Gains and setbacks reported in African HIV testing scale-up efforts

May 2008

More than 40 million people have been tested for HIV in the past three years in Africa because of a dramatic increase in international HIV funding coupled with creative approaches to increase testing.

Although new programs mark increased efforts to fight HIV in Africa, the goal of universal testing faces numerous cultural, social and political barriers.

“The question should not be ‘have you ever been tested,’ but rather, ‘when was your most recent HIV test,’” said Elizabeth Marum, PhD, a behavioral scientist with CDC Global AIDS Program.

Continued international support for HIV testing in Africa, policy reform and the adoption of measures to increase numbers of health care workers are essential to increase access to knowledge of HIV status, Marum said. Currently, it is estimated that fewer than 20% of Africans know their HIV status. “We hope the 2007 Kenya AIDS Indicator Survey and other surveys will show a higher percentage of adults who report knowing their status,” Marum said.

Marum, who has visited many testing sites in many nations, presented both the triumphs of and pitfalls to HIV testing efforts in Africa at the 15th Conference on Retroviruses and Opportunistic Infections, held recently in Boston.

Barriers to testing

The global shortage of health care workers is one of the greatest obstacles to wide-scale HIV testing in Africa. “Advances in technology are sabotaged in many countries by the extreme shortage of health care workers,” said Marum. Health care workers are often too overburdened with acute cases to administer HIV tests. In addition, workers may believe lengthy counseling sessions are required when they administer HIV tests.

To address the shortage, many sites have trained laypersons to administer HIV tests. Some countries, however, adhere to rigid rules barring nonhealth care workers from giving tests.

Social barriers caused by fear of HIV status exposure and resulting discrimination also decrease testing efforts. Some adults may want to be tested, but their fear of exposure is too great.

Pediatric HIV testing rates remain extremely limited, also in part because of fear. “We’ve faced many barriers including fears about HIV testing and a sense of hopelessness about AIDS,” Marum said. “There is a conflict between parents’ readiness to accept a positive HIV diagnosis and the child’s right to access treatment.”

Improved technology

According to Marum, the availability of low cost and high quality rapid tests has been a key component of the scale-up in Africa.

Decreased wait times for HIV test results have already increased testing and acceptance. In 1999, the average wait for HIV test results was two-weeks. Same hour results were introduced in 2000-2001 in Malawi and Kenya and major increases in testing were reported. At some sites, counselors are able to perform HIV tests in front patient, including strip interpretation of rapid tests. This practice can make clients feel comfortable that their test results are correct because their blood does not leave their sight

“Many clients really love this approach,” Marum said. “They’ve told me ‘now that I’ve seen it done in front of me, I believe it.’”

Innovative efforts

Numerous measures and innovative efforts have been successful in increasing HIV testing in Africa. To increase access, many countries offer a wide range of sites for HIV testing. In Kenya, a youth center offers HIV testing in addition to an Internet café, billiards and other recreational activities. Other successful innovative test sites in Africa include the workplace, prisons, a center for the deaf and pediatric wards.

Mobile testing, including the use of camels for delivering HIV testing supplies and staff to nomadic people, is increasing in both numbers and use by target groups. In some countries, health care workers and community counselors go door-to-door to administer rapid HIV tests or set up tents as makeshift clinics. The mobile sites are also helping to decrease the stigma sometimes attached to HIV testing. “Even in rural communities, being seen going to a testing event doesn’t seem to affect uptake,” Marum said.

Malawi pioneered a national testing week in 2006. The testing goal was 50,000 people and 97,000 people were tested. Based on that success, Malawi officials held another national testing event in July 2007, through which 187,000 people were tested in only six days. In both cases, organizers exceeded ambitious testing goals, Marum said.

HIV testing events in Lesotho, Ethiopia, Malawi, Tanzania and Kenya have been successful in wide-scale testing because of marketing, promotion and advertising. Even simple gimmicks, such as plastic awareness bracelets, have boosted uptake at clinics.

“The nurses at one site in Zambia told me that after HIV tests, young people specifically ask for the bracelets as a sign that they’ve been tested,” Marum said. “This also suggests that promotion may help make HIV testing a social norm.”

Progress has met with challenges as some nations fail to accept measures to increase testing.

Kenya was one of the first countries in Africa to issue guidelines for testing in clinical settings. Guidelines introduced in 2004 established HIV testing as a standard of care, especially for pregnant women, at STD clinics and for tuberculosis patients. The introduction has lead to an increase in HIV testing in clinical settings.

The May 2007 release of the WHO and UNAIDS guidance on provider-initiated HIV testing and counseling in health facilities was a major development for promotion of clinical HIV testing. Many countries, however, have not yet adopted or adapted the guidelines.

Testing is especially limited for pregnant women, infants and children. In addition, testing rates for couples are low despite efforts to promote testing for this group.

Despite barriers, voluntary, client-initiated testing centers can be successful.

“After much advertising, the day the first center in Uganda opened for testing in 1990, one man showed up, and after his pretest counseling, he decided not to be tested,” Marum said. “Now millions have been tested in Uganda, so we know that even if it starts slow, people will come.”

For more information:

• Marum E. Scale-up of HIV testing in Africa. Presented at: The 15th Conference on Retroviruses and Opportunistic Infections; Feb. 3-6, 2008; Boston.