Based on the results of a systematic literature review, a World Health Organization (WHO) expert panel concluded that trained and supervised lay health workers should be permitted to provide HIV testing services (HTS). A report on the literature review and the expert panel’s rationale for its conclusion was recently published in AIDS Care.1
Led by Caitlin Kennedy, PhD, director of the social and behavioral interventions program in the department of international health at Johns Hopkins Bloomberg School of Public Health in Baltimore, Maryland, the study was commissioned by WHO to inform decision making on whether WHO guidelines should recommend that countries allow lay providers to conduct HIV testing.
Currently, only 42% of 50 countries permit lay health are workers —healthcare workers who are trained to provide specific interventions, but who lack formal professional or paraprofessional certificates or postsecondary education — to perform rapid diagnostic testing (RDT) for HIV.
In an email interview, Dr Kennedy told Infectious Disease Advisor that HIV testing services must be expanded in order to achieve the United Nations 90-90-90 target, in which 90% of people living with HIV know their status; 90% who know their status are on antiretroviral therapy; and 90% on antiretroviral therapy achieve viral suppression.2 She noted that testing programs facilitate diagnosis and access to treatment among people who are HIV-positive, while simultaneously reaching populations at risk and linking people who are HIV-negative to prevention programs. “In many countries, a critical shortage of healthcare providers limits expansion of testing services, and traditional testing approaches such as clinic-based testing may do a poor job of reaching populations that are most likely to be HIV-infected but not know it, such as key populations, young people and men,” she noted.
In order to perform the literature review, Dr Kennedy and colleagues searched 10 electronic databases for peer-reviewed studies comparing the effectiveness of RDT performed by lay providers to RDT performed by professional healthcare workers, or to no intervention. They also examined studies focused on end-users’ values and preferences regarding RCT performed by lay providers. Ultimately included in the review were 5 studies on effectiveness and 6 studies on values and preferences. Of the 5 studies on effectiveness:
- One from Malawi demonstrated an increase in testing from 1300 tests per month in 2003 to 6500 tests per month in 2009 when testing was delegated to lay providers with 13 weeks of training.
- One randomized trial from the United States showed that emergency department patients randomly assigned to receive HTS by lay providers (trained HIV counselors) had a testing uptake of 57% (1382/2446) vs 27% (643/2409) in patients randomly assigned to receive HTS by regular emergency department healthcare providers (emergency service assistants).
- A total of 3 studies from Cambodia, Malawi, and South Africa showed that HTS results from lay providers and professional healthcare workers were highly concordant, with sensitivity calculated as ≥98%.
Analysis of the values and preferences studies evinced support for the use of lay providers, particularly in studies that examined their use in real-world vs hypothetical scenarios.
The expert WHO panel made the following recommendation based on the literature review in combination with prior program experience and cost considerations: “Lay providers who are trained and supervised to use rapid diagnostic tests (RDTs) can independently conduct safe and effective HIV testing services.”
“As many countries still require HIV testing services to be performed only by nurses, doctors, or other health care professionals, country adoption of this recommendation and changing policies that limit HIV testing to professional health care providers could increase availability of HIV testing services worldwide and facilitate them better reaching the populations who most need to be tested and linked to HIV prevention and treatment services,” concluded Dr Kennedy.
- Kennedy CE, Yeh PT, Johnson C, Baggaley R. Should trained lay providers perform HIV testing? A systematic review to inform World Health Organization guidelines [published online April 24, 2017]. AIDS Care. 2017:1-7. doi:10.1080/09540121.2017.1317710
- 90–90–90 – An ambitious treatment target to help end the AIDS epidemic. UNAIDS. www.unaids.org/en/resources/documents/2017/90-90-90. Published January 1, 2017. Accessed April 29, 2017.