Country uptake of WHO recommendations on differentiated HIV testing services approaches: a global policy review

Abstract

Objectives: In 2015 and 2016, WHO issued guidelines on HIV testing services (HTS) highlighting recommendations for a strategic mix of differentiated HTS approaches. The policy review examines the uptake of differentiated HTS approaches recommendations in national policies.

Methods: Data were extracted from national policies published between January 2015 and June 2019. The WHO-recommended HTS approaches included facility-based testing, community-based testing, HIV self-testing and provider-assisted referral (or assisted partner notification). Other supportive recommendations include pre-test information, post-test counselling, lay provider testing and rapid testing. Descriptive analyses were conducted to examine inclusion of recommendations in national policies.

Results: Of 194 countries worldwide, 65 published policies were identified; 24 WHO Africa region (AFR) countries (51%, 24/47), 21 WHO European region (EUR) (40%, 21/53), 6 WHO Eastern Mediterranean region (EMR) (29%, 6/21), 5 Pan-American region (AMR) (14%, 5/35), 5 Western Pacific Region (WPR) (19%, 5/27) and 4 WHO South East Asia Region (SEAR) (36%, 4/11). Only five countries included all recommendations. 63 included a minimum of one. 85% (n=55) included facility-based testing for pregnant women, 75% (n=49) facility-based testing for key populations, 74% (n=48) community-based testing for key populations, 69% (n=45) rapid testing, 57% (n=37) post-test counselling, 45% (n=29) lay provider testing, 38% (n=25) HIV self-testing, 29% (n=19) pre-test information and 25% (n=16) provider-assisted referral. The proportion in each region that included at least one recommendation were: 100% AFR (24/47), 100% EMR (6/6), 100% AMR (5/5), 100% WPR (5/5), 100% SEAR (4/4) and 95% EUR (20/21). AFR followed by EMR included the highest number of reccomendations.

Conclusion: There was substantial variability in the uptake of the WHO-differentiated HTS recommendations. Those in EMR included the most WHO-differentiated HTS recommendation followed by AFR. Countries within AMR included the least number of recommendations. Ongoing advocacy and efforts are needed to support the uptake of the WHO-differentiated HTS recommendations in country policies as well as their implementation.

Keywords: HIV & AIDS; health policy; public health.

Figure 1

Process to identify country policies including recommendations on HIV testing services. 82 country policies were excluded as they were published before January 2015.

Figure 2

Countries with a national policy identified between January 2015 and June 2019. A map of all 65 countries within this review (n=65). Countries highlighted in orange are those that included all recommendations relevant to their country setting (n=5).

Figure 3

Number of countries that included recommendations valid in all settings and populations from the 2015 WHO consolidated guidelines for HTS, by type of recommendation and WHO region. AFR, WHO Africa region; AMR, Pan-American region; EMR, WHO Eastern Mediterranean region; EUR, WHO European region; SEAR, WHO South East Asia Region; WPR: Western Pacific Region.

Figure 4

Number of countries included in the review that included population-specific or epidemic-specific recommendations from the 2015 WHO consolidated guidelines for HTS, by type of recommendation and WHO region. Facility-based testing for key popualtions here refers to provider-initiated testing and counselling; this is recommended in malnutrition clinics or sexually transmitted infections or hepatitis and tuberculosis services or health services for key populations in all settings. Facility-based testing for pregnant women, infants and children applies to all countries (n=65). Community-based testing for key populations applies to all countries (n=65). Facility-based testing for all those presenting with signs and symptoms is recommended only in countries with a concentrated epidemic (n=24); facility-based testing for adolescents only in countries with a generalised epidemics (n=22). AFR, WHO Africa region; AMR, Pan-American region; EMR, WHO Eastern Mediterranean region; EUR, WHO European region; SEAR, WHO South East Asia Region; WPR: Western Pacific Region.

Figure 5

Number of countries including the new recommendations, by year. HIVST, HIV self-testing.