It appears that long process of developing new testing guidelines resulted in a final product that satisfies these two people with very high standards. But they note that it is in the implementation of the guidelines that the real challenges remain. The [him] moderator is on record that monitoring and evaluation is the biggest one.
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New guidance on recommended HIV testing and counselling
Comment
The Lancet 2007; 370:202-203. DOI:10.1016/S0140-6736(07)61102-7
Daniel Tarantola a and Sofia Gruskin b
After a series of meetings, open internet-based reviews, and
consultations over a year, WHO and UNAIDS recently released guidance
on HIV testing and counselling initiated by health providers.1 Those
not engaged in this exercise might not fully appreciate the evolution
of thinking represented by this final document, nor the role played
by active debate between constituencies with diverging views on key
issues. Among these issues was whether HIV testing should be included
in the panoply of routine tests given in health settings on the
initiative of the clinician, unless the patient specifically opted-in
by asking to be tested for HIV or opted-out by refusing the test,
despite not having been prompted to consent to it. Many found the
ideas confusing2–4 and questioned the underlying assumption of this
approach—ie, that patients who signed off on admission forms when
consulting or being admitted to a care facility de-facto agree to any
diagnostic test found necessary by the treating doctor. Concerns were
raised that, unlike other tests, in view of prevailing stigma,
discrimination, and risks of violence attached to an HIV-positive
result in many settings, particularly for women, specific individual
agreement to the test remained necessary.5,6
As the WHO/UNAIDS guidance evolved towards its now final form,
despite some reference to opting-in and opting-out, liberal use of
this language was dropped and replaced with ideas more reflective of
sound public health, medical ethics, and human rights. Specifically,
the ambiguous notion that providers would initiate testing (with lack
of clarity about whether this testing is with or without expressed
consent) has shifted to a model in which providers recommend testing
(thus proceeding with the test only after consent has been given by
the patient). The WHO/UNAIDS guidance continues to use the term
provider-initiated testing, but provider-recommended testing is now
what the guidance advocates. The crucial difference here is that
doctors are now encouraged to recommend a test, and not simply to
test without securing the patient's specific agreement. In many ways,
the WHO/UNAIDS document is far clearer and better anchored in
evidence than the rather confusing 2006 guidelines of the US Centers
for Disease Control and Prevention (CDC), to which it refers
supportively several times.7 The CDC guidelines use terms
inconsistently, and thereby create (deliberately or not) a wide space
for doctors to do HIV tests on patients with or without express
consent. The strength of the WHO/UNAIDS document lies in its
attention to specific elements to be considered when formulating or
reformulating HIV-testing policies according to various environments,
epidemic types, health settings, clinical presentations, and testing
practices.
Yet, several issues will require attention while this guidance is
implemented, including the rather vague approach to monitoring and
evaluation, even as WHO is under stress to anchor its guidelines more
strongly in evidence.8 Critical indicators, sources of information,
and means of measurement could have been suggested to set groundwork
for risk-management and further revisions of this guidance. The more-
than-elusive description of how the guidance is to be adapted to
specific country settings is another area that needs attention. This
description will require rapid pre-emptive measures by WHO/UNAIDS and
others, such as development of methods to facilitate adaptation
process, failing which adaptation might go astray on the initiative
of those who believe that widespread HIV testing is an effective
response to the epidemic.
A further issue is the lack of reference to how this form of testing
will intersect with the trend towards criminalisation of HIV
transmission,9 in particular when a previous record of a positive HIV
test could be interpreted to mean that a person knowingly transmitted
HIV to others, whether deliberately or negligently.
Policymakers may now opt-in to the guidance and model policies, and
practice can proceed along the lines proposed, even though there will
be substantial differences in how this change is made. Some
policymakers will no-doubt opt-out, holding that the guidance is
insufficient and does not respond to local realities. Clinicians,
other health practitioners, and civil society will have to be
vigilant in their attention to the uses and abuses of HIV-testing
policies as the policies are reformulated and, just as importantly,
to the observed gaps between public-health goals, policy, and
practice.
We declare that we have no conflict of interest. Both authors are
members of the UNAIDS Reference Group on HIV and Human Rights, which
commented on earlier drafts of the guidance.
References
1. WHO/UNAIDS. Guidance on provider-initiated HIV testing and
counselling in health facilities. Geneva, Switzerland: World Health
Organization, 2007:
http://www.who.int/hiv/who_pitc_guidelines.pdf
(accessed June 18, 2007)..
2. Human Rights Watch. Comments on WHO/UNAIDS draft, "Guidance on
Provider Initiated HIV Testing and Counseling in Health
Facilities"/Submission to WHO, January 2007
http://hrw.org/pub/2007/hivaids/hrwWhoGuidance.pdf
(accessed June 19, 2007)..
3. Jürgens R. "Routinizing" HIV testing in low- and middle-income
countries—background paper. New York, USA: Public Health Program of
the Open Society Institute, 2007:
http://www.soros.org/initiatives/health/articles_public...
(accessed June 19, 2007)..
4. Kippax S. Comments on guidance on provider-initiated HIV testing
and counselling in health facilities—WHO/UNAIDS document. Nov 27,
2006:
http://groups.yahoo.com/group/HIVtesting_policy/files/P...
(accessed Jan 7, 2007)..
5. Ehiri JE, Anyanwu EC, Donath E, Kanu I, Jolly PE. AIDS-related
stigma in sub-Saharan Africa: its contexts and potential intervention
strategies. AIDS Public Policy J 2005; 20: 25-39.
6. Medley A, Garcia-Moreno C, McGill S, Maman S. Rates, barriers and
outcomes of HIV serostatus disclosure among women in developing
countries: implications for prevention of mother-to-child
transmission programmes. Bull World Health Organ 2004; 82: 299-307.
MEDLINE
7. Centers for Disease Control and Prevention (CDC). Revised
recommendations for HIV testing of adults, adolescents, and pregnant
women in health-care settings
http://www.cdc.gov/hiv/topics/testing/resources/reports...
(accessed June 19, 2007)..
8. Oxman AD, Lavis J, Fretheim A. Use of evidence in WHO
recommendations. Lancet 2007; 369: 1883-1889. Abstract | Full Text |
Full-Text PDF (90 KB) | CrossRef
9. UNAIDS Reference Group on HIV and Human Rights. Criminalization of
HIV transmission. Feb 12–14, 2007:
http://data.unaids.org/pub/BaseDocument/2006/070216_HHR...
(accessed Jun 18, 2007)..
Affiliations
a. Faculty of Med
icine, School of Public Health and Community
Medicine, University of New South Wales, Sydney, NSW 2052, Australia
b. Program on International Health and Human Rights, Harvard School
of Public Health, Boston MA, USA
