Understanding Universal Routine HIV Testing, Counselling and Treatment

THE UNAIDS 90-90-90 targets were launched in 2014 to accelerate progress so that by 2020, 90 percent, of all people living with HIV know their HIV status, 90 percent, of all people with diagnosed HIV are accessing sustained antiretroviral therapy and 90 percent, of all people accessing antiretroviral therapy are virally suppressed.

The report shows that in 2016 more than two thirds (70 percent,) of people living with HIV now know their HIV status. And of the people who know their status, 77 percent, were accessing treatment, and of the people accessing treatment, 82 percent, were virally suppressed, protecting their health and helping to prevent transmission of the virus.

To date, seven countries have already achieved the 90–90–90 targets, and these include: Botswana, Cambodia, Denmark, Iceland, Singapore, Sweden and the United Kingdom of Great Britain and Northern Ireland - and many more are close to achieving it.

Like we stated in our 2-part article titled: “AIDS to End by 2030: understanding the 90-9090 targets” which we published in this column recently, Zambia has adopted these fast tract targets and a lot of work has been and continues to be done to ensure that we are on course and that we attain these targets way before or indeed on time.

But where are we now, as a country?

Zambia currently has 1.2 million people living with HIV and AIDS. And to date, there are over 800,000 people who are on anti-retroviral therapy across the country.

Now, since the country has adopted the Test and Treat approach as I have mentioned in my previous articles and also as we saw from the theme of the HIV Testing, Counselling and Treatment (HTCT) launch last August, it means therefore that the country still has a gap of 400,000 people who need to be on treatment but they are currently not.

This is because they do not know their status…why? …they have not yet taken an HIV test.

The Zambia Population-based HIV Impact Assessment (ZAMPHIA) report of 2016 tells us that the proportion of Zambians who are living with HIV and know their HIV status is 67 per cent (i.e. nearly 70 percent,); leaving a gap of nearly 30 per cent of those that are HIV positive but do not know their status.

And every year, an estimated 46,000 people get newly infected with HIV in Zambia; with many of them being young women and girls aged 15 – 24 years old and also young men aged 25 – 35 years old.

Furthermore, over 35,000 people die annually in Zambia as a result of HIV-related causes.

Now with this scenario, I want to believe, the government, through the Ministry of Health (as the custodian of health matters in the country) had to take this bold and progressive policy decision to broaden, up-scale and fast track the uptake for HIV testing services (HTS) so the country is able to close this gap by reaching this 30 percent, of people who are living with HIV but have not tested and therefore are not accessing treatment.

Now, in our recent article on AIDS to End by 2030; understanding the 90-90-90 targets, I did mention that the danger associated with having people who are living with HIV but do not know their status is that they contribute to slowing down progress in strategies and measures being implemented to reduce new HIV infections; by simply not knowing their HIV-positive status, these folks are on the other hand increasing ‘community’ viral load levels.

These people are going about life as business as usual. There is a high likelihood that many of them may or could be engaging in unsafe sexual activities. And with higher viral loads, the chances of transmission to the next person (i.e. a sexual partner) are very high.

And so by expanding HIV testing services through various innovative strategies and policies such Universal Routine HIV Testing, Counselling and Treatment, this should put the country in a position where within reasonable space of time, we should have very low or indeed undetectable individual and community viral load levels and therefore significant reduction in or indeed the ultimate zero HIV transmission.

Of course this new policy and strategy (of Universal Routine HIV Testing, Counselling and Treatment) should and will work to consolidate on and complement other, already existing HIV testing approaches; and these include:

(i) mobile HIV testing, whereby HIV testers test large numbers of people in areas visited by the general public (such as markets, transport hubs or bus stations, shopping centres, roadsides e.t.c.); (ii) targeted mobile testing for key populations and adolescents (such as youth centres e.t.c.);

(ii) (iii) Facility-based client-initiated testing and counseling (VCT), where people walk-in to a testing centre or health facility to undergo or take an HIV test, usually after they have on their own made a decision to do so; (iv) communitybased testing where testers go door-to-door offering and conducting HIV testing and counselling, and also index testing where health care workers or trained lay workers visit households with existing HIV-positive members in order to target and test other household members; (v) the new modality or approach of HIV Self-testing, which we discussed at length in this column, a few weeks ago.

Now, Universal Routine HIV Testing, Counselling and Treatment should be looked at as an improved or strengthened or expanded form of provider-initiated HIV testing and counselling (PITC) where an individual patient is offered testing and counselling by a health care worker or trained lay health worker as part of medical care; hence testing and counseling is routine unless the patient declines or opts out of the test.

However, in many cases, in the implementation of PITC, health care workers, unfortunately, would mainly apply it (PITC) when they see a patient or client who would present with signs and symptoms that may be suggesting the possibility of HIV (such as in patients with conditions like TB, STIs, e.t.c) and indeed in antenatal settings; and so those people who went to the clinic with ailments that were not necessarily “directly or obviously” related to HIV would actually not be tested, even if in the real sense, the health care worker was required to offer HIV testing to all, according to the policy.

And so with Universal Routine HIV Testing, Counselling and Treatment, the health worker is ‘strongly’ advised to at all times be extra proactive in offering HIV testing to all patients or clients who visit the health facility, irrespective of the nature of the illness; whether it’s a tooth ache, an ordinary flu, a sore throat, a simple cough, a headache, a small pimple, a nosebleed, a fracture or even when someone is, say a known diabetic, hypertensive, asthmatic or indeed any other illness (you can think of) and they don’t have any complaint at all but have simply come to the clinic or hospital to pick up drugs, the health care worker must remember (indeed they must) as part of their routine and daily service delivery practice to offer HIV testing and counselling to all the patients or clients to they attend to, unless the patient or client has declined the test.

In all this however, the health care workers are advised and will be expected to observe and respect the patient’s or client’s human rights, the patient’s charter and indeed uphold medical ethics.

In other words, all the people who go to the health facilities seeking medical attention for various reasons will be routinely offered HIV testing but they will and they do however, retain their basic human rights.

This means that in order for an HIV test to be conducted, informed consent (written or even verbal) will still have to be obtained from the client or their guardian as the case may be, and those who don’t want the test to be done there and then, they still retain their right to say, ah ah, no!.. I don’t want to take the test today…kapena mailo…!

However, all our health care workers in Zambia now, more than ever before, have a duty to explain to their patients or clients whom they come across in the course of duty, all the benefits of taking an HIV test and knowing one’s status and starting HIV treatment early should the HIV test result be confirmed positive.

That said, we encourage our people, every Zambian to support this new, innovative and progressive policy of Universal Routine HIV Testing, Counselling and Treatment (URHTCT) which the government and indeed our health authorities and experts have launched.

We believe that fundamental human rights, the patient’s charter and medical ethics will be observed or respected; and people (i.e. clients or patients) will still retain their right to decline or opt out of the test; but again we advise that opting-in remains a progressive and healthy decision.

Our considered view and position is that this bold decision was taken in good faith and in the best interest of all Zambians; and therefore, we all need to work together, without leaving anyone behind as stakeholders, and without losing our renewed focus and determination towards achieving an HIV-free, AIDS-free Zambia by 2030.

We end here…. I will see you next week with yet another very important health topic.

We wish you good health.