Where are we on HIV testing services - the achievements and the gaps

Initiation of Antiretroviral Therapy in HIV-Infected Adults

Where we are on HIV testing services the achievements and the gapsRachel Baggaley, Cheryl JohnsonWHO Geneva

Dissemination of New WHO Guidelines for HIV Prevention, Treatment and Care Workshop

Johannesburg, South Africa April 25 29, 2016

# |EXPLAIN to participants that this session will discuss HIV testing services in Southern and Eastern Africa.

EXPLAIN that this session will take 45 minutes.

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Global health sector strategies 2016-2021

ADOPTED

# |Strategically framing WHO's approach towards.. elimination as a public health threat by 2030

# |In addition to reflecting the strategic focus of the SDGs the strategies use a common structure, reflecting three organizing frameworks: universal health coverage (UHC); the continuum of health services; and the public health approach.

UHC is achieved when all people receive the services they need, which are of sufficient quality to make a difference, without those people incurring financial hardship. It comprises three major, interlinked objectives: improving the quality and availability of needed essential health interventions and services (covering the range of services needed); improving the equitable and optimal uptake of services in relation to need (covering the populations in need of services); and improving cost efficiencies and financial protection (covering the costs of services). As resources, efficiencies and capacities increase, the range of services provided can be expanded, the quality improved, more populations covered with fewer direct costs to those who need the services a progressive realization of universal health coverage.

Each of the strategies address the continuum of health sector interventions and services that are needed to curb the epidemics, including interventions to reduce vulnerability and risk, prevent transmission, enable early and accurate diagnosis, link individuals to care, deliver quality treatment and provide chronic care.World Health Organization2 June 20163

Current HIV TrendsGlobally in 2015:

17 million estimated people with HIV did not know their status 17 million people on treatment22 million people in need of ART were not accessing it

# |Antiretroviral therapy coverage and number of AIDS-related deaths, global, 20002015Sources: GARPR 2016; UNAIDS 2016 estimates.

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New HIV infections among people aged 15 years and over, by region, 20102015Source: UNAIDS 2016 estimates.

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Hepatitis compared to other major global epidemicsSources Hepatitis: GBD ; HIV: UNAIDS; TB and malaria: WHO

# |Frameworks for action: Universal health coverage; the continuum of services; and, a public health approachStrategic Direction 2:

Interventions for impact

The what

Strategic Direction 4:

Financing for sustainability

The financing


Information for focused action

The who and the where


Innovation for acceleration

The future

Strategy Implementation: Leadership, Partnership, Accountability, Monitoring & Evaluation Vision, Goal and TargetsStrategic Direction 3:

Delivering for equity

The how

The three dimensions of Universal Health Coverage

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Four Packages of HIV Policy Guidance to guide national action

UnderstandStrategic InformationTreat AllTestPreventin KPs

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The 1st 90 is the most problematic

Nearly half all people w/ HIV unaware of HIV status, globally men, adolescents, key populations

Suboptimal linkage post HTS to ARTPeople delay & still initiate ART late

More focus and targetingBalance between HTS approaches in low & concentrated epidemicsWhy focus on testing

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Source: GARPR (WHO, UNAIDS, UNICEF) 6 July 2015. In 2014, across 129 LMIC, >150 million children & adults received HTS.

Note this is for countries reporting number tested and positive for children and adults11

Make Up Approximately 70% of Those Tested in 2014Much testing in ANC, even in low and concentrated epidemicsWomenSource: GARPR (WHO, UNAIDS, UNICEF) 6 July 2014; 76 reporting countries Row LabelsSum of Adults Tested - FemaleSum of Adults Tested - MaleCountries Total% Female% MaleAfrica25,988,03213,214,1032739,202,13566%34%America3,467,470587,287114,054,75786%14%Eastern Mediterranean1,053,193473,078101,526,27169%31%Europe2,563,3691,442,143114,005,51264%36%South-East Asia18,970,6608,405,973827,376,63369%31%Western Pacific2,826,0801,081,07993,907,15972%28%Grand Total54,868,80425,203,6637680,072,46769%31%

Generally Two-Thirds AMRO and SEARO Exceptions, Based on counts with known gender

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In 2014 3 million children & adults tested HIV +ve in 81 LMIC reporting on HIV+ve testsbut 50% of people with HIV remain undiagnosed

Source: GARPR 6 July 2014; 81 low and middle-income countries reporting both adults and children who tested HIV-positive in 2014. Important to note this is not equivalent to new infections or HIV-prevalence as it includes re-testers and known positives. GARPR 6 July 2015 , select countries GARPR (WHO, UNAIDS; UNICEF); HIV prevalence estimates accessed 7 July 2015 UNAIDS AIDSinfo.org

Note this is for countries reporting number tested and positive for children and adults

Zambia and South Africa not depicted as Positive tests are not reported.13

Outside of Africa, those who tested HIV+ve more likely to be men in all regionsSource: GARPR (WHO, UNAIDS, UNICEF) 6 July 2015. 65 countries reporting men and women tested HIV-positive and received their results, in 2014. Important to note this is not equivalent to new infections or HIV-prevalence as it includes re-testers and known positives. In 2014, in 65 countries reporting, approximately 2 million adults (15+) tested HIV+veBased on (65 countries)Total PositiveTotal Male PositiveTotal Female PositiveTotal CountriesMale %Female %AFRO1,881,668654,6721,226,9962635%65%AMRO14163791762461256%44%EMRO22071437770565%35%EURO579535482247861%39%SEARO266,004149,209116,795756%44%WPRO278461576912077757%43%Total1,984,135715,8491,268,2866436%64%

Based on counts with known gender (Male, Female adults 15+).

If you include children, nearly 3 million children14

HTS positivity rate - proportion people testing HIV+ve & estimated national HIV prevalence, 27 reporting countries in WHO African RegionSource: GARPR 6 July 2014; 81 low and middle-income countries reporting both adults and children who tested HIV-positive in 2014. Important to note this is not equivalent to new infections or HIV-prevalence as it includes re-testers and known positives. GARPR 6 July 2015 , select countries GARPR (WHO, UNAIDS; UNICEF); HIV prevalence estimates accessed 7 July 2015 UNAIDS AIDSinfo.org

Note this is for countries reporting number tested and positive for children and adults15

Source: GARPR 6 July 2015 , select countries GARPR (WHO, UNAIDS; UNICEF); HIV prevalence estimates accessed 7 July 2015 UNAIDS AIDSinfo.org In many low prevalence settings adult (15+) men more likely to test HIV+ve than womenoften exceeding national HIV prevalence estimates

Note this is for countries reporting number tested and positive for adults16

Source: 1. UNAIDS 2014; 2. GARPR 6 July 2015 , select countries GARPR (WHO, UNAIDS; UNICEF); HIV prevalence estimates accessed 7 July 2015 UNAIDS AIDSinfo.org Thailand

Cascade of people with HIV diagnosed and undiagnosed in Thailand (millions), 20141 Proportion adults (15+) testing HIV-positive, disaggregated by men and women) compared to estimated HIV prevalence, 201421.8 million people with HIV in Thailand & >70% have been diagnosed1.

>1.3 million adult men and women received HTS and 1.3% tested HIV-positive, in 20142.

Majority adults receiving HTS services were womenbut adult men were ~2x more likely to test HIV-positive cf adult women (Fig. 2.)2. Adults 15+MenWomenTotalTotal tested332,0121,009,0291,341,041Tested HIV- positive 12,0385,74217,780

Note this is for countries reporting number tested and positive for adults17

Source: GARPR 6 July 2015 , select countries GARPR (WHO, UNAIDS; UNICEF); HIV prevalence estimates accessed 7 July 2015 UNAIDS AIDSinfo.org BoliviaProportion adults (15+) testing HIV-positive, disaggregated by men and women) compared to estimated HIV prevalence, 20142Adults 15+MenWomenTotalTotal tested49,654322,844372,498Tested HIV- positive 1,3456912,036

Estimated national HIV prevalence is 0.03%.

>372,498 adult men and women received HTS and 0.5% tested HIV-positive, in 20142.

Majority adults receiving HTS were womenbut adult men were nearly 2.5x more likely to test HIV-positive compared to adult women (Fig. 2.)2.

Data are for the registration of HIV tests that are performed routinely in the network of establishments. Note this is for countries reporting number tested and positive for adults. The number of cases reported is the total of reported cases confirmed with WB in national reference laboratories.18

Source: GARPR 6 July 2015 , select countries GARPR (WHO, UNAIDS; UNICEF); HIV prevalence estimates accessed 7 July 2015 UNAIDS AIDSinfo.org United Republic of TanzaniaAdults 15+MenWomenTotalTotal tested935,8281,533,1822,469,010Tested HIV- positive 124,606155,46315,990

Estimated national HIV prevalence is 5%.

2.5 million adult men and women received HTS and 11% tested HIV-positive in 20142.

Majority adults receiving HTS were womenthe proportion of adult men testing HIV-positive was 13% compared to 10% among adult women2.

Note this is for countries reporting number tested and positive for adults. Data is from routine programme reporting. HIV testing and counselling services programme reports.19

Source: GARPR 6 July 2015 , select countries GARPR (WHO, UNAIDS; UNICEF); HIV prevalence estimates accessed 7 July 2015 UNAIDS AIDSinfo.org BotswanaAdults 15+MenWomenTotalTotal tested107,563207,622 315,185Tested HIV- positive 8,13213,86621,998

Estimated national HIV prevalence is 22%.

>300,000 adult men and women received HTS and nearly 7% tested HIV-positive in 20142 cf national adult prevalence of >20%

Adult men were 2x less likely to receive HTS than adult womenbut the proportion of men testing HIV-positive was slightly higher 8% compared to 7% 2.

Note this is for countries reporting number tested and positive for children and adults. Data is from reporting health facilities and NGOs. Data was compiled from the public facilities and civil society organizations providing HTC services. Data from CSO lumps age 0-4 and doesn't disaggregate by 350 cells: pooled 59%

Missing PopulationsMenKey PopulationsYoung women (not pregnant)Highly AcceptableHome based 82% (#18)Index partner 93% (#6)Mobile/outreach 93% (#9)Workplace 59% (#4)

Source : Suthar 2013; WHO 2014??

MENTION test for triage.25

Chart10.540.460.90.10.950.05

PLHIV diagnosedPLHIV undiagnosed

Sheet1PLHIV diagnosedPLHIV undiagnosedSeries 3Current coverage54%46%2020 Goal90%10%2025 Goal95%5%2030 Goal100%To resize chart data range, drag lower right corner of range.

Chart1178100001265000516000

CoveredUncovered

Sheet1CoveredUncoveredPeople with HIV17810000People diagnosed HIV-positive12650005160000.7102751263To resize chart data range, drag lower right corner of range.

Healthcare

Where are we on HIV testing services - the achievements and the gaps