HIV is a virus that attacks the immune system, our body’s natural defense against illness. If HIV is left untreated, a person’s immune system will get weaker and weaker until it can no longer fight off life-threatening infections and diseases.
Services prior to HIV testing
Certain basic services should be provided prior to testing in all settings, regardless of the approach used to deliver HTS. These services apply to all adults, couples or partners, and adolescents.
Ensuring a confidential setting and preserving confidentiality
All HTS providers must remain committed to preserving confidentiality, one of the 5 Cs of HTS. Confidentiality applies not only to the test results and reports of HIV status but also to any personal information, such as information concerning sexual behaviour and the use of illegal drugs. HTS should avoid practices that can inadvertently reveal a client’s test results, or HIV status, to others in the waiting room or in the health facility. Such practices might include counselling all people diagnosed HIV-positive in a special room or by a specific provider or making it obvious to others which clients will need or is receiving additional testing or lengthy post-test counselling. Lack of confidentiality discourages people from using HTS. For example, in Cambodia some sex workers refused HIV testing because the outreach setting where peer educators were providing counselling was not perceived as private. Health workers and others who provide HIV testing may need special training and sensitization regarding the confidentiality of medical records, particularly where key populations are concerned.
Providing pre-test information
Historically, HIV counselling has been provided both before and after HIV testing. Before the introduction of RDTs, same-day results were not feasible, so counsellors included comprehensive information in the pre-test session in case the client did not return for their test results. Moreover, in the pre-treatment era pre-test counselling often focused on providing a risk assessment, preparing clients to cope with an HIV-positive diagnosis in the absence of treatment and encouraging clients to return to receive their test results.
With the widespread use of HIV RDTs, most people receive their HIV test results – at least results of the first test – and often a diagnosis on the same day. Therefore, intensive pre-test counselling is no longer needed and may create barriers to service. Individual risk assessment and individualized counselling during the pre-test information session is no longer recommended. Depending on local conditions and resources, programmes may provide pre-test information through individual or group information sessions and through media such as posters, brochures, websites and short video clips shown in waiting rooms. When children and adolescents are receiving HTS, information should be presented in an age-appropriate way to ensure comprehension.
Offering or recommending HIV testing to a client or a group of clients includes providing clear and concise information on:
- the benefits of HIV testing
- the meaning of an HIV-positive and an HIV-negative diagnosis
- the services available in the case of an HIV-positive diagnosis, including where ART is provided
- the potential for incorrect results if a person already on ART is tested
- a brief description of prevention options and encouragement of partner testing
- the fact that the test result and any information shared by the client is confidential
- the fact that the client has the right to refuse to be tested and that declining testing will not affect the client’s access to HIV-related services or general medical care
- potential risks of testing to the client in settings where there are legal implications for those who test positive and/or for those whose sexual or other behaviour is stigmatized
- an opportunity to ask the provider questions.
Special considerations for pregnant or postpartum women
Pre-test information or health education for women who are or may become pregnant or are postpartum should also include:
- the potential risk of transmitting HIV to the infant
- measures that can be taken to reduce mother-to-child transmission, including the provision of ART to benefit the mother and prevent HIV transmission to the infant
- counselling on infant feeding practices to reduce the risk of HIV transmission
- the benefits of early HIV diagnosis for mothers and infants
- encouragement for partner testing.
Services for those who test HIV-negative
Individuals who test HIV-negative should receive brief health information about their test results. Research to date has not demonstrated that a lengthy counselling session is needed or is beneficial. Further, lengthy post-test counselling for people testing negative may divert counselling resources that are needed by those who test HIV-positive, those whose results are inconclusive and those who are found to be in a serodiscordant relationship.
Counselling for those who test HIV-negative should include the following:
- an explanation of the test result and reported HIV status;
- education on methods to prevent HIV acquisition and provision of male or female condoms, lubricant and guidance on their use;
- emphasis on the importance of knowing the status of sexual partner(s) and information about the availability of partner and couples testing services;
- referral and linkage to relevant HIV prevention services, including voluntary male medical circumcision (VMMC) for HIV-negative men, PEP, PrEP for people at substantial ongoing HIV risk;
- a recommendation on retesting based on the client’s level of recent exposure and/or ongoing risk of exposure.
- an opportunity for the client to ask questions and request counselling.
Retesting during the window period
non-reactive (HIV-negative) test result should return for retesting to rule out acute infection that is too early for the test to detect – in other words, in the window period. However, retesting is needed only for HIV-negative individuals who report recent or ongoing risk of exposure. For most people who test HIV-negative, additional retesting to rule out being in the window period is not necessary and may waste resources.
For most people who test HIV-negative, additional retesting to rule out being in the window period is not necessary.
Retesting for those who remain at high risk of HIV acquisition
People who are diagnosed HIV-negative but remain at high risk, such as some people from key populations, may benefit from regular retesting. Retesting gives these people both the opportunity to ensure early HIV diagnosis and to receive ongoing health education on HIV prevention. WHO recommends that people in high-risk categories retest at least annually.
Services for adolescents who test HIV-negative
Particularly in high prevalence settings, adolescents who test HIV-negative need information and education about healthy behaviours, such as correct and consistent condom use, reduction of risk-associated behaviours and prevention of HIV and unwanted pregnancy and about the need for retesting if they have new sexual partners. Those testing negative also need referral to appropriate prevention services, such as VMMC, contraception and harm reduction
Services for partners who both test HIV-negative
Particularly in high prevalence settings, couples and others who test for HIV with a sexual partner and are both diagnosed HIV-negative can benefit from the standard health information and prevention education given to individuals who test negative. In addition, the counsellor or health worker may offer further counselling at the couple’s or a partner’s request.
Services for those whose HIV status is inconclusive or test results are not yet confirmed
An HIV-inconclusive status means, in high prevalence settings, that the first reactive test result was not confirmed by additional testing using subsequent HIV assays or that, in low prevalence settings, the first two test results were reactive but the third assay was non-reactive. All clients with an HIV-inconclusive status should be encouraged to return in 14 days for additional testing to confirm their diagnosis.
Receiving an HIV-inconclusive status may be confusing and stressful for the individual or couple and may be difficult for the provider to explain. As with many other tests for medical conditions, resolving the discrepancy with a third test is not useful, given the high probability that it may equally produce a false-reactive result. Most, if not all, HIV-inconclusive statuses can be resolved with retesting 14 days later. Clients with an HIV-inconclusive status should be told that a definitive diagnosis cannot be provided that day and that immediate referral to HIV care or ART initiation is not appropriate. They should be given a clear plan for follow-up testing.
Unconfirmed results occur when clients who have an initially reactive HIV test result do not receive additional testing in the same visit to confirm their HIV diagnosis. This may occur in community settings where only one assay is performed, an approach known as test for triage. It is the responsibility of providers and counsellors to explain that this initial result is not an HIV diagnosis and needs confirmation and to refer clients with a reactive test result to a site where they can receive an HIV diagnosis. These providers should encourage clients to go as soon as possible to a facility, such as a clinic or laboratory, for additional HIV testing and a diagnosis. It is not necessary for these clients to wait 14 days to go to the facility. After the test result is confirmed and an HIV diagnosis is given, HIV-positive clients should receive post-test counselling. In particular, every effort is needed to reduce loss to follow-up between a test for triage and additional testing and HIV diagnosis.
Services for those whose test results are HIV-positive
An HIV-positive diagnosis is a life-changing event. Before giving HIV-positive test results, the health worker, trained lay provider, or counsellor should keep in mind the 5 Cs of HTS, as recommended by WHO and UNAIDS, in particular correct test results.
A diagnosis of HIV infection is a life-changing event. Before giving these results, the provider should keep in mind the 5 Cs of HTS.
Once health workers or lay providers are confident of adherence to all measures to ensure correct test results, they should provide post-test health education and counselling. All post-test counselling should be “client-centred”, which means avoiding formulaic messages that are the same for everyone regardless of their personal needs and circumstances. Instead, counselling should always be responsive to and tailored to the unique situation of each individual or couple. Health workers, professional counsellors, social workers and trained lay providers can provide counselling. People with HIV who are trained in counselling may be particularly understanding of the needs and concerns of those who receive an HIV-positive diagnosis.
WHO good practice recommendation
To ensure that clients who are misdiagnosed are not needlessly placed on lifelong ART (with potential side-effects, waste of resources and psychosocial and emotional implications), WHO recommends that all clients be retested to verify their HIV diagnosis prior to enrolling in care and/or starting ART.
The information and counselling that health workers, or others, should provide to HIV-positive clients is listed below. Absorbing all of this information in one session may be very challenging, and a follow-up counselling session may be required. Indeed, the shock of learning of an HIV-positive diagnosis may make it difficult for a person to take in further information immediately.
- Explain the test results and diagnosis.
- Give the client time to consider the results and help the client cope with emotions arising from the diagnosis of HIV infection.
- Discuss immediate concerns and help the client decide who in her or his social network may be available to provide immediate support.
- Provide clear information on ART and its benefits for maintaining health and reducing the risk of HIV transmission, as well as where and how to obtain ART.
- Make an active referral for a specific time and date. (An active referral is one in which the tester makes an appointment for the client or accompanies the client to an appointment, including an appointment for co-located services, and enrolment into HIV clinical care.) Discuss barriers to linkage to care, same-day enrolment and ART eligibility assessment. Arrange for follow-up of clients who are unable to enrol in HIV care on the day of diagnosis.
- Provide information on how to prevent transmission of HIV, including information of the reduced transmission risk when virally suppressed on ART; provide male or female condoms and lubricants and guidance on their use.
- Discuss possible disclosure of the result and the risks and benefits of disclosure, particularly among couples and partners. Offer couples counselling to support mutual disclosure.
- Encourage and offer HIV testing for sexual partners, children and other family members of the client. This can be done individually, through couples testing, index testing or partner notification.
- Assess the risk of intimate partner violence and discuss possible steps to ensure the physical safety of clients, particularly women, who are diagnosed HIV-positive.
- Assess the risk of suicide, depression and other mental health consequences of a diagnosis of HIV infection.
- Provide additional referrals for prevention, counselling, support and other services as appropriate (for example, TB diagnosis and treatment, prophylaxis for opportunistic infections, STI screening and treatment, contraception, ANC, opioid substitution therapy (OST), and access to sterile needles and syringes, and brief sexuality counselling ).
- Encourage and provide time for the client to ask additional questions.