of correct results.

  With the introduction of treat all three key messages must be given in the post test counselling for those testing positive:

  1. Treatment is available for all people living with HIV and retesting to verify status is done before ART initiation
  2. Starting treatment as soon as possible will prevent your health from worsening and also prevent transmission to others
  3. Taking ART properly will allow you to live a long and fulfilling life

  All HIV Testing Services in Zimbabwe should be conducted in accordance with the best interest of the client (child, adolescent or adult). HIV testing should never be coercive or mandatory, except in unique situations such as court orders.

• HTS Guiding Principles (5 min)

  All forms of HTS should be voluntary and adhere to the following “5Cs” guiding principles. For women in labour, an additional C is added for “comfort”. See the Session 12 for more information about that C.

  Tap on the tabs below to learn more about each of the “Cs”

  • Consent
  • Confidentiality
  • Counselling
  • Correct and accurate results
  • Connections to post-test services

  Consent

  Always get informed consent for HIV testing, including during labour: your client must receive clear and accurate information about HIV testing, and you as the tester must respect the client’s right to decide whether to be tested.

  Three crucial elements are necessary in obtaining informed consent for HIV testing:

  • Providing pre-test information on the purpose of testing (see HTS Guidelines).
  • Ensuring client is informed of post-test HIV prevention, treatment, care and support services that are available.
  • Confirming understanding by the client, while respecting their autonomy.

  These elements must be in place for a client to make a fully informed decision on whether or not to be tested for HIV. In addition, a client has the right to withdraw their consent at any time, even after blood has been taken for HIV testing.

  Confidentiality

  Discussions between the service provider and the client should not be disclosed to anyone without the permission of the client. Inform the client of shared confidentiality and ensure proper storage and disposal of client records in accordance with appropriate standards of confidentiality.

  Confidentiality in the provision of HTS must be protected at all times. The client’s privacy should be respected including information shared by the client during pre and post-test counselling and the test results. Service providers should offer the highest possible levels of confidentiality to respect the client’s privacy and create the trust necessary for counselling. Any limitation on the degree of confidentiality is likely to diminish the effectiveness of counselling.

  Counselling

  The client can receive high-quality group education or individual pre-test information or pre-test counselling followed by individual post-test counselling, including ongoing/supportive counselling and adherence counselling to ART when needed.

  Correct and accurate results

  Correct and accurate HIV test results should be provided by trained service providers with support for internal control and external quality assessment from the laboratory personnel as stipulated in the national rapid HIV testing QA/QC protocols.

  Connections to post-test services

  Connections to HIV prevention, treatment, care, and support services must be in place with follow-up services and appropriate long-term HIV treatment, care, and support for those who test HIV-positive. Clients who test HIV-negative should be linked to HIV prevention services focusing on risk reduction and the need to remain HIV-negative.

• Minimum Package for Prevention, Care, and Treatment (5 min)

  When counselling clients, be sure that they understand:

  • The clinical and prevention benefits of testing
  • Their right to defer testing, testing process
  • The follow-up services that will be offered
  • Issues around importance of disclosure

  For clients who have self-tested for HIV, ask them why you are following up (linkage to prevention or confirmatory testing). Be sure to praise them for coming in and following up on their test result.

  If a client is requesting linkages for prevention, provide an explanation of HIV prevention methods. Refer male clients for VMMC site and explore and address any barriers to VMMC.

  If a client is requesting confirmatory testing after HIV ST, offer HIV testing using the national algorithm.

  Ask clients about their experience using the HIVST. Did they have:

  • Any challenges using the test?
  • Any challenges interpreting the test?
  • Any instance of harm?
• Index Client Testing (10 min)

  As mentioned earlier, index client testing is an approach that is now being used in HTS.

  Tap on each step to learn more about index client testing.

  

  Step 1

  • Client test HIV positive
  • Ask client to consent/assent for partner and family testing as well as client follow up

  ×

  Step 2

  List all family members on page 5 of the patient care and treatment book

  ×

  Step 3

  Ask client to bring partner and family members to the facility for testing.

  • Previous partners should be contacted directly by the client or anonymously by the HCW

  ×

  Step 4

  If partner and family members are not tested after one month, trigger community-based index client testing.

  ×

  Step 5

  Perform community-based index client testing through one of these strategies:

  • Health care worker outreach.
  • Links with a community-based cadre who is trained to test. This may be through supervised use of self-tests.
  • Giving the client self-test kits for unsupervised self-testing to be performed at home.

  ×
• Linkages to Services (5 min)

  It is no longer sufficient that clients just get tested for HIV. Following up with clients, whether they test positive or negative, is important to link people to care, treatment, prevention, and support services. Systematic reviews have revealed some interventions that can improve linkage to services. These include involving community outreach workers to identify those lost to follow up and linking with expert clients along with mobile health strategies.

  Tap on the tabs below to learn more about linkages to prevention, treatment, care, and support services for clients testing HIV negative or HIV positive.

  • HIV negative
  • HIV positive

  HIV negative

  • Screen for TB
  • Screen for STIs
  • Provide condoms
  • Refer to HIV prevention services, VMMC, and cervical cancer screening, family planning, etc.

  HIV positive

  • Discuss need for re-testing before ART initiation
  • Link with community health worker or expert client
  • Refer for OI and ART services – all clients are eligible for ART
  • Screen for TB, STIs, and other OIs
  • Refer for other services as appropriate (family planning, nutrition, and psychosocial support)
  • Use the MOHCC referral form to refer and track the client
• Knowledge Check (10 min)

  1Which of the following is true about PITC? (Select all that apply.)

  1. PITC can be facility or community-based.
  2. PITC is HTS recommended by health care providers.
  3. PITC does not need consent.
  4. In PITC the pre-test approach is preferably a group education session.

  Clear Feedback

  A, B, and D are correct.

  2All of the following are true of CITC, except:

  1. CITC is only conducted in stand-alone facilities.
  2. CITC allows service providers to encourage behaviour change.
  3. CITC usually targets the “worried well.”
  4. CITC can be conducted through mobile services.

  Clear Feedback

  A is correct.

  3Which of the following is true about HIVST? (Select all that apply.)

  1. The client interprets their own test results.
  2. The process involves a person collecting their own blood and bringing it to the facility.
  3. HIVST provides a definitive result, whether negative or positive.
  4. If someone tests positive, a confirmatory test by a trained provider using the national algorithm is needed and a retest before they start treatment.

  Clear Feedback

  A and D are correct.

  4Tinashe has taken the HIVST and has come back to the facility after taking the test. Which questions will you ask him? (Select all that apply.)

  1. Why did you choose to take the self-test instead of testing here at the facility?
  2. Why have you come today?
  3. Did you have any challenges using the test?
  4. Did you have any challenges interpreting the test?

  Clear Feedback

  B, C, and D are correct.

  5All of the following are the components of the HIV testing service package, except:

  1. Pre-test information giving.
  2. Conducting the HIV test.
  3. Post-test counselling.
  4. Follow-up counselling and referrals.
  5. Pregnancy testing for women.

  Clear Feedback

  E is correct.

  6What are ways to adhere to the guiding principles of HTS? (Select all that apply.)

  1. Obtain informed consent.
  2. Let the client know that if they test positive, you will need to inform their family.
  3. Provide counselling.
  4. Nothing needs to be done if the client tests HIV-negative.

  Clear Feedback

  A and C are correct.

  7The following linkages should be done when someone tests HIV-negative, except:

  1. Empower client to continue with risk reduction strategies.
  2. Screen for STIs.
  3. Refer for OI and ART services.
  4. Provide condoms.

  Clear Feedback

  C is correct.

  8Which of the following are components of index client testing? (Select all that apply.)

  1. Tell HIV-positive client that it is the law to test the family and partner.
  2. Document all family members in the patient care and treatment booklet.
  3. Ask client to bring partner and family members to the facility for testing.
  4. If partner and family members are not tested after one week, perform community-based testing through outreach.

  Clear Feedback

  B and C are correct.

• Key Points (5 min)
  • Routinely offer PITC to all clients with unknown HIV status.
  • Community-based HTS may assist in overcoming barriers to individuals and household who are unable/unwilling to access facility-based services.
  • HIV self-testing is a promising and innovative model that may increase the uptake of HTS.
  • HIV self-testing is a promising and innovative model that may increase the uptake of HTS.
  • Presentation of HIV disease is highly variable in infants and young children.
  • HTS should always adhere to the guiding principles of the 5 “Cs” (Consent; Confidentiality; Counselling; Correct and accurate HIV test results; Connection to HIV prevention, treatment, care and support services)