Feedback
3.1.1 Background
Among people newly diagnosed with TB globally in 2022, 80% had a documented HIV test result (1). At the regional level, the highest percentages were achieved in the WHO African and European regions, at 89% and 93%, respectively, in 2022 (1). Globally 7.3% of people with a new episode of TB who had an HIV test result were living with HIV. HIV testing for people with diagnosed or presumptive TB offers a strategic entry point to a continuum of prevention, care, support and treatment of HIV and for TB. Offering HIV testing services along with TB contact tracing among close or family contacts of people with TB can help in the targeted scale-up of HIV testing, and in TB prevention due to early identification of those who do not know their HIV status, early initiation of ART and treatment of TB disease or TB infection when TB disease is ruled out.
3.1.2 Summary of evidence and rationale
Recommendations 22–26: HIV testing for people with presumptive and diagnosed TB and their contacts
Evidence from a review of studies that informed these recommendations found that offering HIV testing, now referred to as “HIV testing services” (HTS) to people with presumptive and diagnosed TB and their contacts yields a high number of new diagnoses of HIV (10), also for those with presumptive TB who turn out not to have TB disease (94, 95). A systematic review of HIV prevalence among adults with signs and symptoms of TB, primarily among studies conducted in sub-Saharan Africa, showed substantial variability in the yield of HIV testing, with a median HIV prevalence from 19.2% (interquartile range: 8.3–40.4%) at the community level to 55.7% (interquartile range: 20.9–71.2%) at primary care level and 80.7% (73.8–84.6%) among hospital inpatients (96). Despite the low quality of evidence at the time of policy update in 2012, the GDG strongly recommended routine HIV testing and counselling to all people with presumptive and diagnosed TB as benefits of testing accrue to the individual, their partner, the family and the community at large.
The two recommendations on the provision of HIV testing services to household or close contacts of people with TB were based on a study in a concentrated HIV epidemic setting which showed a relatively high yield of HIV testing in contacts of people with TB, with a higher HIV prevalence rate (13.8%) among contacts of people with HIV-associated TB as compared with contacts of people who had TB but not HIV (2.5%). Furthermore, there was a 74% acceptance rate of HIV testing among contacts of people with TB (21).
HIV partner services is a process whereby a trained provider offers voluntary HTS to the partners and contacts of consenting HIV-positive individuals. WHO recommends a range of feasible and acceptable HIV partner service approaches to enable programmes to reach as many people with HIV as possible, which can be adapted according to setting, population, available resources and client preferences. Provider-assisted referral for HIV testing (also called assisted partner notification, index testing or family-based index case testing) is an effective method of delivering HIV partner services to people with TB living with HIV and is an important strategy for extending HIV testing, prevention and treatment services to their sexual partners and household members (21).
The provider can contact partner(s) by telephone or email or in person and offer them home-based HIV testing services or invite them to visit a facility to receive HIV testing services. Assistance in partner notification for sexual or drug-sharing partners, with shared disclosure and mutual support, may also improve the uptake of and adherence to ART, benefiting both the index individual and their partners regardless of HIV status (97). A strategic mix of facility-based, community-based, home-based and HIV self-testing options should be made available to ensure access to HIV testing services across these groups.
In all circumstances, HTS should be provided in accordance with WHO’s essential five Cs: consent, confidentiality, counselling, correct test results and connection or linkage to prevention, care and treatment. Age-appropriate algorithms should be in place for undertaking HIV testing in young children, and HIV testing should be family- and child-focused. All people diagnosed with HIV should be offered HIV prevention, diagnosis, treatment and care services, including ART. These services should be offered by TB programmes or through effective referral to HIV services.
