AHF’s 12 TEST & TREAT PRINCIPLES
1) Conduct Targeted Community Testing among High-Risk Groups and establish Provider Initiated Testing and Counseling (PITC) at facility level.
The number of HIV-positive individuals who are unaware of their status is staggering. It is estimated that approximately 17 million individuals in Sub-Saharan Africa have undiagnosed HIV infection and only about 40% of people living with HIV know their status. Evidence indicates that individuals who do not know their HIV status are more likely to transmit the virus to others.Hence, testing efforts that enable people to know their status are paramount to deterring the spread of the virus. Establishing and ensuring convenient and accessible HIV testing services should become a standardized practice if the goal of global AIDS control is to be achieved. The large number of undiagnosed cases demonstrates the need for targeted testing to those populations that are at higher risk for HIV so that they can be diagnosed early. This should include routine provider initiated testing and counseling (PITC) since ill people whom physicians see may have HIV related symptoms which go unnoticed.
2) 80% Rapid Testing with Rapid Confirmatory Result (double rapid testing)
Some governments require the use of a Western Blot test to confirm a preliminary HIV positive result obtained via a rapid test. Depending on the setting, this practice can dramatically slow down the confirmation of an HIV positive test, and present a barrier to knowing one’s HIV status. AHF’s goal is to ensure that 80% of people identified as having a preliminary HIV positive result, receive a confirmatory diagnosis with a second different rapid test the same day.
3) Testing of Children and Partners of Clients at all ART Care and Treatment Sites
There are 2.4 million children living with HIV around the world and every year 400,000 babies are born with HIV. According to UNAIDS children are less likely to receive antiretroviral therapy than the population at large. In resource-limited settings many children die of undiagnosed AIDS, due to the lack of pediatric HIV-testing and late initiation of treatment. More attention needs to be placed on establishing protocols and systems which ensure that clients are aware of their children’s and partner’s status as well, to ensure that more children are put on lifesaving treatment earlier.
4) 80% Linked into Care from Testing within Three Months
AHF wants to ensure that at least 80% of HIV positive individuals are linked into care within twelve weeks after being diagnosed. Studies have shown that the average time frame between clients testing positive and enrolling into care is about one year.Such a long gap can lead to premature death and higher morbidity. This delay also increases the likelihood that individuals who are not on ART will transmit the virus to others due to having a higher viral load.
5) Provision of Integrated patient-centered care, including, free TB, HIV (including OI), drug-dependence, and STI medications..
In order to provide patient-centered care by increasing client retention and facilitating ART success, all AHF clinics (owned and supported) should make ART, opportunistic infections (OI), sexually transmitted infections (STI), drug-dependence and TB medications and HIV-prevention means available free of charge to PLWHA.
An effort should be made to optimize referral systems in order to improve effectiveness of the program and reduce client waiting time in the provision of comprehensive care and treatment services. When opening new clinics or expanding service programs, priority should be given to the decentralized care model.
In many countries people do not have the financial means nor the time to afford travelling to clinics and between health facilities to receive care and services that they need. This also applies to multiple referrals for consultations, lab and specialty care. Sometimes patients can be asked to pay for medicines for OI, TB and even ART. In such circumstances economic barriers can become the main impediment to successful ART. Studies have shown that integrated and decentralized care leads to better retention and beneficial health outcomes. There is also evidence that requiring payment for ART is associated with higher rates of loss to follow-up (LTFU) when compared to free provision of medications.
TB is the leading cause of death for HIV patients. The main cause of mortality for patients with co-infections is associated with delays in detecting TB infections and delays in initiating ART. Many studies have shown that when TB and HIV treatment programs are integrated, the outcomes in terms of mortality and morbidity are improved. AHF clinics should ensure availability of TB diagnostics, care and services to all patients registered in care.
Since HIV is primarily transmitted sexually, and is frequently present together with other STIs, treatment for STIs should be offered to patients when clinically appropriate. Additionally, establishing HIV testing at STI clinics with an appropriate linkage mechanism should be encouraged, given the likelihood of co-infections.
Injection drug use is another key risk factor for HIV transmission. Programs that offer HIV treatment in combination with drug replacement therapy such as methadone have demonstrated improved outcomes in terms of decreased LTFU, better adherence to ART and better survival. Based on this evidence AHF advocates for the integration of TB, STI, and drug treatment into the HIV treatment programs.
The provision of services, tailored to injection drug users’ needs, such as syringe distribution or exchange and provision of wound care supplies is encouraged for AHF programs that operate in places where injection drug use is a common mode of HIV transmission. Studies have shown that requiring payment for ART is associated with higher rates of LTFU when compared to free provision of medications. Therefore to limit LTFU, ensuring that ART and OI drugs are available to PLWHA free of charge should be a priority.
6) Universal Condom Availability at ART and Testing Sites & Prevention with Positives (PwP).
AHF’s prevention strategy includes universal condom availability and distribution of free condoms to HIV-positive people and their partners at all ART sites and within the community, especially in high-traffic areas. According to scientific evidence HIV-positive people who are aware of their status are less likely to engage in risky sexual behaviors that could potentially pass on the infection to their partners.
7) Initiation on ART in Less than 30 Days of Being Linked/Registered.
Given the WHO current guidelines, and in accordance with the median CD4 of patients upon linkage and/or patient’s clinical staging at registration, currently almost all patients are considered medically eligible for ART initiation. Globally, it is estimated that among the 30 million people who are living with HIV, only 5 million (17%) are on ART. Furthermore, delays in initiation of ART has been associated with poor health outcomes including increased mortality rates.
Reasons for this delay are multi factorial. Poor laboratory infrastructure is often detrimental to getting people on ART quickly. For instance, delays in receiving a CD4 test, in order to determine if a client is medically eligible for ART, has resulted in late initiation of treatment. Delays in treatment initiation are also often the result of operational and clinic flow barriers such as limited communication between different sections/departments of a clinic, copious requirements for pre-ART education, etc. AHF will attempt to overcome these barriers and reduce the time between linkage and/or registration as a patient to initiation on ART to 30 days or less.
8) Use of best available drugs in a first line ART regimen.
AHF favors the use of the best available as part of the first-line ART regimen. Tenofovir, when compared to AZT or D4T, has a more favorable side effect profile. AZT carries a high-risk of anemia which can worsen an individual’s baseline anemia due to malnutrition – a condition that is common in resource-limited settings, given food insecurities. An extensive body evidence shows that long-term irreversible side effects of D4T can result in toxic metabolic disorders and severe peripheral neuropathy. Based on this data, the WHO has changed its policy to include TDF as part of its recommendation for first-line ART regimens.
9) Three Month Follow-up Intervals for Stable Patients.
Stable HIV positive patients in care and treatment, should be seen by a medical provider at minimum every three months. Stable patients are defined as clients who do not have any acute illnesses and/or do not require an earlier follow-up. In addition to regular HIV primary care follow-up visits, medical providers should evaluate each patient’s ART medical eligibility. An evaluation should include a number of factors, such as whether the patient is yet to commence treatment, adherence to ART regimen and continued counseling on safer sexual practices. Asking stable patients to return more frequently than every three months puts an unnecessary burden on both the healthcare infrastructure and the patients. Stable patients will not necessarily need to see a physician for routine health evaluations and eligibility determination for ART initiation utilizing task-shifting models, can be done by mid-level healthcare workers and also by the use of Para-professionals “HIV Medics” as a task-shifting cadre developed and instituted by AHF to train individuals within their communities to provide tasks once performed by doctors and nurses such as triage, phlebotomy, vitals, medication refills, adherence counseling and finding defaulters for HIV and TB visits. WHO has recognized HIV Medics as a “best practice of task-shifting in their White Paper on task-shifting. Currently 100 HIV Medics have been trained and are being used in AHF’s Uganda and Zambia clinics.
10) 80% of All Patients Have their CD4 and Viral Load Count Evaluated at Least Once a Year.
Since the laboratory infrastructure is underdeveloped in many countries with a high burden of HIV, AHF aims to conduct CD4 counts and/or viral load count for at least 80% of all patients at each treatment site at least once per year. Evidence indicates that ART can be administered safely and consistently with limited laboratory monitoring.The use of CD4 counts is an inexpensive and accessible method of monitoring how a patient responds to treatment.
11) All clients receiving HIV care are screened for TB and have on-site full and immediate access to TB diagnosis and both preventative and curative TB treatment..
Given the deadly, intimate and complex association between HIV and TB-infection, AHF advocates for- and supports full integration of TB services and specific evidence-based interventions aimed at reducing TB transmission and TB prevention among PLHIV at all its supported HIV care and treatment facilities. Mortality of patients with co-infection is associated with delay in detecting active TB as well as delay in initiating ART. Many studies have shown that when TB and HIV treatment programs are effectively integrated, outcomes in terms of mortality and morbidity are improved. In all countries with a high burden of HIV, where TB is a leading cause of mortality, AHF supports implementation of the “Three I’s” for TB control among PLHIV: Intensive Case-finding (IC), Isoniazid Preventive Therapy (IPT) and Infection Control (IC). Rapid, accurate and cost-effective TB screening must be carried out for every client at every clinical visit for HIV care and treatment. Those positive at screening and any TB-symptomatic client, must undergo appropriate diagnostic work-up (with a special focus on the pediatric HIV population) and if confirmed to have clinical TB, must be registered for prompt effective treatment.
The screening tool (symptom screen, sputum test AFB or Xpert, urine LAM test and chest X-ray), and subsequent diagnostic methodology varies per country and per risk population and follows national policy and guidelines, in line with current WHO guidelines. Those negative after screening, with no clinical TB and no contra-indications must be offered Isoniazid Preventive Therapy (IPT) or one of its alternatives following national guidelines based on WHO Guidelines. AHF supports effective TB infection control strategies at all facilities where it supports HIV care services.
12) Universal Access to Second Line Treatment & Advocacy Efforts for Access to Third Line Treatment.
With the creation of the Global Fund and PEPFAR, ART initiation has increased exponentially. However, often this increase avails access for first-line and second-line ARV therapy remains limited. As the history of ART delivery in resource rich countries has shown, ART resistance will be a natural outcome of the administration of ART. Improved and cost effective detection for first line ART failure is crucial to keep patients on an active ART regiment that ensures their survival. Once failure is suspected or detected, second and third line ART must be immediately accessible. Given this compelling need, AHF advocates for universal access to life-saving second and third line treatment for those who require it. In countries where AHF operates, advocacy for access to second and third line treatment is crucial.