Evolution and scale up of global HIV testing service approaches
: 2000-2020

  • Vincent J. Wong

Student thesis: Doctoral Thesis


The HIV pandemic has existed for forty years. In 2020, there were an estimated 37.7 million individuals living with HIV/AIDS. HIV testing services (HTS) have been a critical intervention to the global HIV response, increasing knowledge of serostatus among persons living with HIV/AIDS and linking them to HIV treatment to reduce HIV-related morbidity, mortality and transmission.

This thesis integrates my 29 peer reviewed articles within a health service coverage framework, and includes additional contributions through conference abstracts and WHO guidelines from 2000 to 2020, along with a purposeful, non-systematic review of other relevant literature. Across studies, methods included randomized trials, observational studies, systematic reviews and critical commentaries. Ethical approvals are included, and broader ethical issues around programming are addressed. Throughout this period, four phases of HIV testing expansion are described and contextualize the thesis evidence base:

1. Early phase to increase HTS access (est. 2000-2004): Introduction and expansion of rapid HIV testing, a prevention paradigm, limited treatment availability and the establishment of WHO minimum standards.
2. HIV testing expansion (2005-2009): Increased funding, expansion of routine testing in clinical settings, a scale up of community approaches; expansion of treatment access
3. Clinical paradigm focus (2010-2017): Increased understanding of ‘treatment-as-prevention’ and early treatment, introduction of 90-90-90 goals and an increased focus on a continuum of HIV care
4. New HIV testing pathways (2017-2020) Expansion of HIV self-testing and index/partner testing to reach new sub-populations; new approaches given high rates of diagnosis in some countries.

Across the included studies and articles, HTS domains were outlined within the Tanahashi health service coverage framework to demonstrate the utility in analyzing program effectiveness and unmet need. and increased availability and accessibility were achieved through a number of key findings:

Accessibility and Availability
 . Increasing HTS Access through expansion of PITC, ANC testing and community based HTS that reached PLHIV earlier; critical assessments of the use of risk screening tools
• Expansion of index and partner testing and effectiveness around reaching undiagnosed sexual partners and identifying serodiscordant couples.
• Expansion of HIV self-testing with identified use and awareness, and leveraging to expand coverage for example within OPDs or for key populations. Measuring linkage and outcomes remains a challenge area.
Acceptability  • HIV testing quality evidence assessed the degree to which lay counselors have been integrated into national policies; factors related to misdiagnosis and misclassification in HIV testing programs; and programmatic output shifts resulting        from HTS optimization strategies that include the integration of index approaches. • HIV testing service delivery and linkage to care included assessments of data gaps, facilitators and barriers to linkage to treatment following diagnosis; how IPV services may be best integrated into standard HTS; and best practices for              providing psychosocial services for children receiving a positive result. Addressing Contact Coverage Gaps • Studies identified HTS gap areas in populations at risk including adult males and pediatric populations and identified correlates of     ‘never testing’ among males that included low HIV knowledge and higher acceptance of GBV and stigma. Through program data, testing access was shown to be higher in females than males across 20 sub-Saharan African countries, largely      a result of high ANC testing rates. Age of consent policies were identified as one barrier to testing in pediatric populations. 
Findings demonstrate contributions to key HTS elements that resulted in increases in effectiveness through increased proportions of PLHIV knowing their serostatus and accessing anti-retroviral therapy. Across lowand middle-income countries, knowledge of serostatus among persons living with HIV/AIDS increased to 84% in 2020, with 73% of all PLHIV were estimated to be accessing HIV treatment.
Evidence and practice from 20 years of HIV testing programming, along with health service coverage framing can inform future directions for achieving global 95-95-95 goals. Lessons learned from successes and challenges in HIV can inform responses to other current and future pandemics.
Date of AwardSep 2021
Original languageEnglish
SupervisorSasee Pallikadavath (Supervisor)

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