HIV Testing and Counseling: A Vital Gateway to Scaling Up High-Impact Interventions

Posted by Eric Goosby
August 15, 2013
Patient Undergoes Pin Prick Blood Test at Mobile Healthcare Clinic

This year marks the tenth anniversary of PEPFAR, the U.S. President’s Emergency Plan for AIDS Relief, and we have much to celebrate.  We are closer than ever to achieving an AIDS-free generation.  Today, 13 partner countries have reached the programmatic "tipping point" in their AIDS epidemics -- the point at which the annual increase in adults on antiretroviral treatment is greater than the number of annual new adult HIV infections.  And this past June, the one millionth baby was born HIV-free due to PEPFAR-supported efforts to prevent mother-to-child transmission.

With an AIDS-free generation within our reach, PEPFAR continues to prioritize combinations of interventions that are based on sound scientific evidence and have a significant impact on reducing new HIV infections and saving lives.  HIV testing and counseling (HTC), which has been a cornerstone of PEPFAR since its inception, is one such activity.  HTC is the gateway to many high-impact interventions, such as treatment, prevention of mother-to-child transmission, and voluntary medical male circumcision.

During the last decade, PEPFAR has helped to engender an unprecedented expansion in the number of people accessing HTC.  In its first year, PEPFAR supported almost 2 million HIV tests; in 2012 alone, it supported more than 46 million.  Since its inception in 2003, PEPFAR has supported nearly 190 million HIV tests along with appropriate counseling to people around the globe, principally in sub-Saharan Africa.

A key factor in this growth has been rapid HIV testing, which PEPFAR has been instrumental in promoting.  This simple-to-use technology allows people to learn their HIV status in under an hour, eliminating the challenge of getting patients to return days later for their results.  Rapid tests are easy to administer, enabling over-stretched clinics and hospitals to shift the task of HTC to lower-level health workers.  Best of all, rapid tests are portable, allowing testing to go where the people who most need it live and work.  With the advent of these technologies, PEPFAR has been able to help countries bring HTC to remote rural areas, as well as to populations at higher risk for HIV infection, who are often less likely to go to clinics.  This expansion has been further aided by PEPFAR’s pioneering of novel approaches to HTC -- mobilizing whole communities to get tested, bringing health workers to worksites, bars and sporting events, even going door-to-door in high-burden areas.  These approaches have allowed millions more individuals to learn their HIV status and, if they are HIV-positive, to get the care and treatment they and their families need.

Despite this extraordinary progress, key challenges remain.  Globally, fewer than 40 percent of persons living with HIV know they are positive.  Without knowledge of serostatus, many people living with HIV do not seek treatment until they are very ill -- meaning the opportunity to provide them with optimal care and to protect their sexual partners and children from HIV is missed.  As PEPFAR continues to evolve, so does our approach to HTC.  We are increasingly shifting our focus from testing as many people as possible, to identifying as many people living with HIV as possible.  This requires more strategic, targeted approaches that overcome the barriers to testing faced by many undiagnosed people living with HIV.

Partner governments, PEPFAR teams, and implementing partners are collaborating on these approaches.  In Kenya, PEPFAR piloted a new family-centered HIV testing program, encouraging the partners and children of HIV-positive clients at a treatment clinic to come in for testing.  This method has yielded much higher rates of partner HIV testing than the traditional stand-alone testing sites, and helped identify many children living with HIV and link them to care.  In Malawi, a country with a high prevalence of HIV, new programs that include support for HIV self-testing at home are bringing HTC to more at-risk groups including urban adult men -- a group that is often reluctant to attend clinics or testing centers.  Moving forward, PEPFAR will continue to support our partner countries in making this shift from high-volume to highly-targeted HTC -- to improve results, reduce unnecessary testing, and maximize the impact of each dollar invested.   

As we enter the next phase of PEPFAR, with the strong support of the Obama Administration and bipartisan support from the U.S. Congress, the United States remains firmly committed to doing our part to help make an AIDS-free generation a reality.  Reaching this goal is a shared responsibility, with country governments convening donors, civil society, and other stakeholders to determine how all can contribute meaningfully to this collective goal.  This is especially true of HTC programming, where government leadership is critical to ensuring that resources are directed toward those most in need of these services.

We look forward to continuing to work closely with our partners on this crucial component to the AIDS response.

About the Author: Ambassador Eric Goosby is the U.S. Global AIDS Coordinator and head of the State Department's Office of Global Health Diplomacy.


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