The future of HIV testing in eastern and southern Africa: Broader scope, targeted services

Abstract

• Scale-up of HIV testing services (HTS), primarily through routine offer of HIV testing in health services, has led to an increase in the proportion of people with HIV who know their status and are accessing HIV treatment. • In eastern and southern Africa (ESA), home to more than half of people living with HIV globally, many countries are close to reaching global targets for HIV treatment and viral suppression, with slower progress towards the global target that 95% of people should know their HIV status. Given this, it is critical to update the approach to HIV testing to reflect changes in the HIV epidemic, the response to it, and to acknowledge ongoing resource constraints. • An expert consultation series defined this updated approach as a shift to “broader scope, targeted services.” Over the next decade, HTS in ESA should implement a status-neutral approach that maintains core testing services to reach the greatest number of people with HIV not on treatment, while broadening the scope to support linkage to appropriate prevention and treatment. It is important that HTS programs use a strategic mix of modalities focused on people most likely to have undiagnosed HIV, those who are not on ART, and people who are more vulnerable to HIV acquisition. • Ten key themes for the future of HTS were articulated. The most critical are: promote a status-neutral approach to HTS; realize the potential of HIV self-testing (HIVST); prioritize facility-based HTS; reframe retesting among those previously diagnosed but not currently on antiretroviral therapy (ART) as an opportunity; and involve and invest in community leadership and community-led monitoring (CLM) to ensure HTS meets the needs and preferences of clients. • The country-specific epidemiological context must inform the focus and mix of testing approaches. Testing programs should acknowledge regional transmission dynamics including that the majority of new infections are acquired from people living with HIV for longer than a year, with transmission driven by many who transmit to a few, rather than by a few who transmit to many. • HTS programs should not reduce the volume of HIV testing. Rather HTS programs should broaden the scope of testing to encapsulate both prevention and treatment objectives and prioritize services to the people at the highest risk of HIV.