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TEST FOR TRIAGE: A NEW APPROACH TO COMMUNITY-BASED HIV TESTING AND COUNSELLING R. Baggaley1, K. Curran1, C. Johnson1, A. Sands2, M. Brostrom3, V. Andreeva4 1World

Health Organization, HIV/AIDS, Geneva, Switzerland, 2World Health Organization, Essential Medicines and Health Products, Geneva, Switzerland, 3Joint United Nations Programme on HIV/AIDS, Rights, Gender, Prevention and Community Mobilization, Geneva, Switzerland, 4Joint United Nations Programme on HIV/AIDS, Regional Support Team, Asia and the Pacific, Bangkok, Thailand

BACKGROUND

COMMUNITY-BASED HIV TESTING APPROACHES

Despite recent achievements in scaling-up HIV testing and counselling (HTC), programmes still face challenges increasing the number of people who know their HIV status, particularly key populations (KP) and people at highest risk for HIV. WHO recommends communitybased HTC in generalised epidemics and for key populations in all epidemics. However, in some settings, there are policy and regulatory barriers that limit lay providers from collecting specimen, performing HIV rapid diagnostic test (RDTs) and issuing test reports. Strategies are needed to scale-up community-based HTC, in such settings, and reach high risk populations who may not otherwise test for HIV.

The “test for triage” could be a simple way to support community-based HTC and overcome barriers in settings with policies that currently restrict lay providers from providing HIV testing and where community-based HTC is not supported or implemented widely. In this approach, trained and supported lay providers conduct a single RDT. Individuals with a reactive test result are then linked, in a timely manner, to a facility for further HIV testing (starting at the beginning of the national testing algorithm) and if HIV positive, to an assessment for treatment. Individuals with a non-reactive test result are given their results, referred for appropriate HIV prevention services and recommended for re-testing according to recent or on-going HIV risk and national guidelines.

TEST FOR TRIAGE STRATEGY Perform test for triage A01

Link to HIV testing for diagnosis, care & treatment

Community-based HIV Testing Approaches

Approach 1

Approach 2

Rapid test for triage

Rapid test in community settings with definitive diagnosis

Rapid test and ART initiation in community settings

A0

A1, A2 + A3

A1, A2 + A3 Clinical assessment,CD4,ART, care, prevention

HIV Test and Services

DESCRIPTION

A0 +

Level of Test Sophistication & Cost

A0 Report HIV Link to prevention Recommend re-testing as needed

Where “test for triage” can be implemented: •

Setting with currently low access to HTC by people at high risk for HIV, including KP;

•

Settings where outreach HTC would be appropriate & acceptable for KP;

•

Communities with limited community HTC services or infrastructure.

Key advantages: •

Increase the scope of work for community health workers & lay providers;

•

Simplifies logistics, supply chain & training constraints—lay providers trained on 1 RDT;

•

Greater access for those at highest risk & not currently testing for HIV;

1 Assay

A0 is a rapid assay considered a separate, preliminary HIV test rather than a national HIV testing algorithm.

•

Ability to introduce community-based HTC gradually, on a continuum;

•

Scale-up triage HIV testing in “hot spots”.

Linkage

HIV Services Provided at Health Facility / Clinic

Link to HIV testing, care, and treatment, prevention HIV Test: Start in ART 1 Assay

Link to prevention, care and treatment Clinical assessment, CD4, VL, ART, care, prevention

Approach 3

Link to specialist clinical care Specialist clinical care

A0, A1, A2, A3 represent four different assays. Assays can be RDTs, EIA or combination of both.

LESSONS LEARNED A “test for triage approach” is already being used in many community settings, often by NGOs and community organisations. It may be considered preferable to provide a definitive diagnosis in the community, but where community HTC is currently not widely available or not used by specific populations, a test for triage may be a first step to increase access to HTC for currently underserved key populations and vulnerable groups. This approach encompasses: (1) expansion of community-based HTC, and in particular outreach HTC; (2) increasing scope of work of lay providers; and (3) emphasis of timely linkage for HIV diagnosis and, if HIV positive, treatment assessment at health facilities. Test for triage is an approach for settings that may not be able to widely implement Approach 2 or 3, where HIV can be diagnosed or where clinical assessment and ART can be initiated. This approach may help to overcome policy barriers which do not support lay testing as providing an HIV diagnosis will rely on a partnership between lay providers and health worker. Test for triage could serve as an initial step toward community-based HTC and scaling-up such approaches. Supportive HTC policies, training, mentoring and quality assurance for lay providers, clear messages for clients and providers to understand test results and strong linkage-to-care are critical to the success of this approach.

CONCLUSIONS / NEXT STEPS The test for triage offers a simplified approach to community-based HTC and may address current challenges to implementing HIV testing, particularly in concentrated epidemics and settings with policy constraints. Expansion of community-based HTC can also help to overcome inequity in access to testing for key populations and complement facility-based testing approaches in achieving universal access and knowledge of HIV status, earlier diagnosis and linkage to the continuum of prevention, care and treatment.