Academic journal article Bulletin of the World Health Organization

From Caution to Urgency: The Evolution of HIV Testing and Counselling in Africa/De la Prudence a L'urgence: L'evolution Des Activites De Conseil et De Depistage Du VIH En Afrique/De la Cautela a la Urgencia: La Evolucion De Las Pruebas De Deteccion del VIH Y El Asesoramiento En Africa

Academic journal article Bulletin of the World Health Organization

From Caution to Urgency: The Evolution of HIV Testing and Counselling in Africa/De la Prudence a L'urgence: L'evolution Des Activites De Conseil et De Depistage Du VIH En Afrique/De la Cautela a la Urgencia: La Evolucion De Las Pruebas De Deteccion del VIH Y El Asesoramiento En Africa

Article excerpt

Background

Since the first antibody tests for human immunodeficiency virus (HIV) infection became available, public health organizations and human rights activists have debated the best approach to HIV testing and counselling (HTC). (1) At a time when there was no effective treatment and HIV-infected individuals faced widespread discrimination and stigmatization, (1) many argued that HTC was inappropriate because it provided little benefit to the individual. (1,2) Conversely, others believed that testing was the key to promoting a change in behaviour. (1,3) These two concerns framed early debates about HTC. (4)

Initially, there was general support for a cautious response to HTC and HIV infection, although this was considered "exceptional" compared with responses to other infectious diseases, (1,5) For example, in 1987, the World Health Organization (WHO) emphasized caution in extending routine HIV testing beyond blood donors. (1) At that time, standards for HTC, which were based on an international consensus reached by WHO and other stakeholders, emphasized voluntarism and gave rise to the adoption of voluntary counselling and testing. (1) This approach consisted of three primary components: counselling before and after an HIV test, which included an individualized risk-reduction plan based on the test results; informed written consent; and confidentiality. (1)

As evidence emerged that antiretroviral therapy (ART) could significantly reduce mother-to-child HIV transmission and "alter the clinical course" of HIV infection, the HTC debate changed. (1,3,6) Clinicians and public health professionals now argued that an exceptional approach to HTC was no longer appropriate. The view was that HTC should be standard clinical practice in settings where patients present with symptoms of an HIV infection and where ART is available. (1,2)

At first, however, ART was not universally available. In 2003, only 1% of individuals in need of ART had access to treatment and WHO declared a global health emergency. (7) This declaration gave rise to a series of initiatives for expanding access to ART in developing countries, including the 2003 WHO 3-by-5 initiative and The World Bank's Multi-Country HIV/AIDS Program. (7-9) In the same year, increased funding for extending treatment became available through the United States President's Emergency Plan for AIDS Relief and the Global Fund to Fight AIDS, Tuberculosis and Malaria. In addition, the political climate changed and increased access to prevention and treatment of HIV infection was endorsed. These developments profoundly influenced the debate on HTC at a time when fewer than 10% of those infected with HIV were aware of their status (10) and most were diagnosed at the end stage of the disease, when immune suppression made ART less effective. (11,12) Consequently, voluntary counselling and testing was no longer seen as sufficient for enabling people to become aware of their HIV status. In the era of ART, alternative approaches to HTC were required. (1,2)

One development was the emergence of provider-initiated HIV testing and counselling (PITC). (1) In 2003, only 52% of pregnant women in Botswana knew their HIV status. (13) To increase the knowledge of HIV status, the government instituted a policy of "routine" PITC in various clinical settings in 2004. (14) Similarly, Uganda implemented PITC in referral hospitals in 2005 and Zambia implemented it in tuberculosis clinics in 2004. (15,16) In 2006, the United States Centers for Disease Control and Prevention recommended that PITC be offered to adults aged 13 to 64 years in all health-care settings, with consent being assumed unless the patient explicitly declined. (1,17) As treatment was scaled up, routine HTC gained traction and several countries introduced PITC in clinical settings. Early results demonstrated an increase in HTC uptake. (18-20) With the implementation of PITC expanding globally, WHO recognized the need for guidance. …

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