Academic journal article Bulletin of the World Health Organization

Point-of-Care HIV Tests Done by Peers, Brazil/Tests Du VIH Effectues Par Des Pairs Sur le Lieu Des Soins Au Bresil/Pruebas del VIH En El Punto De Atencion Realizadas Por Expertos, Brasil

Academic journal article Bulletin of the World Health Organization

Point-of-Care HIV Tests Done by Peers, Brazil/Tests Du VIH Effectues Par Des Pairs Sur le Lieu Des Soins Au Bresil/Pruebas del VIH En El Punto De Atencion Realizadas Por Expertos, Brasil

Article excerpt

Introduction

To respond to the human immunodeficiency virus (HIV) epidemic it is important to diagnose HIV-infected people early, because diagnosis allows infected people to start antiretroviral therapy (ART) and--by reducing their viral load --reduces HIV transmission. (1) However, fear of the disease and the consequences of being infected make people hesitant to test themselves for HIV. (2-4)

Key populations -men who have sex with men, transgender people, sex workers and people who use drugs--are disproportionally affected by the HIV epidemic. (5) Their risk of infection is higher than the general population and they face legal and social barriers in accessing health services. To improve access to HIV care and diagnosis, community-based interventions are essential. (6,7)

To expand HIV testing for key populations in Brazil, the health ministry developed a community-based testing strategy, called Viva Melhor Sabendo ("live better knowing"). We present lessons learnt during the first 15 months of its implementation.

Local context

In Brazil, the HIV epidemic is largely concentrated in key populations. For men who have sex with men, prevalence was 14.8% in 2015, 40 times higher than in the general population (0.4% in 2012). In other key populations the prevalence is about 5% (female commercial sex workers 4.9% in 2009; drug users 5.0% in 2013). (8-12)

The Brazilian acquired immunodeficiency syndrome (AIDS) programme has a set of preventive actions for key populations such as financial support for specific activities, distribution of educational and prevention materials--such as male and female condoms--and workshops on HIV prevention. These actions are done in partnership with non-governmental organizations (NGOs). Since 2013, the health ministry aims to provide ART to every person living with HIV, irrespective of their CD4+ T-lymphocyte count. (13)

Approach

Once the programme implemented treatment as prevention, early diagnosis emerged as the next requirement, especially for key populations. To meet this need, the Department of Sexually Transmitted Infections (STIs), AIDS and Viral Hepatitis developed a key populations-focused strategy, which combined prevention, testing and counselling initiatives. The strategy included a peer point-of-care testing intervention with an oral fluid HIV rapid test. The test, DPP* HIV-1/2 (Biomanguinhos/Fiocruz, Rio de Janeiro, Brazil), is only for screening when administered alone, despite its high sensitivity (99.5%) and specificity (99.0%). (14) Therefore, any positive result from an oral fluid rapid test needs diagnostic confirmation through a finger puncture rapid test or another conventional test. To include the combination of two rapid tests--either two finger puncture rapid tests or one oral fluid test and one finger puncture test--in HIV diagnosis, national algorithms for HIV testing had to be updated. (15) Moreover, legislation had to be reinterpreted through a ministerial decree so that the administration of oral fluid HIV rapid tests would no longer be restricted to health professionals, but open to any person trained in rapid testing by the health ministry. (16)

In partnerships with selected NGOs, the department ran a pilot project for the strategy between January 2014 and March 2015. The department selected 53 NGOs from all five geographical regions of Brazil through a bidding process that considered the NGOs' experience in community work with key populations.

To support the implementation of the project, people from the health ministry held a two-day training session for NGO staff involved, either at the NGO's office or at the local STI/AIDS and viral hepatitis coordination office. Staff were trained to implement the project by learning to develop an action plan; carry out the oral fluid test; counsel the person tested; inform only the patient of the results; make a referral to health services; and monitor the project. …

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