1. Dossier of evidence Why is it necessary to scale up HIV testing in Europe?

2. Content Know your HIV epidemic – the situation of HIV in Europe
Late diagnosis of HIV infection
Characteristics of persons with late HIV diagnosis
Consequences of late diagnosis
Barriers to HIV testing
Overcoming barriers to HIV testing
Monitoring and evaluation
Conclusions
Content slide

3. Know your HIV epidemic The situation of HIV in Europe

4. Situation of HIV in Europe People living with HIV
In the WHO Europe region it is estimated that around 2.3 million people are living with HIV (end 2011)
Approaching 1 million in the European Union
1.4 million in Eastern Europe and Central Asia
Of these 30-50% are unaware of their HIV infection...and even more in some countries
Key populations at higher risk of HIV in Europe are:
Men who have sex with men
Injecting drug users
Sex workers
Migrants
Prisoners
Estimated number of people living with HIV in the WHO European region and percentage that are unaware of their HIV infection.
Hamers FF & Phillips AN, Diagnosed and undiagnosed HIV-infected populations in Europe HIV Medicine (2008), 9 (Suppl. 2), 6–12
UNAIDS, Global report: UNAIDS report on the global epidemic 2012

5. Situation of HIV in Europe Annual number of new HIV cases European region 2006-2010
Annual number of new HIV cases (incidence) in the WHO European region. Note the high number of new HIV cases in Eastern Europe and Central Asia.
Stagnated HIV epidemic in Western and Central Europe, escalating HIV epidemic in Eastern Europe and Central Asia
World Bank & WHO, HIV in the European Region, Policy Brief, 2013

6. Characteristics of cases
Situation of HIV in Europe HIV infections diagnosed in WHO European Region
In Western Europe the most common transmission mode for HIV is men who have sex with men (MSM)
Furthermore, despite a decrease in new infections in Western Europe, new 2013 data shows a rise in HIV incidence has occurred in MSM in some parts of Western Europe
Characteristics of cases
WHO European Region*
West*
Centre*
East
Number of HIV cases
25 659
2 478
90 198
Rate per population
13.7
6.6
1.3
31.7
Percentage of cases
Age years**
11.6%
10.0%
17%
13%
Female
38%
27%
19%
42%
Transmission mode**
Heterosexual
43%
24%***
24%
48%
Men who have sex with men
20%
39%
29%
0.7%
Injecting drug use
23% 4%
Unknown
16%
41% 7%
New HIV infections in WHO European region in Note the difference between groups most affected in the different regions. Also the high number of newly HIV infected injecting drug users in East is worth nothing.
*No data from the following countries: Austria, Liechtenstein, Monaco.
**Countries with no data on age or transmission mode excluded.
***Excludes individuals originating from countries with generalised epidemics.
ECDC/WHO, HIV/AIDS Surveillance in Europe, 2010
Phillips AN, et al. Increased HIV Incidence in Men Who Have Sex with Men Despite High Levels of ART-Induced Viral Suppression: Analysis of an Extensively Documented Epidemic. PLoS ONE, 2013

7. Situation of HIV in Europe AIDS diagnoses 2004–2010 WHO European Region
Trends of AIDS diagnosis from 2004 to 2010 in WHO European region.
The increasing number of AIDS diagnosis in East reflect problems with access to ART in this region resulting in higher morbidity and mortality.
ECDC/WHO, HIV/AIDS Surveillance in Europe, 2010

8. HIV Testing Guidelines
European HIV testing guidelines recommend:
1. Making voluntary, confidential and free HIV testing available in a variety of settings:
Routine and universal offer to attendees of specified services:
STI clinics
Antenatal
Termination of pregnancy
Drug dependency services
Patients with clinical indicator disease attending a range of healthcare services (e.g. patients with tuberculosis, viral hepatitis and lymphoma)
Community testing sites/outreach targeted at key populations at higher risk at conveniently located testing sites and with the involvement of target populations
2. Robust monitoring and evaluation
European HIV testing guidelines recommend routine offer of HIV testing in specific healthcare settings and targeted testing interventions for key populations at higher risk
World Health Organization. Scaling up HIV testing and counseling in the WHO European Region - as an essential component of efforts to achieve universal access to HIV prevention, treatment, care and support. Policy framework Geneva: World Health Organization.
World Health Organization. Guidance on provider-initiated HIV testing and counselling in health facilities. WC Geneva: World Health Organization.
.European Centre for Disease Prevention and Control. HIV testing: increasing uptake and effectiveness in the European Union. Stockholm: ECDC; 2010.

9. The HIV treatment continuum
Example from France, showing ART uptake, retention in care and treatment success
150,200
121,400
111,300
96,800
84,200
51%
92%
87%
87%
Supervie et al. Presentation. HIV in Europe, March2012

10. Know your HIV epidemic Template slide for national data
Populate this slide with the below:
Number of new diagnoses per year
Total number of people living with HIV (PLHIV)
PLHIV in need of treatment on ART
Key populations at higher risk of HIV
Geographical spread
Time trends
National HIV testing guidelines
Useful resources:
ECDC/WHO: HIV/AIDS surveillance in Europe 2011 (2012)
ECDC: HIV testing: increasing uptake and effectiveness in the European Union (2010)
WHO: Scaling up HIV testing and counselling in the WHO European Region (2010)
These data are important to track to follow the trend(s) in the national epidemic – to know who, where and when to test.

11. Late diagnosis of HIV infection

12. What does late diagnosis/ presentation for HIV care mean?
The expression late presentation is used when people are unaware of their HIV infection and not diagnosed until their CD4 count is below 350 cells/mL or have an AIDS-defining event, regardless of the CD4 cell count
The expression presentation with advanced HIV disease is used when people are diagnosed with a CD4 count below 200 cells/mL or an AIDS-defining event, regardless of the CD4 cell count
A common definition of late presentation/diagnosis and presenting/diagnosed with advanced HIV infection is important to facilitate cross-country or regional comparisons and to allow investigation of temporal trends.
European late presenter working group: Late presentation of HIV infection: A consensus definition, HIV Medicine 2010

13. Late diagnosis in Europe
In 21 countries across Europe (EU/EEA) with available data in 2011:
49% of all HIV cases were diagnosed late (27-68%)
Including 29% with advanced HIV disease
In 7 countries across Europe (non-EU/EEA) with available data in 2011:
62% of all HIV cases were late diagnosed (22-76%)
Including 38% with advanced HIV disease
Not all countries have data on late diagnosed HIV infections. But available data shows that between 49-62% are diagnosed late in the WHO European region and between 29-38% are diagnosed with advanced HIV disease.
ECDC/WHO Europe, HIV/AIDS surveillance in Europe

14. Late diagnosis in Europe
Although there has been a small downward trend over the years, data shows that very little has changed in terms of reducing late diagnosis
Figure 1. Changes over time in late presentation and CD4 count at HIV diagnosis: COHERE 2000–2011.
Mocroft A et al. Risk Factors and Outcomes for Late Presentation for HIV-Positive Persons in Europe: Results from the Collaboration of Observational HIV Epidemiological Research Europe Study (COHERE). PLoS Med, 2013

15. Late diagnosis in Europe
LP decreased over time in both Central and Northern Europe among homosexual men, and male and female heterosexuals, but increased over time for female heterosexuals and male intravenous drug users (IDUs) from Southern Europe and in male and female IDUs from Eastern Europe.
Late presenters had 6-13 fold excess risk of contracting AIDS or die within first year after diagnosis
Earlier and more widespread testing, timely referrals after testing positive, and improved retention in care strategies are required to further reduce the incidence of late diagnosis across Europe (and elsewhere)
Mocroft A et al. Risk Factors and Outcomes for Late Presentation for HIV-Positive Persons in Europe: Results from the Collaboration of Observational HIV Epidemiological Research Europe Study (COHERE). PLoS Med, 2013

16. Late diagnosis of HIV infection Template slide for national data
Populate this slide with the below:
Percentages of new HIV cases who present with late diagnosis
Percentages of new HIV cases who present with advanced HIV infection
Useful resources:
ECDC/WHO: HIV/AIDS surveillance in Europe 2011 (2012)
Available data on late diagnosed HIV infections and people diagnosed with advanced HIV disease can be found on the link on the slide.

17. Characteristics of persons with late HIV diagnosis

18. Characteristics of persons with late diagnosis
Across Europe the most common characteristics of persons with late diagnosis include:
migrant status
being older
being heterosexual (not in Eastern Europe)
living in low HIV prevalence areas
being male
having children
...but...
Showing the most common characteristics across Europe of persons with late diagnosis of HIV.
Adler A, Mounier-Jack S & Coker J
Late diagnosis of HIV in Europe: definitional and public health challenges AIDS Care 21, 03 (2009)

19. Characteristics of persons with late diagnosis
Characteristics vary from country to country
The prevalence of late diagnosis in any given risk group will depend on a number of factors and vary between countries. These factors include the following…
Local trends in the incidence of infection
The perception of risk by individuals
The availability of testing programmes and access to these
Awareness in healthcare settings of HIV and the willingness to carry out an HIV test
Laws discriminating PLHIV and high-risk groups
... but characteristics vary from country to country and depend on of a number of factors. It is important, on a national basis, to identify factors that may led to late diagnoses of HIV infection and characteristics of persons with late diagnosis of HIV.

20. Consequences of late diagnosis

21. Consequences of late diagnosis
Increased mortality and morbidity
Increased transmission of HIV to uninfected people
Increased economic burden for healthcare systems
There are 3 main consequences of late diagnosis; increased mortality and morbidity; increased transmission of HIV; and increased economic burden for health systems.

22. Consequences of late diagnosis Increased morbidity and mortality
Late diagnosis causes:
Increased risk of acquiring co-infections
Increased risk of treatment failure
Up to a third of all HIV-related deaths are estimated to be a consequence of late diagnosis
Up to 33% of all HIV-related deaths are estimated to be a consequence of late diagnosis.
Moreno S, Mocroft A & Monfonte A Review: Medical and Societal consequences of late presentation Antiviral Therapy, 2010, 15, suppl 1; 9-15.
Adler A, Mounier-Jack S & Coker J. Late diagnosis of HIV in Europe: definitional and public health challenges AIDS Care 21, 03 (2009)

23. Consequences of late diagnosis Increased morbidity and mortality
Cumulative probability of death of people with HIV according to timing of diagnosis
Showing the cumulative probability of death because of late diagnosis.
It is very clear that people diagnosed late have a much higher risk of HIV-related death (the red top line).
Nakawaga F et al. Projected life expectancy of people with HIV according to timing of diagnosis. AIDS 2011, 25.

24. Benefits of early diagnosis
Earlier HIV diagnosis is one of the most important factors associated with better life expectancy
The benefits of early HIV testing on morbidity and mortality:
“With timely diagnosis, access to a variety of current drugs and good lifelong adherence, people with recently acquired infections can expect to have a life expectancy which is nearly the same as that of HIV negative individuals.”
As also shown in the graph on the last slide, if diagnosed early and well treated, people can live with HIV almost as long as those who are HIV negative.
Nakagawa F, May M, Phillips A. Life expectancy living with HIV: recent estimates and future implications. Curr Opin Infect Dis Feb;26(1): doi: /QCO.0b013e32835ba6b1.

25. Consequences of late diagnosis Increased transmission of HIV
Late HIV diagnosis contributes to the spread of the HIV epidemic because:
People on ART who are well-treated are less likely to transmit HIV onwards (a decline of 96% has so far been reported between early vs. delayed initiation of ART)
Evidence shows that people who know they are HIV positive decrease risk behaviour
People unaware of their HIV infection do not get treatment (ART) and are thus more infectious than people who know their positive HIV-status and are on ART. One of the consequences of this is that about half of all new HIV infections derive from people unaware of their positive HIV status.
Moreno S, Mocroft A & Monfonte A Review: Medical and Societal consequences of late presentation Antiviral Therapy, 2010, 15, suppl 1; 9-15.
Marks G, Crepaz N and Janssen RS, Estimating sexual transmission of HIV from persons aware and unaware that they are infected with the virus in the US. AIDS 2006, 20:1447–1450.
Hall HI et al. HIV Transmission Rates from persons living with HIV who are aware and unaware of their infection, United States AIDS 2012.
Cohen MS, Chen YQ, McCauley M, Gamble T, Hosseinipour MC, Kumarasamy N, et al. Prevention of HIV-1 infection with
early antiretroviral therapy. N Engl J Med. 2011;365:493–505.

26. Consequences of late diagnosis Increased transmission of HIV
It is estimated that 54% of all new HIV infections derive from people who are not aware of their positive HIV status
Unaware of infection
Accounting for:
Aware of infection
Data from the US shows that the 25% who are unaware of their HIV infection account for 54% of new HIV infections.
Campsmith ML, Rhodes PH, Hall HI, Green TA. Undiagnosed HIV prevalence among adults and adolescents in the United States at the end of J Acquir Immune Defic Syndr. 2010;53:
Marks G et al. Estimating sexual transmission of HIV from persons aware and unaware that they are infected with the virus in the US AIDS 2006, 20:1447–1450.

27. MSM in the UK The source of most new infections is from undiagnosed men
Observed increases in HIV incidence in last 10 years despite an increase in the precentage of MSM on fully suppressive ART
Increasing trends likely explained by more condom-less sexual behaviour
Source of new infections in 2010:
undiagnosed primary infection 48%
undiagnosed not primary infection 34%
diagnosed ART naive 10%
diagnosed ART experienced 7%
If testing frequency was increased to 68% of all MSM each year (compared with current rate of 25%), it is predicted that incidence would be reduced by 25%
More testing = less new infections
more testing = less new infections
Phillips A et al. Increased HIV Incidence in Men Who Have Sex with Men Despite High Levels of ART-Induced Viral Suppression: Analysis of an Extensively Documented Epidemic. PLoS One 2013

28. Benefits of early diagnosis Cost-effectiveness of HIV testing
Medical expenses for late diagnosis are up to 3.7 times as high as expenses for timely diagnosis and treatment
Even after 7 to 8 years, late diagnosis is still associated with higher cumulative expenses
Studies suggest that HIV testing remains cost-effective as long as the undiagnosed HIV prevalence is above 0.1%
Late diagnosis of HIV is more expensive for health systems than early HIV diagnosis. The degree to which HIV screening is cost effective can vary with type, frequency and context; improving with increased undiagnosed HIV prevalence in the population being screened. Studies from the US and France suggest that HIV testing remains cost-effective as long as the undiagnosed HIV prevalence is above 0.1%. Below this threshold, consideration should be given to testing only in circumstances where the added cost of performing a test can be justified. Justifications include potentially adverse consequences if the HIV infection is not identified. Cost-effectiveness analyses assume that individuals diagnosed with HIV enter care and have access to antiretroviral therapy, and hence will benefit from treatment.
Krentz, HB & Gill MJ. Cost of medical care for HIV-infected patients within a regional population from 1997 to HIV Medicine (2008), 9, 721–730.
Fleishman JA, Yehia BR, Moore RD, Gebo KA& HIV Research Network . The Economic Burden of Late Entry Into Medical Care for Patients With HIV Infection. Med Care December ; 48(12): 1071–1079.

29. Benefits of early diagnosis Cost-effectiveness of HIV testing
Data from France showing HIV testing to be cost-effective when undiagnosed HIV prevalence is above 0.1%
Undiagnosed HIV prevalence
0% % % //
Base case *
Direct method
Late diagnosis of HIV is more expensive for health systems than early HIV diagnosis. The degree to which HIV screening is cost effective can vary with type, frequency and context; improving with increased undiagnosed HIV prevalence in the population being screened. Studies from the US and France suggest that HIV testing remains cost-effective as long as the undiagnosed HIV prevalence is above 0.1%. Below this threshold, consideration should be given to testing only in circumstances where the added cost of performing a test can be justified. Justifications include potentially adverse consequences if the HIV infection is not identified. Cost-effectiveness analyses assume that individuals diagnosed with HIV enter care and have access to antiretroviral therapy, and hence will benefit from treatment.
*QALY – quality of life years
Yazdanpanah Y, et al. (2010) Routine HIV Screening in France: Clinical Impact and Cost-Effectiveness. PLoS ONE 5(10): e doi: /journal.pone

30. Benefits of early diagnosis Cost-effectiveness of HIV testing
Cost-effective threshold for expanded HIV testing in the US
1 new HIV diagnosis/1,000 tested in general medical services3
Shown to be cost-effective in:
US1: to test every 3 years costs $63,000 per QALY
France1: to test everyone once costs €56,000 per QALY
Absence of published data for Europe:
Expansion of HIV testing cost of £7,500 per QALY gained (RTI, Gilead Fellowship) - UK
No indication in which services HIV testing would be most cost-effective
HIV testing has shown to be a cost effective intervention in US general medical services when 1 out of 1000 tests is found to be positive.
QUALY= quality adjusted life years
1. Paltiel AD et at, N Engl J Med 2006/2005.
2. Yasdanpanah Y et al. Routine HIV Screening in France: Clinical
Impact and Cost-Effectiveness. Plos One 2010.
3. MMWR 2006.

31. Benefits of early diagnosis Summary
Late presentation delays access to ART, adversely impacting on the health of the individual while also allowing inadvertent onward transmission
The solution is more effective strategies to:
Test more effectively
Ensure better access to care for those diagnosed

32. Barriers to HIV testing

33. Barriers to HIV testing
Barriers to HIV testing exist on three levels
Patient level
Healthcare provider level
Institutional/policy level
Barriers to HIV testing have to be confronted at different levels.

34. Barriers to ask for HIV testing Patient level
Patient level barriers vary from country to country – but cross-cultural barriers include:
Low-risk perception
Fear of HIV infection and its health consequences
Fear of disclosure (worries about stigma, discrimination and rejection by significant others)
Denial
Difficulty accessing service, especially migrant populations
Barriers to HIV testing at patient level vary from country to country, but some barriers are common.
Deblonde J et al. Barriers to HIV testing in Europe: a systematic review. European Journal of Public Health, 2010, Vol. 20, No. 4, 422–432.

35. Barriers to offer HIV testing Healthcare provider level
Healthcare provider level barriers to HIV testing:
Insufficient time
Burdensome consent process
Lack of knowledge/training
Pretest counselling requirements
Competing priorities
Inadequate reimbursement
Patient not perceived to be at risk
Leading to many missed opportunities for HIV testing within healthcare setting encounters
Barriers to HIV testing at healthcare provider level
Mounier-Jack Set al. HIV testing strategies across European countries. HIV Medicine (2008), 9 (Suppl. 2), 13–19.
Sullivan AK, Raben D, Reekie J, Rayment M, Mocroft A, et al. (2013) Feasibility and effectiveness of indicator condition-guided testing for HIV: results from HIDES I (HIV Indicator Diseases across Europe Study). PLoS One 8: e doi: /journal.pone
Partridge DG et al. HIV testing: the boundaries. A survey of HIV testing practices and barriers to more widespread testing in a British teaching hospital International Journal of STD & AIDS 2009; 20:

36. Barriers to HIV testing Institutional/policy level
Barriers at institutional/policy level:
Lack of national policy/guidelines for HIV testing
A recent survey revealed that only half of European countries have national guidelines on HIV testing
Laws and justice systems that jeopardise HIV prevention efforts
Laws that criminalise PLHIV (for not disclosing, exposing and transmitting)
Laws that criminalise sex workers, injecting drug users and men having sex with men
Laws that do not protect PLHIV against discrimination
Barriers to HIV testing at institutional/policy level.
Global Commission on HIV and the Law. HIV and the Law: Risks, Rights & Health. UNDP, HIV/AIDS Group, 2012.

37. Barriers to HIV testing Laws and policy system/enabling legal and social environments for MSM (men who have sex with men)
The legal and social environments for MSM vary from country to country and influence barriers to HIV testing.
World Bank & WHO, HIV in the European Region, Policy Brief, 2013

38. Barriers to HIV testing Template slide on country data
Populate this slide with the below:
What are the barriers to asking for an HIV test (patient level)?
What are the barriers to offering an HIV test (healthcare provider level)?
What are the barriers at an institutional/policy level?
Are policy/guidelines for HIV testing implemented?
Are laws and justice system jeopardising HIV prevention efforts?

39. Overcoming barriers to HIV testing

40. Overcoming barriers Implementation of national HIV testing guidelines
According to European guidelines scaling up of HIV testing should be done in compliance with core principles for an ethical approach based on human rights
WHO has outlined 10 main principles for HIV testing, including detailed recommendations for endeavouring the scaling up of HIV testing
Some of the principles are as follows…
National guidelines on HIV testing should be implemented and in accordance with European guidelines from WHO or ECDC.

41. Overcoming barriers Implementation of national HIV testing guidelines
HIV test must be voluntary and confidential
Expanded HIV testing must be tailored to different settings, populations and client needs
Expanded HIV testing must expand beyond clinical settings and involve civil society organisations
Provider-initiated testing in health facilities should be implemented when appropriate
Efforts to increase access to HIV testing must be accompanied by efforts to ensure supportive social, policy and legal environments
Five of the ten main principles from WHO guidelines.
WHO/Europe. Scaling up HIV testing and counselling in the WHO European Region

42. Overcoming barriers Outreach to populations at higher risk of HIV
Many populations at higher risk of HIV are in limited contact with the healthcare system
Special interventions designed to reach these groups are essential, e.g.:
Community based walk-in rapid HIV testing
Mobile clinics
Offer tests at needle and syringes programmes
Peer-led mobile outreach programme for sex workers
Must be offered in a non-judgmental manner
Peer-driven recommendation is advisable, i.e. awareness raising activities (to combat stigma and discrimination, to inform target groups on risk and risk behaviour, link to test and care)
Populations at higher risk must be targeted with special interventions.
WHO/Europe. Scaling up HIV testing and counselling in the WHO European Region, 2010.

43. Overcoming barriers Normalisation of HIV testing
Offer of HIV test acceptable to patients in many settings e.g. 83% acute medical patients
But tests often not offered, e.g. only 43% cases of tuberculosis tested for HIV
High variability between clinicians in offering HIV tests e.g % among doctors
Missed opportunities for HIV testing
Opt-out (automatic) testing leads to increased testing rates, e.g. 96% for antenatal screening in UK in 2010
Most people accept an offer of an HIV-test.
Ellis S et al. Clinical Medicine 2011; 11:
Thomas William S et al. Int J STD & AIDS 2011; 22:
Petlo T et al. Int J STD & AIDS 2011; 22:
National Antenatal Infections Screening Monitoring. HPA.

44. Approaches to testing complimentary testing is effective
Self referral
Healthcare facilities
Community based testing (check points)
Provider-initiated
All (non-targeted)
Subgroup (targeted)
Ethnicity, country of origin, sexual preference, etc
Type of condition presenting

45. Overcoming barriers Indicator Condition guided HIV testing
An approach by which healthcare professionals can be encouraged to test more patients based on suspicion of HIV
In healthcare settings where HIV testing is not part of standard medical care HIV testing should be offered routinely for certain clinical conditions
A number of diseases can indicate an undiagnosed HIV infection
It has been demonstrated that testing for these ‘indicator diseases’ will detect higher than average rates of HIV and is a cost-effective intervention
Useful resources:
HIV in Europe: HIV Indicator Conditions: Guidance for Implementing HIV Testing in Adults in Health Care Settings (2012)
People with specific diseases should be offered an HIV test in healthcare settings where HIV testing is not part of standard medical care.
HIV in Europe. HIV Indicator Conditions: Guidance for implementing HIV testing in adults in Health Care Settings 2012.

46. Overcoming barriers Indicator condition guided HIV testing
Feasibility and effectiveness
Indicator condition guided testing is an effective method of targeting HIV testing
Individuals having HIV test (number)
HIV positive (number)
Prevalence
(95% Cl)
Total
3588 66
1.84 (1.42 – 2.34)
Indicator condition
Sexually transmitted infection (STI)
764 31
4.06 (2.78 – 5.71)
Malignant lymphoma (LYM)
344 1
0.26 (0.006 – 1.61)
Cervical or anal dysplasia or cancer (CAN)
542 2
0.37 (0.04 – 1.32)
Herpes zoster (HZV)
207 6
2.89 (1.07 – 6.21)
Hepatitis B or C (HEP)
1099 4
0.36 (0.10 – 0.93)
Ongoing mononucleosis-like illness (MON)
441 17
3.85 (2.26 – 6.10)
Unexplained leukocytopenia/thrombocytopenia (CYT) 94 3
3.19 (0.66 – 9.04)
Seborrheic dermatitis/exanthema (SEB) 97
2.06 (0.25 – 7.24)
North
West Central
East Central
South
Total number of tests (%)
1288 (35.9)
459 (12.8)
1412 (39.4)
429 (12.0)
Number tested HIV positive
8 (0.6)
17 (1.5)
23 (1.6)
28 (6.5)
Sullivan et al. Feasibility and Effectiveness of Indicator Condition-Guided Testing for HIV: Results from HIDES I (HIV Indicator Diseases across Europe Study). PLOS ONE 2013.

48. Monitoring and evaluation

49. Monitoring and evaluation
Monitoring and evaluation (M&E) is an essential component of an HIV testing programme and ensures that the programme provides high quality HIV testing
FACTS criteria can be used when designing M&E:
Feasibility
Acceptability
Effectiveness and Cost-effectiveness
Target populations are reached
Sustainability
Monitoring and evaluating HIV testing programmes are essential.
ECDC, HIV testing: increasing uptake
and effectiveness in the European Union, 2010.

50. Monitoring and evaluation Examples of indicators to assess local HIV testing initiatives using FACTS criteria
Criteria for project success
Examples of indicators
Feasibility
Number and % of persons offered HIV testing
% newly diagnosed individuals who are successfully transferred to care within three months
Acceptability
Number and % uptake of an HIV test (overall and among populations at higher risk)
% of patients agreeing that the offer of an HIV test in this setting is acceptable
% of patients willing to disclose risk behaviour
% of staff reporting barriers to offer an HIV test in this setting
% of staff reporting specific training needs
Effectiveness and Cost effectiveness
Positivity rate (overall and among populations at higher risk)
Staff costs associated with intervention
Resource costs associated with intervention
Outcome of cost-effectiveness model
Target populations reached
% of populations at higher risk who had an HIV test in the last 12 months and know their results
Positivity rate among populations at higher risk tested in the setting
Sustainability
Number and % uptake of an HIV test (overall and among populations at higher risk)
Examples of indicators to assess HIV testing initiatives using FACTS criteria.
ECDC, HIV testing: increasing uptake and effectiveness in the European Union, 2010.

51. Examples of indicators
Monitoring and evaluation Examples of indicators for monitoring at national level
Examples of indicators
Process Indicators
Existence of national testing policies and guidelines that are consistent with international standards (WHO/UNAIDS)
% men and women who had an HIV test in the last 12 months and know the results
% of populations at higher risk (MSM, IDU, migrants) who had an HIV test in the last 12 months and know their results
% of pregnant women who have been tested for HIV in the last 12 months and know their results
% of TB patients who have been tested for HIV in the last 12 months and know their results
% of STI patients who have been tested for HIV in the last 12 months and know their results
Number and proportions of persons offered testing stratified by setting (particularly, anonymous testing sites and primary care sites)
Outcome indicators
Total number of new diagnoses stratified by populations at higher risk including unknowns
Number and % of new diagnoses which are diagnosed late with CD4 <200 (overall and by population at higher risk)
Number and % of new diagnoses which are diagnosed late with CD4 <350 (overall and by population at higher risk)
Number and % of new diagnoses which are diagnosed late with AIDS at presentation (overall and by overall and by population at higher risk)
% new diagnoses who are recently infected (RITA or other seroconversion algorithms)
% of newly diagnosed individuals who are successfully transferred to care within three months (overall and by population at higher risk)
Total number and proportion of undiagnosed infections
Number and proportion in populations at higher risk of undiagnosed infections
Examples of indicators for monitoring at national level.
ECDC, HIV testing: increasing uptake and effectiveness in the European Union, 2010.

52. Monitoring and evaluation Template slide on country data
Populate this slide with the below:
Have a robust monitoring and evaluation system been implemented?
What criteria have been used when deciding indicators?
Useful resources:
ECDC: HIV testing: increasing uptake and effectiveness in the European Union (2010)

53. Conclusions

54. Conclusions Rationale for HIV testing (and timely treatment and care):
Reduce mortality and morbidity
Reduce the onward transmission of HIV
Lessen the economic burden for health systems
Barriers to HIV testing may exist at three different levels:
Patient level
Healthcare provider level
Institutional/policy level
The benefits of early HIV testing.

55. Conclusions
Populations at high risk should be targeted with focused interventions
National HIV testing guidelines should be implemented and should take an ethical approach based on human rights principles
Training and awareness raising is crucial in order to normalise HIV testing in the healthcare system, e.g. by implementing indicator condition-guided HIV testing
Laws that jeopardise HIV prevention efforts should be abolished
Monitoring and evaluation systems should be implemented
Barriers to HIV testing can be confronted at different levels.

56. Examples of efforts to scaling up HIV testing
For examples of testing initiatives visit the European HIV testing week website at