UNAIDS - June 1, 2004

As access to antiretroviral treatment is scaled up in low and middle income countries, there is a critical opportunity to simultaneously expand access to HIV prevention, which continues to be the mainstay of the response to the HIV epidemic. Without effective HIV prevention, there will be an ever increasing number of people who will require HIV treatment. Among the interventions which play a pivotal role both in treatment and in prevention, HIV testing and counselling stands out as paramount.

The current reach of HIV testing services remains poor: in low and middle income countries only 10 per cent of those who need voluntary counselling and testing, because they may have been exposed to HIV infection, have access to it. Even in settings in which voluntary counselling and testing is routinely offered, such as programmes for prevention of mother-to-child transmission, the number of people who avail themselves of these services remains low in many countries. The reality is that stigma and discrimination continue to stop people from having an HIV test.

To address this, the cornerstones of HIV testing scale-up must include improved protection from stigma and discrimination as well as assured access to integrated prevention, treatment and care services. The conditions under which people undergo HIV testing must be anchored in a human rights approach which protects their human rights and pays due respect to ethical principles. (cf Appendix 1). Young people require special attention to their needs through the provision of confidential youth friendly health services. Public health strategies and human rights promotion are mutually reinforcing.

The conditions of the '3 Cs', advocated since the HIV test became available in 1985, continue to be underpinning principles for the conduct of HIV testing of individuals. Such testing of individuals must be:

-- confidential

-- be accompanied by counselling

-- only be conducted with informed consent, meaning that it is both informed and voluntary.

In many low and middle income countries, the primary model for HIV testing has been the provision of client-initiated voluntary counselling and testing services. Increasingly, provider-initiated approaches in clinical settings are being promoted, i.e. health care providers routinely initiating an offer of HIV testing in a context in which the provision of, or referral to, effective prevention and treatment services is assured. To reach people in need of treatment, tens of millions of tests will have to be conducted among those who may have been exposed to HIV.

UNAIDS recommends that the following four types of HIV testing be clearly distinguished:

1) Voluntary counselling and testing

Client-initiated HIV testing to learn HIV status, provided through voluntary counselling and testing, remains critical to the effectiveness of HIV prevention. UNAIDS promotes the effective promotion of knowledge of HIV status among any population that may have been exposed to HIV through any mode of transmission. Pre-testing counselling may be provided either on an individual basis or in group settings with individual follow-up. UNAIDS encourages the use of rapid tests so that results are provided in a timely fashion and can be followed up immediately with a first post-test counselling session for both HIV-negative and HIV- positive individuals.

2) Diagnostic HIV testing is indicated whenever a person shows signs or symptoms that are consistent with HIV-related disease or AIDS to aid clinical diagnosis and management. This includes HIV testing for all tuberculosis patients as part of their routine management.

3) A routine offer of HIV testing by health care providers should be made to all patients being:

-- assessed in a sexually transmitted infection clinic or elsewhere for a sexually transmitted infection - to facilitate tailored counselling based on knowledge of HIV status

-- seen in the context of pregnancy - to facilitate an offer of antiretroviral prevention of mother-to-child transmission

-- seen in clinical and community based health service settings where HIV is prevalent and antiretroviral treatment is available (injecting drug use treatment services, hospital emergencies, internal medicine hospital wards, consultations etc.) but who are asymptomatic.

Explicit mechanisms are necessary in provider-initiated HIV testing to promote referral to post-test counselling services emphasising prevention, for all those being tested, and to medical and psychosocial support, for those testing positive. The basic conditions of confidentiality, consent and counselling apply but the standard pre-test counselling used in VCT services is adapted to simply ensure informed consent, without a full education and counselling session. The minimum amount of information that patients require in order to be able to provide informed consent is the following:

-- the clinical benefit and the prevention benefits of testing

-- the right to refuse

-- the follow-up services that will be offered and

-- in the event of a positive test result, the importance of anticipating the need to inform anyone at ongoing risk who would otherwise not suspect they were being exposed to HIV infection

For provider-initiated testing, whether for purposes of diagnosis, offer of antiretroviral prevention of mother-to-child transmission or encouragement to learn HIV status, patients retain the right to refuse testing, i.e. to 'opt out' of a systematic offer of testing.1

4) Mandatory HIV screening UNAIDS supports mandatory screening for HIV and other blood borne viruses of all blood that is destined for transfusion or for manufacture of blood products. Mandatory screening of donors is required prior to all procedures involving transfer of bodily fluids or body parts, such as artificial insemination, corneal grafts and organ transplant.

UNAIDS does not support mandatory testing of individuals on public health grounds. Voluntary testing is more likely to result in behaviour change to avoid transmitting HIV to other individuals. Recognising that many countries require HIV testing for immigration purposes on a mandatory basis and that some countries conduct mandatory testing for pre-recruitment and periodic medical assessment of military personnel for the purposes of establishing fitness, UNAIDS recommends that such testing be conducted only when accompanied by counselling for both HIV-positive and HIV-negative individuals and referral to medical and psychosocial services for those who receive a positive test result.

1 HIV testing without consent may be justified in the rare circumstance in which a patient is unconscious, his or her parent or guardian is absent, and knowledge of HIV status is necessary for purposes of optimal treatment.

Appendix 1 Ensuring a rights based approach

The global scaling up of the response to AIDS, particularly in relation to HIV testing as a prerequisite to expanded access to treatment, must be grounded in sound public health practice and also respect, protection, and fulfilment of human rights norms and standards.

The voluntariness of testing must remain at the heart of all HIV policies and programmes, both to comply with human rights principles and to ensure sustained public health benefits.

The following key factors, which are mutually reinforcing, should be addressed simultaneously:

1. Ensuring an ethical process for conducting the testing, including defining the purpose of the test and benefits to the individuals being tested; and assurances of linkages between the site where the test is conducted and relevant treatment, care and other services, in an environment that guarantees confidentiality of all medical information;

2. Addressing the implications of a positive test result, including non-discrimination and access to sustainable treatment and care for people who test positive

3. Reducing HIV/AIDS-related stigma and discrimination at all levels, notably within health care settings;

4. Ensuring a supportive legal and policy framework within which the response is scaled up, including safeguarding the human rights of people seeking services;

5. Ensuring that the healthcare infrastructure is adequate to address the above issues and that there are sufficient trained staff in the face of increased demand for testing, treatment, and related services.

UNAIDS Global Reference Group on HIV/AIDS and Human Rights

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