WHO HTS Guidelines - Presentation Part 1: Who HTS: HTS Info On The Go: WHO HTS Data Dashboards
WHO HTS Guidelines - Presentation Part 1: Who HTS: HTS Info On The Go: WHO HTS Data Dashboards
WHO HTS Guidelines - Presentation Part 1: Who HTS: HTS Info On The Go: WHO HTS Data Dashboards
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Access the full
guidelines on the
WHO HTS APP!
• Search ‘WHO HTS Info’ wherever you
get Apps
• Notifications when new content is
available
• Search, save, send
• Country HTS data in one place w/
guidelines
• Language updates: French on the
way!
• Available online and off
• Videos coming for 2020
New WHO HTS Guidelines for a changing epidemic
Outline
80%
60%
20%
0%
2015 2016 2017 2018
91% 89%
85% 87%
79% 79% 82% 80%
76% 78% 77% 77% 78%
72% 74% 72%
69% 69%
64%
53%
47%
East and Southern Africa West and Central Africa Asia and Pacific Caribbean Eastern Europe Central Middle East North Africa Latin America
Asia
3.1 million 1.8 million 1.9 million 100,000 500,000 130,000 400,00
undiagnosed undiagnosed undiagnosed undiagnosed undiagnosed undiagnosed undiagnosed
20.6 million PLHIV 5 million PLHIV 5.9 million PLHIV 340,000 PLHIV 1,700,000 PLHIV 240,000 PLHIV 1.9 million PLHIV
fri ca f SSA
A
t he rn All o
Sou
ica
al Afr r ica
e ntr A f
C
ste rn
We
f rica
e rnA
t
Eas
8
Slide courtesy of Maheu-Giroux 2019, ICASA
Number of people with HIV who do not know their
64% 76%
The number of adult
PLHIV aware of
their status but not
on ART is higher
The number of adult
than the number
PLHIV unaware of
who do not know
their HIV status
their HIV status
decreased from 2.5
to 1.5 million
Source: Estimates shared in personal communication from K Giugere, M Maheu-Giroux, JW Eaton, October 2019; UNAIDS/WHO, 2019; Marsh K et al AIDS. 2019, doi: 10.1097/QAD.0000000000002355
HIV testing and treatment scale-up has led to
declining HTS positivity in many settings
(% testing positive in national HTS programme)
5+)
e n (1
m
Wo
5+ )
n (1
Me
11
Slide courtesy of Maheu-Giroux 2019, ICASA
Absolute diagnosis gaps in 2018
Number to
diagnose to
All sub- reach 90% target
2020 90%
Saharan Africa target
12
Slide courtesy of Maheu-Giroux 2019, ICASA
Distribution of new HIV infections (2018)
West and Central Africa Eastern and Southern Africa
(among 15-49 years) (15-49 years)
13
Source: UNAIDS 2019 Estimates
Comparison of awareness of HIV status:
men with men who have sex with men
5 +)
1
e n(
M
MSM
91 countries with
policies, of which 73
are using partner
services
77 countries with
policies, of which 38
97% 96% are fully
82% implementing
57% 55%
20%
PITC ANC HTS Community HTS Partner Lay provider HTS HIVST
notification
PITC based on reported use, 2018=126/130 countries reporting; ANC HTS based on reported use, 2018=125/130 countries reporting; Community HTS based on reported use, 2018=107/130 countries reporting; Partner
notification or index testing based on reported policy and use, 2018=73/128 countries reporting; Lay provider HTS based on reported use, 2018=71/130 countries reporting; HIVST based on policy and full implementation,
2018=77/194.
Number of countries with a provider-assisted referral policy
(often called partner notification or index HIV testing), 2017-2018
61% and 70% of countries reporting had an assisted partner notification or index HIV testing policy in
2017 and 2018, respectively
50 68%
45 61% 44
59%
40 38
40%
35
32
30 30
30
5 4 4
0
AFR AMR EMR EUR SEAR WPR
2017 # With Policy 2017 Total # Reporting 2018 # With Policy 2018 Total # Reporting
GAM – WHO, UNAIDS, UNICEF, 25 June 2019; reported by WHO region 2017 = 72/118 countries reporting; 2018=91/130 countries reporting
National HIVST policy and implementation 2018, by region
40% (77/194) reporting countries have HIVST policies, of these only 49% (38) are implementing
% Implementing
8% 46%
19
18
0%
48% 6% 5% 4%
11 11
10 19%
9 9
8
7 7 7
6 6
5 5 5
4 4 4
3 3 3 3
2 2 2 2 2
1 1 1 1 1 1 1 1
Asia and Pacific Caribbean East and Eastern Europe Latin America Middle East and West and Western and
# Reporting Southern Africa and Central Asia North Africa Central Africa Central Europe
and North
N=40 N=16 N=21 N=16 N=17 N=21 N=25 N=41
America
HIVST Policy and implementation HIVST policy and pilots HIVST policy only, no pilots or implementation No HIVST policy
No HIVST policy but policy under development
Source: GAM WHO, UNAIDS, UNICEF 15 July 2019
Priorities for first 95
Tremendous progress over last decade:
Closer to achieving first 90 – but priority populations still missed.
Achieving high awareness of status is challenging:
Key populations are more likely to be undiagnosed.
Partners of PLHIV, STI patients missed
In southern Africa, men (25+) missed and AGYW incidence high and no standard
HTS in FP services.
WHO policy gaps
Significant gaps in implementation of WHO HTS guidelines – particularly high
impact differentiated HTS approaches.
2030 target is 95% awareness – how to achieve it:
Additional challenges, decreasing positivity.
Need to optimize HIV testing services to focus on priority populations.
Reduce both absolute and relative gaps. 21
Access the full
guidelines on the
WHO HTS APP!
• Search ‘WHO HTS Info’ wherever you
get Apps
• Notifications when new content is
available
• Search, save, send
• Country HTS data in one place w/
guidelines
• Language updates: French on the
way!
• Available online and off
• Videos coming for 2020
New WHO HTS Guidelines for a changing epidemic
New WHO guidelines on HTS for a changing epidemic
8 updates and new recommendations/guidance
Prioritizing population: Reaching who is missing?
• Globally the 21% of PLHIV
undiagnosed are primarily
• Biggest gaps in
• Key populations (KP) and their partners
• Men in high HIV burden settings
• Young people (age 15-24) from KP and in
high HIV burden settings
• FP service attendees in high HIV burden
settings
• Partners of PLHIV
• STI patients
• PLHIV lost to follow-up (also need to
tested to be re-engaged in care)
WHO recommended HIV testing service delivery approaches
HTS is an important gateway to treatment and prevention for individuals, partners, couples and families
Facility-based: Offering HIV testing in a facility, e.g. VCT, in-patient and out-patient
clinics, ANC, TB, STI, family planning/contraceptive services
Concentrated epidemic
WHO guidance:
33
**Simplified algorithm - consecutive reactive HIV tests only
Positive predictive value depends on positivity
Outcomes per 100,000 tested
Assuming 99% sensitivity; 98% specificity; simplified algorithm -- consecutive HIV+ tests only.
Prevalence Per 100,000 tested After 1 assay After 2 assays After 3 assays
9900 true+ (99%) 9801 true+ 9703 true+
10,000 HIV+
10% 1800 false+ (2%) 36 false+ 0.7 false+
90,000 HIV-
85% PPV 99.6% PPV 99.9% PPV
4950 true+ 4901 true+ 4851 true+
5000 HIV+
5% 1900 false+ 38 false+ 0.8 false+
95,000 HIV-
72% PPV 99.2% PPV 99.9% PPV
990 true+ 980 true+ 970 true+
1000 HIV+
1% 1980 false+ 40 false+ 0.8 false+
99,000 HIV-
33% PPV 96% PPV 99.9% PPV
99 true+ 98 true+ 97 true+
100 HIV+
0.1% 1998 false+ 40 false+ 0.8 false+
99,900 HIV-
5% PPV 70% PPV 99.1% PPV
34
Challenges in operationalizing diagnosis
guidance
Current guidance on choosing 2-test vs 3-
test strategy:
Countries experienced challenges in adopting
WHO’s diagnostic guidance.
Should reflect positivity amongst tested population
(not national prevalence).
Requires clarification in 2019 HTS GL revision.
Source: WHO GL 2019; WHO/UNAIDS/Malawi Department of HIV/AIDS, 2019 derived from Maheu-Giroux M et al AIDS 2019. DOI: 10.1097/QAD.0000000000002386.
It remains important to retest:
HIV Syphilis
1.4 M 930,000
2-23% 11%
MTCT
150,000 102,000
New infections (2015) Congenital infections (2012)