POLICY BRIEF
HIV TESTING
WHO RECOMMENDS HIV TESTING BY LAY PROVIDERS JULY 2015
New Consolidated guidelines on HIV testing services from the WHO recommend that Lay providers who are trained can, using rapid diagnostic tests, independently conduct safe and effective HIV testing services.
Task sharing: larger role for trained lay providers Task sharing – that is, rational redistribution of tasks between cadres of health-care providers with longer training and other cadres with shorter training, including trained lay providers – is a pragmatic response to health workforce shortages. It seeks to increase the effectiveness and efficiency of all available personnel and, thus, to enable the existing workforce to serve more people. Expanding HIV testing services (HTS) to trained lay providers working in the community may help to increase access to these services and their acceptability to people from key populations and other priority groups. These groups may be reluctant or unable to use HTS in health facilities.
As part of developing the new consolidated guidelines on HTS, the WHO Guideline Development Group reviewed the evidence on HIV testing by lay providers. The Group considered the evidence and made the following recommendation:
New recommendation Lay providers who are trained can, using rapid diagnostic tests, independently conduct safe and effective HIV testing services. [ moderate quality of evidence , strong recommendation ].
WHO had previously recommended that lay providers perform and promote various health services but had not formally considered HTS. Task sharing to scale-up HTS has taken place for over a decade in many countries across the Americas, Europe, sub-Saharan Africa and Asia, but it can be expanded. Several systematic reviews, from various domains of health care, support the general conclusion that transferring more tasks to nurses and to lay or community health workers can lead to good health outcomes.
Lay provider — any person who performs
functions related to health-care delivery and has been trained to deliver specific services but has received no formal professional or paraprofessional certificate or tertiary education degree. Services delivered by trained lay providers, including peer-led interventions, can be both welcome and important, providing information and teaching skills that facilitate safer behaviours. Trained lay providers based in the community or a facility can conduct HTS and also can link people to treatment and prevention services and provide ongoing care and support. Beyond this, trained lay providers who are their clients’ peers can act as role models and offer non-judgemental and respectful support. Their role can help to reduce stigma, expand the coverage of HTS and improve the uptake of services.
#Test4HIV WHO/HIV/2015.14
Guangzhou Centre for Disease Control and Prevention; Guangdong Province, China.
Key evidence Key evidence supporting a larger role in HTS for lay providers includes: • Uptake of HTS can increase when trained lay providers deliver services. • HIV testing conducted by trained lay providers is accurate – as accurate as testing by laboratory staff and health-care providers. • Clients express satisfaction and support for services delivered by trained lay providers. • National policies permit trained lay providers to perform HIV testing with RDTs in 21 of 48 countries studied worldwide, including 16 of 25 countries in Africa. Even more countries permit lay providers to give pretest information and post-test counselling (28 of the 48 countries worldwide and 20 of the 25 African countries). • Trained lay providers can deliver various other health services, beyond HTS and HIV prevention, care and treatment, such as vaccination, screening and testing for tuberculosis and sexually transmitted infections and distributing bed nets for malaria prevention. • Task sharing with trained lay providers may cost less than using other health workers to perform the same tasks. Full programme costs, costeffectiveness and affordability vary, however.
• HTS can be more sensitive to the culture of the community when offered by trained lay providers. Trained lay providers may reach more people because they often are culturally competent at talking with their peers, particularly people from key populations and adolescents.
standards can help to ensure that lay providers offer high-quality HTS and are adequately trained in medical ethics and how to conduct full HTS procedures. • Adequate remuneration. Trained lay providers should receive adequate wages and/or other appropriate compensation. Otherwise, turnover may be high. The main reason for involving lay providers is to increase access to HTS, not to cut costs. • Policy and regulatory change. National policies need to establish a role for trained lay providers with special skills to perform HTS and to include their terms of reference in the national salary grid. National policies and regulatory frameworks, such as human resource for health and HIV testing policies, should address the roles of trained lay providers.
Considerations for success For successful implementation of HTS conducted by trained lay providers, programmes should consider: • Appropriate selection. Programmes should select and train lay providers who are well-matched to the people they serve. They may be their clients’ peers, people with HIV and people from key populations. Trained lay providers should have the trust of their clients and demonstrate professional conduct, knowledge, skill in dealing with sensitive issues, respect for confidentiality and an ability to listen. • Training, mentoring and ongoing support. As for all health-care providers, ongoing supportive supervision of lay providers should cover both the testing and counselling aspects of their work, provide up-to-date job aides and standard operating procedures, and involve regular external quality assessment. A system for quality assurance, including external quality assessment should be in place for HTS provided by trained lay providers. National competency
Policies should permit trained lay providers to provide all HIV testing services, including collecting specimens, performing HIV rapid diagnostic test, interpreting tests results and issuing an HIV status, giving pre-test information and post-test counselling, and supporting linkages to prevention, care and treatment services.
For the full guidelines see http://www.who.int/hiv/ topics/vct/en/
For more information, contact: World Health Organization Department of HIV/AIDS 20, avenue Appia 1211 Geneva 27 Switzerland
POLICY BRIEF E-mail: hiv-aids@who.int www.who.int/hiv © World Health Organization 2015
WHO RECOMMENDS HIV TESTING BY LAY PROVIDERS