HIV Testing Services(HTS)

An assessment of HIV test rates andyield at Treat All learning phase healthfacilities showed a 290% increase inHIV testing from month 0 to month 6of Treat All. While the total number ofnew HIV positive diagnoses increasedby 71%, the trend was not as marked(see Figure 1).

This Treat All Tool willprovide practical tips onmaintaining high quality,high yield HTS servicesunder Treat All.

1. Ensure that focus and attention on providing quality HTS at all health facilities increaseswith Treat All.

2. Offer HIV testing to ALL clients with unknown HIV status in all entry points.

3. Ensure all clients testing HIV positive after a confirmatory test undergo HIV retesting priorto ART initiation.

4. Understand which groups are at greater risk to HIV infection in your area and reach out to support uptake of HIV testing and treatment services.

5. Ensure all clients testing HIV positive are linked to care and treatment and initiated on ART.

Keep momentum towards the First 90 under Treat All

Tool 4

Treat All is not just about ART initiationIt also involves effectively identifying HIV positive individuals through HIV Testing and Services (HTS) and linking themto care.

HIV testing is a critical entry point to achieving the 1st 90which will subsequently lead to the achievement of thesecond and third 90s.

90% on ARTvirally

suppressed

90% whoknow their

status on ART

90% of PLHIVknow their

status

Figure 1: HIV test rates and positive diagnoses

1. Ensure that the focus and attention on providing quality HTS at all health facilitiesincreases with Treat All

With increased access to HIV treatment, HIV test rates (the number of people tested for HIV) and the number ofnew positives identified should continue to increase, not decrease, at all health facilities under Treat All.

• Keep track of your HIV testing data – analyse age/sex disaggregation/yield and testing trends

• Your emphasis should be on HIV testing “in the right place, at the right time, for the right people”

• Identify and problem solve any barriers to providing HIV testing at all health facilities

• Do a regular inventory of HIV testing commodities and order new commodities before stock outs occur – HIV testing should be available at all times.

HIV Testing Services (HTS)

2. Offer HIV testing to ALL clients with unknown HIV status in all entry points

HIV Test Yield Assessmentsconducted by OPHID in 2016demonstrated that the majority ofclients testing HIV positive athealth facilities are identified afterpresenting for general outpatientcare (Figure 2). However, theassessment also showed OPD isthe entry point with the lowestpercentage of clients tested.

• Offer HTS in accordance withthe MOHCC guidance setforth in the 2016 ConsolidatedGuidelines for AntiretroviralTherapy for the Preventionand Treatment of HIV inZimbabwe.

• Identify all clients with unknown HIV status in all entry points and wards,particularly those who have not tested for HIV previously.

• Offer an HIV test to all individuals with unknown status.

• Offer an HIV test to all individuals with an invalid HIV negative result,i.e., clients with a HIV negative result which is more than 3 months.

• Provide dedicated HTS registers and monthly return forms. Consolidatedata on a monthly basis. This is a good way for health facilities tounderstand entry points with highest HIV test yield.

• All those testing positive should have documented linkage to care andtreatment.

Tool 2: Site Preparedness provides some important tips for preparing health facilities for optimal implementation of Treat All.GO TO

Entry points where clients with

unknown status shouldbe offered HIV testing:

TB, Outpatients, Malnutrition Wards,

ANC/MNCH.

Figure 2: HIV testing and yield by entry point

Annex VI provides a Provider Initiated Testing and Counselling (PITC) Implementation Guide used by FACE HIV partner forincreasing HIV testing in all health service entry points.GO TO

HIV Testing Services (HTS)

4. Understand which groups are at greater risk to HIV infection in your area and useexisting resources to reach out to encourage HIV testing

Despite being at known greater risk for HIV infection, HIV testing coverage among key populations is often low.Less than half of key populations know their HIV status. For these reasons, finding ways to reach at risk, vulnerableand key populations with HIV testing and treatment services are recognised as crucial for reaching 90-90-90.

• Depending on the communities in your area, there may be groups facing greater risk of HIV infection that shouldreceive special attention and support to uptake HIV prevention, testing, care and treatment services.

• Use District Health Team and Nurses Meetings as an opportunity to discuss key populations affected by HIV inyour area, and strategies to support uptake of supportive, friendly HTS services, free of stigma ordiscrimination.

• Key populations in your area may include: mobile populations, sex workers, members of the lesbian, gay, bisexual,transgender and intersex (LGBTI) community, prisoners or people who use drugs.

• Adult men of unknown HIV status should be offered testing, as they often only present for HIV testing once ill,both risking their own health and transmitting HIV to sexual partners.

• Adolescents and young people (particularly young women and girls) are known to face greater risk of HIVinfection in Zimbabwe and fail to take up services due to stigma and discrimination.

Annex V: For an FAQ on HIV Retesting

For more information, see the HIV Retesting FAQ provided in this toolkit.

REMEMBER: All HIV testing should be done using the current MOHCC HIV testing algorithm

All Health Care Workers should ensure they are familiar with Chapter 2: HIV Testing Services (HTS) for children, adolescents andadults and Linkage to prevention and treatment in the 2016 Guidelines for Antiretroviral Therapy for the Prevention andTreatment of HIV in Zimbabwe for current MOHCC guidance.

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3. Ensure all clients testing HIV positive after a confirmatory test undergo HIVretesting prior to ART initiation

• If possible, the retest should beconducted by a different provider. If notpossible, the same provider shouldconduct the retest. A new sample shouldbe collected and tested using the sametesting algorithm.

Verified HIV positive clients: should beinitiated on ART.

Test discordant clients: MOHCC guidelinesrecommend that clients with HIV-inconclusive status (i.e. first test and retestresults are discordant) be retested in 14days.

HIV RETESTING

Frequently Asked Questions

(FAQ)This factsheet provides answers

to FAQs documented during Learning Phase implementation

of Treat All in 8 Districts of Zimbabwe. This FAQ is intended

to support Ministry of Health and Child Care health managers

and facility-based health care workers to understand and

optimise the recommendation to support HIV retesting

in ART services.

Q: WHY is HIV retesting before ART initiation beingrecommended?

A. Recent reports of HIV status misclassification, with both false positive and false negativeresults have raised concerns that some individuals might be started on ART inappropriately. Zimbabwe has adoptedthe WHO 2015 guideline to retest all persons newly diagnosed as HIV positive, with a second specimen beforeART initiation, to rule out potential misdiagnosis.

WHAT i

IS t

HOW l

5. Ensure all clients testing HIV positive are linked to care and treatment andinitiated on ART

Recent evidence indicates linkage to care after testing HIV positive is the biggest weakness of HIV treatmentprograms seeking to achieve the UNAIDS 90-90-90 targets (Haber N et al. Lancet HIV, 2017).

REMEMBER: A positive diagnosis is only a client’s first step on the HIV Care Cascade

• Knowing one’s HIV positive status is only effective if clients are linked to care and treatment.

• HIV treatment is only effective if clients adhere to treatment and retain in care to achieve the ultimate goal ofsustained viral suppression.

• Facility-level Standard OperatingProcedures should be in place toensure all clients testing HIVpositive in any entry point havedocumented linkage to HIV careand Treatment.

• Health care workers in multipleentry points should beempowered to conduct ARTinitiations for clients testingpositive.

• Patient navigators such as ClinicReferral Facilitators (CRFs) can beused to support clients moving from one department to another for treatment initiation.

• Clear signs and directions to ART initiating units at your health facility should be displayed.

• Transfers and referrals should be well documented and outcomes noted.

HIV Testing Services (HTS)

Tool 5: ART Counselling and Patient Preparedness and Tool 6: ART Initiation for more tips on how to optimize clientreadiness and procedures to optimize ART initiation.

Tool 9: Documentation and Reporting for guidance on documenting HIV testing, treatment and care provided to decreaseworkload, measure performance and improve client care.

65% of People Living with HIV in Zimbabwe have faced stigma and discrimination.

Supportive and friendly health care services for all people are important to encourage uptake of HIVtesting and treatment services.

Health care workers can lead by example to end stigma and discrimination in their communities.

DiagnosedwithHIV

LinkedtoHIVCare(Pre-ART)

InitiatedonART

EarlyAdherence

&RetentioninHIVCare

Lifelongadherence

andretention

inHIVCare

Sustainedviral

suppression

HIVTreatmentCascade(adaptedfromFoxMandRosenS,PLOS2017)

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Acknowledgements: We gratefully acknowledgesupport from the President’s Emergency Plan forAIDS Relief (PEPFAR) through USAID to Families andCommunities for Elimination of HIV in Zimbabwe(AID-613-A-12-00003, FACE HIV)

For more information contact:Organization for Public Health Interventionsand Development20 Cork Road, Belgravia, Harare, Zimbabwewww.ophid.co.zw/

The 2014 Zimbabwe Stigma Index Research Report (ZNNP+) highlighted: