Know Your HIV Status

This article recently appeared in the December 2018 issue of Health Affairs. You can read the original here.

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The theme of World AIDS Day 2018 is “Know your status.” That sounds simple enough, and it’s not particularly inspiring, but HIV testing is the critical step for people to take so they can get services they need—and health care practitioners can achieve epidemic control. Testing is very important for this reason: UNAIDS reports that only three out of four people living with HIV know that they are HIV-positive. This means there are potentially millions of people worldwide who are infected but don’t know it. Reaching the remaining 25 percent poses many challenges because of persistent stigma and discrimination, lack of confidentiality, and the natural tendency to wait until one is sick before seeking testing. For decades before the “test and treat approach” became the norm, we also sent a confusing and disincentivizing message to the public by waiting until severe immunodeficiency occurred before initiating HIV treatment.

It didn’t used to be so simple to be tested for HIV. When I worked as a clinician for Project HOPE in Swaziland, we didn’t even have HIV testing capability to screen and protect the blood supply until 1988. I gladly gave up my office to make space for the new lab equipment when it arrived at the hospital. On the children’s ward where I worked, we witnessed an explosion of unusually sick children, eventually concluding that the HIV epidemic was unfolding before our very eyes. A system for voluntary counseling and testing (VCT) was urgently needed in the community because it wouldn’t have worked in the health system at the time. Thanks to technical support provided by brilliant colleagues from Uganda, Project HOPE started the first VCT center in Swaziland in 1989, providing a unique and reassuring venue to which to refer the mothers of all those sick children. The fathers were harder to reach, and their status was poorly understood. Add to that the fact that the clinical tools available at the time for HIV were highly limited, and it is clear that this was a very discouraging era for health workers and the public at large.

A number of advances rapidly accelerated HIV testing in Africa in the mid-to-late 1990s. Affordable rapid HIV tests became widely available and offered accurate results in a matter of minutes. This was revolutionary. VCT centers rapidly increased in number and geographic distribution. Evidence accumulated that VCT could change behavior to prevent HIV. More-effective treatments and the recognition of a strong link between HIV and TB also encouraged more routine testing in health systems. Highly active antiretroviral therapy, in which three or more drugs are used, was announced in 1996, but the drugs remained costly and did not become widely available until nearly ten years later, with the advent of the Global Fund and the President’s Emergency Plan for AIDS Relief (PEPFAR). In 2013 it was discovered in the landmark HPTN 052 study by the HIV Prevention Trials Network that treatment with antiretroviral drugs prevented HIV transmission in 96 percent of discordant couples. A public health approach of testing contacts of a first-known patient living with HIV, or index case, ensued, and innovative approaches such as self-testing for HIV were introduced. We’ve come a long way with HIV testing.

It has taken thirty years for the world to finally assemble the arsenal needed to stop HIV in the absence of an efficacious vaccine: test and treat, pre-exposure prophylaxis, male circumcision, index case testing, and self-testing for HIV. We’re there. At Project HOPE we look forward to finding innovative solutions to overcome the remaining program barriers to access to these solutions.