3PRE-TEST AND POST-TEST SERVICES

3.2.1. Promoting HTS

Many countries and programmes have vigorously promoted HTS through mass media, including radio, television, billboards and posters, the Internet and electronic social media. The use of the mass media has been shown to increase the uptake of HTS in the short term (47). In both high and low HIV prevalence countries, as a result of campaigns and promotional activities, there is widespread knowledge that HTS are available and where they are available. For example, among countries with generalized epidemics, recent Demographic and Health Surveys indicate that in Zambia (2014) 96% and in Tanzania (2011–2012) 91% of both men and women know where to receive an HIV test. Knowledge of where to receive HIV testing in countries with concentrated epidemics is lower but still widespread. For example, among both men and women, 69% in Cambodia (2010) and 71% in Sierra Leone (2013), know where to receive a test. Some countries report gender differences. For example, in the Dominican Republic (2010) 96% of women and 85% of men knew where to receive a test, and in Ethiopia (2011) 66% of women and 82% of men knew where to receive one.

Since knowledge of HIV testing and of where it is available is widespread, the continued need for promotion addressing the general population should be assessed. Depending on the goals of the HTS programme, general promotion and awareness campaigns for HTS may no longer be necessary. Even in countries with generally widespread knowledge of HIV testing, however, promotional activities may need to focus on populations where HIV testing rates remain suboptimal, including key populations and adolescent groups, which will likely require tailored messages and approaches – for example, via social media.

In addition to outreach and promotion, clear signs that direct prospective clients to testing are important. This applies to testing in health facilities, in the community and through mobile services. In certain clinic settings, where HIV testing is routinely offered, such as ANC, STI clinics and TB services, signs, printed information and posters and group health education sessions can efficiently inform pregnant women, other clients and family members that testing is offered.

3.2.2. Creating an enabling environment

Critical enablers are elements outside of health sector interventions that allow health interventions and services to be provided effectively and safely. Examples range from tolerance among the larger population toward people from key populations to laws and policies that enable young people to be tested without parental consent. While these factors are not directly the responsibility of the health sector, health-care providers and organizations delivering HTS should work with community-based organizations, legal authorities and advocacy organizations to ensure that the environment supports and enables people to learn their HIV status. For a description of critical enablers, see Chapter 4 and the Consolidated guidelines on diagnosis, prevention, care and treatment for key populations (http://www.who.int/hiv/pub/guidelines/keypopulations/en/) (10).

3.2.3. Ensuring a confidential setting and preserving confidentiality

All HTS providers must remain committed to preserving confidentiality, one of the 5 Cs of HTS (see Section 1.7). Confidentiality applies not only to the test results and reports of HIV status but also to any personal information, such as information concerning sexual behaviour and the use of illegal drugs. HTS should avoid practices that can inadvertently reveal a client's test results, or HIV status, to others in the waiting room or in the health facility. Such practices might include counselling all people diagnosed HIV-positive in a special room or by a specific provider or making it obvious to others which clients will need or is receiving additional testing or lengthy post-test counselling. Lack of confidentiality discourages people from using HTS. For example, in Cambodia some sex workers refused HIV testing because the outreach setting where peer educators were providing counselling was not perceived as private (50). Health workers and others who provide HIV testing may need special training and sensitization regarding the confidentiality of medical records, particularly where key populations are concerned.

3.2.4. Providing pre-test information

Historically, HIV counselling has been provided both before and after HIV testing. Before the introduction of RDTs, same-day results were not feasible, so counsellors included comprehensive information in the pre-test session in case the client did not return for their test results. Moreover, in the pre-treatment era pre-test counselling often focused on providing a risk assessment, preparing clients to cope with an HIV-positive diagnosis in the absence of treatment and encouraging clients to return to receive their test results.

With the widespread use of HIV RDTs, 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 counselling is no longer needed and may create barriers to service delivery (51, 52). Individual risk assessment and individualized counselling during the pre-test information session is no longer recommended. Depending on local conditions and resources, programmes 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.

Offering or recommending HIV testing to a client or a group of clients includes providing clear and concise information on:

• the benefits of HIV testing
• the meaning of an HIV-positive and an HIV-negative diagnosis
• 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
• a brief description of prevention options and encouragement of partner testing
• the fact that the test result and any information shared by the client is confidential
• the fact that the client has the right to refuse to be tested and that declining testing will not affect the client's access to HIV-related services or general medical care
• 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 behaviour is stigmatized
• an opportunity to ask the provider questions.

3.3.1. Retesting during the window period

In many settings post-test counselling messages recommend that all people who have a non-reactive (HIV-negative) test result should return for retesting to rule out acute infection that is too early for the test to detect – in other words, in the window period. However, retesting is needed only for HIV-negative individuals who report recent or ongoing risk of exposure. For most people who test HIV-negative, additional retesting to rule out being in the window period is not necessary and may waste resources.

The routine and widely reiterated advice to everyone with a negative test result to retest after a “three-month window period” is not appropriate. This is because most people who receive HIV testing and test HIV-negative, particularly where HIV testing is offered routinely in clinical settings, will not be at risk from recent infection. For a small minority who identify a specific recent suspected exposure, retesting after four to six weeks can be advised.

See Table 3.1, page 31, and Delivering HIV test results and messages for retesting and counselling in adults (http://www.who.int/hiv/pub/vct/hiv_re_testing/en/) (12) for detailed and specific guidance on messages concerning retesting.

3.3.2. Retesting for those who remain at high risk of HIV acquisition

People who are diagnosed HIV-negative but remain at high risk, such as some people from key populations, may benefit from regular retesting. Retesting gives these people both the opportunity to ensure early HIV diagnosis and to receive ongoing health education on HIV prevention. WHO recommends that people in high-risk categories retest at least annually (12).

3.3.3. Services for adolescents who test HIV-negative

Particularly in high prevalence settings, adolescents who test HIV-negative need information and education about healthy behaviours, such as correct and consistent condom use, reduction of risk-associated behaviours and prevention of HIV and unwanted pregnancy and about the need for retesting if they have new sexual partners. Those testing negative also need referral to appropriate prevention services, such as VMMC, contraception and harm reduction (54). For more information see HIV and adolescents: guidance for HIV testing and counselling and care for adolescents living with HIV (http://apps.who.int/iris/bitstream/10665/94334/1/9789241506168_eng.pdf) (55).

3.3.4. Services for partners who both test HIV-negative

Particularly in high prevalence settings, couples and others who test for HIV with a sexual partner and are both diagnosed HIV-negative can benefit from the standard health information and prevention education given to individuals who test negative. In addition, the counsellor or health worker may offer further counselling at the couple's or a partner's request.

3.5.1. Special considerations concerning disclosure

People who test HIV-negative rarely need assistance or support with disclosing their HIV status to others. In contrast, maintaining privacy about testing HIV-positive and deciding about disclosure are serious concerns for many who are diagnosed HIV-positive.

There are three forms of disclosure relevant and appropriate to HIV testing:

• Disclosure by the individual to a sexual partner, family member or friend. Such disclosure can have considerable benefits, particularly for couples and sexual partners. However, many clients who learn that they are HIV-positive need time to absorb the diagnosis before they are ready to disclose and may benefit from additional counselling. Research findings on the consequences of disclosure, especially disclosure by women to their male partners, are mixed. Women who have experienced intimate partner violence prior to testing may experience violence from their partner after disclosing their HIV status. Providers and counsellors should assess the risk of intimate partner violence in the individuals they serve (59, 60) and make referrals as needed.
• Disclosure by a health worker to a sexual partner of the individual. In some settings laws or regulations require the disclosure of HIV-positive status to sexual and/or drug-injecting partners. Where this is the case, providers should discuss this with clients before asking for informed consent for testing. Providers need to be sensitive to clients who may be more susceptible to adverse outcomes of disclosure, such as discrimination, violence, abandonment or incarceration and to adapt counselling accordingly. Such clients may need additional counselling both before and after testing.
• Disclosure by a health worker to other health workers involved in the client's care. Providers need to inform people who test positive that, in order to assure appropriate medical care, the diagnosis will be shared with other medical workers as needed. Such disclosure should respect the client's basic right to privacy and confidentiality of all medical information.

Disclosure by a health worker to the police or other legal authorities is not considered ethical in the context of HTS unless the client has consented to this disclosure. In this case HTS providers should obtain written consent to disclose a client's HIV status to legal authorities.

3.5.2. Post-test counselling for special populations

Key populations. Intensified post-test counselling combined with follow-up counselling by community health workers significantly increases the proportion of people with HIV from key populations who enrol in HIV care (61). Also, people who inject drugs are more likely to start and stay in HIV treatment if they are participating in OST programmes (62). Therefore, referral to community health workers and to other services such as OST should be included in post-test counselling for people from key populations. Some people 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 counselling as well as peer support services to cope with this diagnosis. A peer counsellor may particularly help people understand and cope with the diagnosis and support linkage to care and treatment by serving as a “peer navigator”, who assists with finding, choosing and obtaining a full range of services.

The 2014 WHO Consolidated guidelines on HIV prevention, diagnosis, treatment and care for key populations (http://www.who.int/hiv/pub/guidelines/keypopulations/en/) (10) describes essential services for key populations. In terms of HTS these guidelines describe interventions to reduce barriers to testing and to linkage to care after testing.

Couples and partner HIV testing services. Couples counselling requires additional training and enhanced counselling skills. Post-test counselling for serodiscordant couples may be especially challenging, as these results may be hard for the provider to explain and difficult for the couple to accept. For more guidance on post-test counselling and services for discordant couples, see Guidance on couples HIV testing and counselling including antiretroviral therapy for treatment and prevention in serodiscordant couples (http://apps.who.int/iris/bitstream/10665/44646/1/9789241501972_eng.pdf) (16).

Pregnant women. Post-test counselling for pregnant 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: providers should encourage HIV-positive pregnant women to deliver in a health facility for their own well-being as well as to ensure access to PMTCT services;
• use of ARVs for the client's health, when indicated and available, as well as the use of ARVs to prevent transmission to the infant;
• the importance of partner testing and information on the availability of couples testing services;
• ensuring screening for TB and testing for other infections such as syphilis;
• counselling on adequate maternal nutrition, including iron and folic acid;
• advice on infant feeding options and support to carry out the mother's infant feeding choice;
• HIV testing for the infant and needed follow-up for HIV-exposed infants.

Adolescents. Along with standard messages for all those diagnosed with an HIV infection, post-test counselling for adolescents with HIV should include (54):

• tailored help with linkage to HIV care and treatment;
• counselling, referral and linkage to specific psychosocial and mental health services tailored to both the situation in which infection happened and the developmental age of the individual;
• information on adolescents' rights and responsibilities, especially their right to confidentiality;
• 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;²
• referral for small-group counselling and structured peer support groups, which may particularly benefit adolescents with HIV.

Children. Informing children of their HIV diagnosis is complex, and the approach depends on the child's age and the counselling skills of the health-care provider. For information on disclosure to children, see Guidance on HIV disclosure counselling for children 12 years of age and younger (http://www.who.int/hiv/pub/hiv_disclosure/en/) (49).

3.6.1. Linkage to treatment and care

Linkage to care after receiving an HIV-positive diagnosis remains challenging. In resource-limited settings, primarily sub-Saharan Africa, it is estimated that as much as 40% of people who are diagnosed through HTS are not linked to care (25, 37, 38), and late initiation of ART continues to be common (39). Factors that may contribute to poor linkage and particularly to poor rates of enrolment in care and treatment following HIV testing range from client factors, such as feeling healthy, depression, lack of social or family support and fear of disclosure, to social or cultural factors, such as stigma and discrimination, structural or economic factors, including legal issues and lack of transportation, and health system barriers, such as poor referrals, stigmatizing or unfriendly services and long waiting times in facilities (65, 66).

3.6.2. Linkage to HIV prevention services

A range of HIV prevention services should be available for those with HIV, in addition to timely initiation of ART (92), and for those who are HIV-negative, (see Table 3.1).

Linkage to prevention services for people who test HIV-negative is not well-documented or studied. It is important to support linkage to prevention services for those with the greatest ongoing risk, for example, people in settings of high HIV incidence, people from key populations and others at high risk of HIV, such as serodiscordant couples. In VMMC-priority countries, linking HIV-negative men to VMMC services is important. Although linkage of men and boys eligible for VMMC from HIV testing to VMMC services can be challenging, it can succeed when linkage is prioritized. For example, in a Mozambique programme where lay providers' HTS was performed, 68% of HIV-negative males were linked to VMMC services (93).

3.6.3. Linkage policy

Countries should consider policies and strategies to improve and prioritize linkage between HTS and prevention, treatment and care services.

For example, in 2009 the Ethiopia Ministry of Health developed its National Referral and Linkage Strategy (94). Key aspects of this strategy include activities to:

• strengthen the community environment 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 administrative processes and the requirement for identification cards for enrolment in HIV care (94).

Monitoring people's linkage following HIV testing is critical to strengthening treatment and prevention cascades. For additional guidance on the monitoring and evaluation of linkage to prevention, treatment and care services, see:

• Consolidated strategic information guide for HIV in the health sector (http://www.who.int/hiv/pub/guidelines/strategic-information-guidelines/en/) (95).
• Metrics for monitoring the cascade of HIV testing, care and treatment services in Asia and the Pacific (http://www.wpro.who.int/hiv/documents/Metrics_to_Mmnitor_and_evaluate_the_Impact_of_ART/en/) (96).