Opt-out HIV testing should be offered to everybody with symptoms suggestive of HIV infection, according to new guidance issued on May 30th by the World Health Organization (WHO) and UNAIDS. The revised testing guidelines also recommend that, in settings where there is a generalised HIV epidemic, all patients accessing healthcare should be offered an HIV test, regardless of symptoms or their reasons for seeking medical attention.
WHO and UNAIDS are stressing, however, that HIV testing must remain voluntary and should be confidential and supported by pre- and post-test counselling.
Opt-out HIV testing has been successfully used in low- and middle-income countries including Botswana, Kenya, Malawi, Uganda and Zambia. In addition, it is also used in some circumstances in richer countries with smaller scale HIV epidemics. The UK offers opt-out HIV testing to all pregnant women, and it is also recommended that gay men attending the UK’s sexual health clinics should be offered an opt-out HIV test annually.
In some low- and middle- income countries up to 80% of individuals with HIV are undiagnosed and it is hoped that the introduction of opt-out testing will help reduce this. Recent studies in sub-Saharan Africa, the region with the world’s highest HIV prevalence, have found that only 12% of men and 10% of women have ever tested for HIV.
Until now, opt-in HIV testing and counselling initiated by the patient (often called voluntary testing and counselling, or VCT) has been the mainstay of HIV testing in most settings. It relies upon individuals actively seeking HIV testing at a health or community-based facility. However, uptake has been low because of limited access to services, fear of stigma and discrimination, and the incorrect assumption by many individuals in high prevalence areas that they are not at risk of the infection.
Where there is a generalised HIV epidemic, opt-out HIV testing and counselling is now recommended for all individuals attending healthcare facilities, irrespective of the presence of symptoms or the patient’s reasons for accessing healthcare.
In settings where HIV prevalence is low, or if focused on particular groups within the population, then WH)/UNAIDS are recommending opt-out testing should be offered to patients with symptoms suggestive of HIV infection, as well as to individuals accessing pregnancy, tuberculosis and sexual health services.
But the new WHO/UNAIDS testing guidelines include key recommendations to try and ensure that opt-out testing remains voluntary and is supported by counselling and access to services. Specifically, the guidelines state:
- All HIV testing must be voluntary, confidential and undertaken with the patient’s consent.
- Patients have the right to decline an HIV test. They should not be tested against their will or without their knowledge. Nor should testing be undertaken without the provision of adequate information or without the patient being informed of the test result.
- Pre- and post-test counselling should be provided.
- Patients should receive support to ensure that disclosure of their HIV status does not have negative consequences.
- Testing must be linked to prevention, care and treatment.
- Decisions about testing must take into account the best interests of the patient.
- Opt-out testing is not an endorsement of compulsory HIV testing.
- Key stakeholders and civil society groups must be consulted about the implementation of opt-out testing.
- A supportive social, policy and legal framework should be in place before opt-out testing is implemented.
- Monitoring and evaluation should be integral to opt-out testing services.
“Scaling up access to HIV testing and counselling is both a public health and human rights imperative,” said Dr Kevin De Cock, HIV director of WHO. “We hope that the new guidance will provide an impetus to countries to greatly increase availability of HIV testing services in healthcare settings”
He added that increasing HIV testing was an essential first-step in efforts to prevent and treat HIV, commenting, “without a major increase in HIV testing and counselling in healthcare facilities, universal access to HIV prevention, treatment and care will remain just a noble goal.”