For years, HIV testing has been the cornerstone of plans to end the HIV/AIDS epidemic. Widespread testing programs have helped connect millions of people to HIV treatment and care and have been the first step in saving lives. However, an estimated 14 million more people who are living with HIV still haven't been tested and remain unaware of their status and unconnected to the treatment and care they need, according to the World Health Organization.
As those of us in the U.S. gear up to celebrate National HIV Testing Day -- a day intended to remind us all of the importance of knowing our HIV status -- it's important to look at ways to leverage HIV testing, whatever the result, to link more people to the services they need.
The benefits of immediately linking people who test HIV positive to care and treatment are clear. With evidence and guidelines pointing to the benefits of "test and start," should an individual want it, more people are being linked directly to antiretroviral treatment (ART) programs -- ideally, the same day they get test results. This has a positive impact on the health of the individual being treated and an added effect of preventing onward transmission once an individual on treatment achieves viral suppression, a concept also known as Undetectable = Untransmittable, or U=U.
But what about those who test negative? HIV testing is not, in and of itself, a prevention service. However, HIV testing linked to comprehensive prevention services is -- or at least it should be.
Comprehensive prevention is not just condoms, referrals for sexually transmitted infection (STI) treatment and -- depending on where an individual lives in the world -- possible counseling about voluntary medical male circumcision (VMMC) or pre-exposure prophylaxis (PrEP). It includes male and female condoms, condom-compatible lubricant, daily oral PrEP, STI treatment and linkages to the most appropriate and needed services, including VMMC, ART for partners living with HIV, opportunities to build social capital, financial support, harm reduction and much more.
In fact, if programs could leverage HIV testing expansion as an entry point for effective prevention, HIV prevention could be transformed and many of those most at risk of HIV could be reached with effective prevention options to protect themselves.
The key to this is regular and ongoing HIV testing for those most at risk. Many people in the U.S. will hopefully heed the call for HIV testing on June 27th and take advantage of programs that make it easy to test on that day. But, will they be linked to effective prevention that is also right for them? Will they commit to ongoing testing as part of that prevention package?
The era of PrEP is also the era of regular HIV testing, since safe and effective PrEP use requires HIV testing on a regular basis to ensure that the mono- or dual-therapy is not being used by someone who has acquired HIV. As PrEP use is increasingly seen as an important and empowering act of self-protection for anyone who uses it, how can that same empowerment principle be extended to regular HIV testing for all who are at risk, regardless of the prevention options they access?
HIV testing programs have come a long way in the last three decades in cutting down stigma, making testing more accessible and linking people who test positive to care and treatment. But programs, policies and funding have not moved where they need to be to link HIV-negative individuals to the prevention options they need. Everyone who tests for HIV -- no matter the result -- needs to be linked to comprehensive, integrated and sustained services that are culturally appropriate.
Is this happening? How often is it happening? No one knows. Data on services offered to people who test HIV negative are inadequate. Outside of the U.S., countries, funders and implementers report on "people reached" by simply counting referrals and condoms distributed, yet data on who is being reached -- particularly among populations at greatest risk -- are insufficient. In the U.S., these linkages vary widely based on the availability of funding and other support to often overstretched clinics and local AIDS service organizations that run testing programs.
What is the solution to linking HIV-negative people to effective prevention services? Data show that connecting people to services immediately after testing can help keep them negative. There are global guidelines in place from the World Health Organization, and national guidelines exist in several countries, including from the Centers for Disease Control and Prevention for the U.S. But experience shows that guidelines and policies do not always reflect the reality of programs and, most importantly, people's lives.
Moreover, funding plays a critical role in the realities of programs. Even as test-and-start treatment has become the standard that testing programs aim for in the U.S. and around the world, budget cuts and health care "reform" threaten to derail these evidence-based and policy-supported programs. Linking HIV-negative people to the services and care they need is likely to suffer even more with health care changes in the U.S. and domestic and global HIV budget cuts.
As advocates for evidence-based prevention, we at AVAC fight for policies that link all people who test to relevant, appropriate and user-friendly services. It's the right thing to do for individual health and to end the epidemic -- and it's cost effective and cost saving.
So, on this National HIV Testing Day, we call on individuals to get tested, know their status and take appropriate steps to access treatment and prevention. And, we call on funders and policymakers in the U.S. and around the world to support life-saving and cost-saving testing programs that are the cornerstone of a comprehensive, integrated and sustained response to HIV.
Mitchell Warren is the executive director of AVAC.