Less than 12 percent of men and 10 percent of women in sub-Saharan Africa have been tested for HIV and received their test results, despite high levels of knowledge about the existence of HIV and the increasing provision of life-prolonging drugs through the public health sector.

The United Nations World Health Organization (WHO) on Wednesday called for health care providers to now begin routinely recommending an HIV test to patients attending their facilities, in a bid to increase the numbers of people who know their status. Until recently, the primary model for providing HIV testing and counselling has been client-initiated voluntary counselling and testing (VCT), rather than provider-initiated.

"WHO and UNAIDS strongly support the continued scale up of client-initiated HIV testing and counselling, but recognise the need for additional, innovative and varied approaches," WHO and UNAIDS said in new testing guidelines released this week. "Health facilities represent a key point of contact with people with HIV who are in need of HIV prevention, treatment, care and support."

The uptake of regular VCT has been limited by low coverage of services, fear of stigma and discrimination, and the perception by many people that they are not at risk. Approximately 80 percent of people living with HIV in low- and middle-income countries do not know their HIV status, WHO noted.

"Scaling-up access to HIV testing and counselling is both a public health and a human rights imperative," WHO HIV/AIDS director, Dr Kevin De Cock, said at a press conference. "Without a major increase in HIV testing and counselling in health facilities, universal access to HIV prevention, treatment and care will remain just a noble goal."

Shifting approach

Views on HIV testing have begun to shift: public health facilities in countries including Botswana, Kenya and Zambia are now routinely offering HIV tests to their patients.

"In Zambia, when provider-initiated testing was introduced, it was widely accepted for paediatric HIV testing, as well as in maternity, TB [tuberculosis] and VD [venereal disease] clinics," said Paul De Lay, UNAIDS director for monitoring and evaluation.

Integrating HIV testing into conventional health services in Botswana has increased testing uptake from 64 percent in 2004 to 83 percent in 2005, while the number of HIV positive pregnant women accessing antiretroviral (ARVs) drugs to prevent mother-to-child transmission has also risen significantly.

But there has been some debate about the effectiveness of provider-initiated testing in resource-poor settings where ARVs and other HIV services are not available.

"We are not pushing for stand-alone testing," said De Lay. "We are hoping that the phasing up of testing will happen in tandem with a phasing up of treatment as well."

Some community health care workers have also expressed concern that routine HIV testing at health centres has the potential to increase stigma and even deter people from seeking treatment for other conditions, but WHO and UNAIDS said the new guidelines continued to stress the importance of the voluntary and confidential nature of the testing process.

"The guidelines should in no way be read to be a move towards mandatory HIV testing," De Lay said. "They are in support of people's rights to health care."

According to Zackie Achmat, of South African AIDS lobby group, the Treatment Action Campaign, in order to reduce the stigma surrounding the epidemic, the management of HIV/AIDS should be treated as a normal part of medical treatment.

"I tested positive for HIV in 1990, and because I had early testing, I was able to access treatment early," said Achmat. "I have had four sero-negative partners since my diagnosis, and they are all still sero-negative; again, this is because I got tested and was able to take the necessary precautions."

Achmat stressed that the testing needed to be done in an arena of non-discrimination, so that all sections of the population had access to the services.

The guidelines suggest that in generalised epidemics, HIV testing and counselling be recommended to all patients attending all health facilities, while in concentrated, low-level epidemics, countries should consider offering HIV testing and counselling in specific health facilities such as clinics that deal with antenatal care, sexual diseases and tuberculosis.