Access to HIV testing and counseling is a key strategy in the prevention and control of the HIV/AIDS epidemic. By knowing their HIV status, infected individuals can access HIV-specific care and treatment, undertake interventions to reduce mother to child transmission and reduce their risk of transmitting to others. However, uptake of HIV testing and knowledge of HIV status is low in most countries worldwide .
The Eastern Mediterranean Region of the World Health Organization (WHO/EMRO) is particularly marked by a low coverage of antiretroviral therapy (ART) relative to the estimated need. The low coverage is not only owing to the inability of countries to provide ART, it is also the result of few HIV-infected persons knowing their serostatus or their status being known to healthcare providers. Little is known about the country specific policies and practices in the EMR that may be contributing to this limited coverage. Moreover, there is limited coverage of HIV prevention, treatment and care services for key populations at increased risk of HIV. This has resulted in limited access for those populations to HIV testing and counseling services. As a recovery measure for this deficiency in understanding, the access needs of the key populations at increased risk have translated into widespread mandatory HIV testing, thus losing the opportunity for instilling prevention and behavior change interventions.
The EMR comprises 22 WHO member states: Afghanistan, Bahrain, Djibouti, Egypt, the Islamic Republic of Iran (Iran), Iraq, Jordan, Kuwait, Lebanon, Libyan Arab Jamahiriya, Morocco, Oman, Pakistan, Palestine, Qatar, Saudi Arabia, Somalia, Sudan, Syrian Arab Republic, Tunisia, United Arab Emirates (UAE), and Yemen. The current review summarizes the available information on HIV testing policy and practice and HIV testing and counseling coverage. It explores attributes of prevailing policies and practices that may impact availability and coverage. For this purpose, three sources of information have been triangulated including a review of policies, a review of current practices and an analysis of country surveillance and program monitoring data reported to the WHO between 1995 and 2008.
We reviewed information available on HIV testing policies and practices in the 22 countries of the EMR. All countries and all the available information sources were used to enable maximum comprehension of the situation without any exclusion criteria. Sources included quarterly HIV surveillance reports sent to the WHO between 1995 and 2008, country reports on indicators for progress towards Universal Access to HIV prevention, treatment and care in 2008 and reports on findings of two reviews of HIV policies and practices commissioned by the WHO in 2008. From the reports on quarterly surveillance data and indicators of progress to Universal Access, we extracted information on the availability of HIV testing and counseling and on population coverage. The reviews applied a variety of methodologies for data collection, including reviews of the published and gray literature on HIV testing and counseling policies and practices, semistructured telephone interviews of key informants of National AIDS Programmes and field observations in four countries (Oman, Pakistan, Sudan and Egypt). These countries were selected with the intention of having examples from varied epidemic specificities (concentrated epidemic in Pakistan, generalized in Sudan and low level in Oman and Egypt), varied HIV response levels as well as geographic diversity. Field observations included site visits to various settings including voluntary testing and counseling (VCT) services, provider initiated testing and counseling services, HIV surveillance sites, blood banks and medical laboratories. Moreover, they included key informant interviews with representatives of the ministries of health, service providers, people living with HIV (PLHIV) and other stakeholders from 60 national and international institutions in all four countries. The interviews were tailored to the interviewee's affiliation and revolved around understanding the process through which people get to learn their HIV status. Literature reviews included national policy documents, guidelines, strategic plans, and reports of meetings, workshops and services.
Our policy review was guided by three over-arching attributes concerning HIV testing and counseling: concordance with WHO/UNAIDS recommended policies (namely, voluntarism and informed consent to HIV testing, confidentiality of HIV test results, counseling on HIV prevention and care options); availability of voluntary HIV testing and counseling services; and population coverage (namely, of the general population and of the key populations at highest risk for infection).
Review of HIV surveillance and Universal Access reports
Between 1995 and 2008, EMR countries reported to the WHO/EMRO a cumulative total of over 55 million HIV tests performed; however, the consistency and frequency of reporting varied greatly by country and reporting period. Of the total tests, around 36 million were conducted for the purpose of blood transfusion safety. Figure 1 shows the percentage of the cumulative total HIV tests performed on each of the different population groups and the distribution of HIV cases detected, excluding tests for transfusion safety. The majority of HIV tests (59.3%) were performed on migrant and foreign workers. Key populations at higher risk [also referred to as most-at-risk populations, including injecting drug users (IDUs), men having sex with men (MSM), sex workers and prisoners] together represented only 4.0% of the total number of tests performed. Another 8.1% was conducted in healthcare settings, primarily tuberculosis (TB), sexually transmitted infection (STI) and antenatal care (ANC) services. Suspected AIDS cases, consisting of people presenting to health services with symptoms suggestive of HIV infection, represented 2.1% of those tested and contacts of PLHIV represent 0.1%. Only 3.0% of all people tested were tested through client-centered VCT services.
The largest proportion (23.4%) of HIV cases was detected among key populations at risk followed by suspected AIDS cases (21.0%). VCT services detected 17.5% of the HIV cases and those detected through services for TB, STI, ANC and blood recipients constituted 17.3%. In contrast, tests conducted on migrant workers yielded only 13% of HIV cases detected.
According to Universal Access progress reports in 2008, 16 countries (Afghanistan, Djibouti, Egypt, Iran, Iraq, Jordan, Lebanon, Morocco, Oman, Pakistan, Saudi Arabia, Somalia, Sudan, Tunisia, UAE and Yemen) reported a total of 1394 health facilities providing HIV testing and counseling services. The reported number of health facilities providing testing and counseling in each country was neither proportional to the population size of the country nor was it related to the type of HIV epidemic (generalized, concentrated or low-level) in the countries. For example, although Pakistan (population 156 million) reported 12 testing and counseling services, Sudan (population 37 million) reported 149 and UAE (population four million) reported 194. The average number of individuals tested per HIV testing and counseling service ranged from a high of 8982 individuals per service in Oman to a low of eight per service in Saudi Arabia.
The Universal Access progress reports also showed limited availability of services tailored to the needs of key populations at risk including HIV testing and counseling.
Review of HIV testing policies
Our review identified 17 EMR countries that formulated national policies on HIV testing and counseling. These policies were either included in national HIV strategic plans or specific policies or guidelines on HIV testing and counseling. Country policies endorsed client-initiated VCT services (Table 1), identifying VCT as a key entry point to HIV prevention, treatment and care. The policies stressed the true voluntary aspect of testing, confidentiality and/or anonymity of solicitation and results and the requirement of informed consent of the client.
Provider initiated testing and counseling (PITC), that is, VCT initiated by the health service provider, was not widely considered in the review of policies of the EMR. In Djibouti, HIV testing was systematically offered to pregnant women attending ANC. In Somalia, TB patients were routinely offered HIV testing. In Iran, healthcare providers offered an HIV test to these same groups only if they presented with signs or symptoms of HIV infection or were at high risk of exposure owing to personal or spouses' behavior. All IDUs presenting to HIV and substance use services and all prisoners in Iran were systematically offered an HIV test. Diagnostic HIV testing for persons with clinical signs or symptoms of HIV was included in policies or guidelines in several countries (e.g., Egypt, Oman, Pakistan, Sudan, Tunisia and UAE). Whether such diagnostic testing always involves consent was difficult to determine.
Table 2 demonstrates that mandatory HIV testing was a widespread policy in the EMR. Djibouti and Pakistan were the only countries which did not impose mandatory testing on any group. Iran and Morocco required mandatory screening for military recruits in order to establish fitness. Other countries had mandated HIV testing for different population groups such as employment seekers, preoperative patients, premarital couples, and STI and TB patients. Foreign residents and migrant workers constituted the population group most widely tested prior to accessing the country for visa eligibility and after arrival for each contract, residency or work permit renewal. Mandatory testing of key populations at risk, namely sex worker, MSM and IDU, was commonly practiced upon arrest, admission to healthcare facilities or intake to prison.
Other policies that resulted in establishing the HIV serostatus of individuals included screening blood donations (with the consent of the donor) and confirmation of positive screening results for blood and organ transplant donations (without the consent of the donor). The review established that such policies were adopted in Bahrain, Iraq, Lebanon, Morocco, Somalia, Tunisia and Saudi Arabia. Iran was the only country reporting the requirement of consent and predonation counseling and Pakistan was the only country that reported discarding donated blood or dismissing the organ donor without confirming an initially reactive test. Our review did not capture information from other countries in this regard.
Policies promoting the use of rapid HIV tests were not prominent in the EMR. Testing strategies adopted by the majority of countries required central laboratory-based ELISA screening and confirmation with Western Blot. Pakistan, Morocco, Egypt and Lebanon introduced rapid testing in point of service settings such as VCT sites. These countries allowed one rapid test on site, which, when reactive, required confirmation by central laboratory ELISA and Western Blot. Only Afghanistan, Djibouti, Somalia and Sudan adopted three serial or parallel rapid tests strategies for determining HIV serostatus.
Review of HIV testing practices
Our review of the literature, key informant interviews and field visits carried out in four countries in 2008 identified and verified the extent of HIV testing practices in the EMR.
A regional workshop in 2006 indicated that the majority of countries were expanding access to VCT and that VCT was already provided in a wide variety of settings (Family Health International, Proceedings of the Regional Training on HIV Voluntary Counseling and Testing; from 26 February to 6 March; Cairo, Egypt). In several countries (e.g., Bahrain, Jordan, Tunisia) VCT was available in primary healthcare centers, integrated within public hospitals and specific health facilities (e.g., TB, family planning, STI and ANC clinics), within university and teaching hospitals, at national infectious disease referral centers, through sites providing ART linked to hospitals or free standing, and through nongovernmental organizations (NGOs) providing HIV prevention services and hotlines via mobile or dedicated fixed sites. VCT was reportedly available to all in Saudi Arabia but no statement of where and how could be documented. There were no organized plans for provision of VCT in Palestine nor were there plans to develop VCT in Kuwait.
The true number and extent of HIV testing and counseling services in the EMR was obscured by the lack of a common definition. Reported services may or may not include medical laboratories, blood banks, mandatory testing programs, stand alone VCT sites, NGO-provided services, some government services or distinguish sites with testing and counseling from sites with counseling only. For example, although the field observation review of HIV testing in Pakistan revealed that there were large numbers of NGO-run HIV testing and counseling sites across the country, the figure reported by Pakistan to WHO/EMRO was only 12 sites. This figure was likely to represent only the government owned testing and counseling services linked to the HIV treatment sites. In the UAE, the 194 sites conducting HIV testing likely corresponded to the number of medical laboratories performing the tests.
Many EMR countries had private healthcare facilities and laboratories providing HIV testing; however, it was not possible to determine numbers of clients, risk group categories of clients, proportion of clients testing HIV positive and whether principles of informed consent, confidentiality and counseling were upheld. In practice, private healthcare providers rarely reported to public health programs on HIV testing. Where stand-alone VCT sites were previously reported (e.g., Oman and Pakistan) low utilization rates also prevailed. The multitude of different settings in which HIV tests are performed made it difficult to assess whether linkages and referral to HIV treatment services existed or were adequate. Current monitoring systems of HIV testing and counseling in countries did not capture all testing settings and therefore obscuring the true extent of how people learn their HIV status.
Some countries implemented anonymous HIV testing and counseling (e.g., Egypt, Iran, Lebanon, Morocco, Palestine and Tunisia), whereas others (e.g. Oman, Bahrain, Iraq and Saudi Arabia) required personal identification to access HIV testing and counseling and individuals testing HIV positive were proactively followed. In practice, ART access required individuals with a positive HIV test to be reported by name to the public health surveillance authorities in all the countries of the EMR except Morocco.
Some EMR countries implemented PITC in practice, for example, for TB and STI clinic patients and for persons with HIV-related symptoms, although the approach may not be termed PITC. Thus, for example, the majority of persons diagnosed with HIV in north Sudan were the result of routine offering of HIV testing and counseling to ‘suspected’ HIV/AIDS cases.
There was little published information on HIV testing and counseling in ANC facilities although our field visits confirmed the practice in Oman, Pakistan, north Sudan and Egypt. In Oman, HIV testing was introduced for pregnant women if there was risk or clinical signs of infection although there was little consent and counseling involved. In Pakistan and Sudan, HIV testing and counseling happened within the small proportion of ANC sites where prevention of mother-to-child transmission was provided. In these settings, individual and group information sessions were provided followed by informed consent to HIV testing and counseling. Although HIV testing and counseling occurred at ANC facilities in Egypt, there were no specifically designated sites nor did it appear to be part of routine practice. Observations made in these four countries demonstrated that the practice of HIV testing and counseling in ANC was variable, ranging from those that did include informed consent and counseling (e.g., PITC) to those that did not (e.g., routine and mandatory HIV testing).
Mandatory or compulsory HIV testing in the EMR was extensive and occurred for a wide array of populations groups such as migrant and foreign workers, TB clinic attendees, prisoners, military, police, IDUs, arrested sex workers and MSM and public and private sector workers (Table 2). Mandatory HIV testing in the Region was required by national disease control regulations, but could also be requested by private companies as a condition of employment or insurance. Generally policies on mandatory HIV testing were not an integral part of national HIV policy documents except for screening of blood products. Only Morocco and Djibouti policies were explicit in stating that they do not support mandatory HIV testing. Within countries, both private and public laboratories were involved in mandatory HIV testing. Data from private laboratories on mandatory HIV testing were very rarely provided to national HIV/AIDS programs. Moreover, mandatory HIV testing was usually not accompanied by risk reduction information and counseling (WHO/EMRO, A review of HIV testing and counseling policies in the Eastern Mediterranean Region; November 2008).
Immigration requirements of Gulf Cooperation Council (GCC) countries (Saudi Arabia, Kuwait, Bahrain, Qatar, UAE, Oman and Yemen)  resulted in large numbers of persons who were mandatorily tested for HIV. In addition to the GCC, several EMR countries also had explicit policies denying entry for people living with HIV, including Iraq, Libya, Sudan, and Yemen (WHO/EMRO, Progress towards Universal Access to HIV prevention, treatment and care in the health sector: report on a Baseline Survey for the year 2007 in the WHO Eastern Mediterranean Region; 2007). Mandatory HIV testing was also required within GCC countries for those foreign workers and students wishing to extend their stay. Persons found to be HIV positive were deported to their home countries. Testimonies by Pakistani returnees during the field visits revealed that persons were often not told what they were tested for nor were results routinely disclosed, causing potential delays in treatment and transmission within their countries of origin after deportation.
Aside from mandatory HIV testing for migrant workers it was difficult to determine the full extent of testing with regard to other population groups. For example, in Oman, municipal laws required HIV testing of food handlers in order for establishments to obtain licenses. Mandatory HIV testing was practiced upon arrest of individuals belonging to high-risk populations such as sex workers, IDUs, and MSM in most countries. In addition, an HIV test was required as a prerequisite for IDUs entering drug treatment programs in at least nine countries (Table 2). Mandatory HIV testing is also conducted upon entry to prisons in the majority of countries and prisoners who test HIV positive are segregated (WHO/EMRO, A review of HIV testing and counseling policies in the Eastern Mediterranean Region; November 2008).
Universal Access progress reports for 2008 indicated that coverage indicators for HIV testing among key populations at risk in the EMR was incomplete and inaccurate. In general, targeted HIV prevention, treatment and care services adapted to the needs of key populations at risk were insufficient, including HIV testing and counseling (WHO/EMRO, Progress towards Universal Access to HIV prevention, treatment and care in the health sector: report on a Baseline Survey for the year 2007 in the WHO Eastern Mediterranean Region; 2007). Generally, successful models of voluntary HIV testing and counseling for key populations at risk were lacking in the EMR with a few exceptions. Some countries (e.g., Oman, Egypt, Morocco, Pakistan, Lebanon) instituted outreach programs in collaboration with NGOs providing prevention information and on-site HIV testing and counseling or referrals. Iran developed a comprehensive harm reduction program with the establishment of VCT services within ‘triangular clinics’ (i.e., clinics providing integrated HIV, STI and substance use services), some of which are linked with prisons. As a result, Iran witnessed an increase in the number of individuals accessing voluntary HIV testing and counseling in recent years both for IDUs and persons with sexual transmission risks . Morocco, with substantial involvement of NGOs, established 40 HIV testing and counseling sites targeting primarily MSM and sex workers, with two more recent sites targeting IDUs . Those sites have further instituted peer outreach programs, which promote and attract the target groups to HIV counseling and testing.
In the majority of EMR countries, HIV test results were not available at the point of service on the same visit owing to the lack of rapid testing (e.g., in Bahrain, Iran, Iraq, Jordan, Kuwait, Libya, Oman, occupied Palestinian territories, Qatar, Saudi Arabia, Syria, Tunisia and UAE) or because initially positive tests require confirmation by a central laboratory-based ELISA or Western Blot (e.g., in Egypt, Lebanon, Morocco and Pakistan). Field visits to VCT services in Pakistan and Egypt confirmed that such testing processes results in many delays and failures to obtain HIV test results by clients.
With the caveat that the situation is not static, our review reveals the range of policies and practices for HIV testing and counseling in countries of the EMR. Most countries in the EMR have national strategic plans and policies in place that support voluntary HIV testing and counseling and mention strategies for reaching key populations at high risk for infection. However, there are often concomitant policies that foster widespread practices such as mandatory and unconsented HIV testing.
In fact, across the region, the majority of HIV tests performed appear to be conducted mandatorily. This practice does not conform to universal guidelines on ethical practice. In addition, it confers little benefit to the individuals tested and to public health, especially when results disclosure is not routine. Migrant and foreign workers in the EMR appear to be the group most affected by mandatory testing. Because laws mandate that the negative HIV status of any foreign worker should be established prior to obtaining a visa or a work permit, those who later test HIV positive have possibly acquired the infection within the host country. In addition to resources to scale-up true voluntary HIV testing and counseling, the considerable resources spent on mandatory HIV testing may be better redirected towards prevention programs for those population groups, which are likely to have distinct vulnerabilities. This suggests that a careful review of the cost effectiveness of the wide-scale mandatory testing is needed, particularly in comparison with the targeted nonmandatory HIV testing services.
Triangulation of information from different sources also suggests a considerable overlap of voluntary and mandatory HIV testing in practice. Accordingly, numbers of HIV testing and counseling sites and numbers of people who received an HIV test and know their result reflect the outcome of a mix of mandatory and voluntary testing practices on the ground. It is therefore difficult to ascertain to what extent the principles of informed consent, confidentiality and counseling are upheld when HIV testing is performed in the EMR.
Our review suggests that there are substantial gaps in the availability of and accessibility to HIV testing services for those who need them most and discrepancies in the implementation of existing policies on voluntary HIV testing and counseling. Numbers of key populations at risk who received an HIV test are low and there is a lack of prevention and care services targeting those populations. The Universal Access progress reports show limited availability of services tailored to the needs of key populations at risk of HIV including HIV testing and counseling. In Iran, however, harm reduction services are comparatively widely available. Six countries (Afghanistan, Egypt, Lebanon, Morocco, Oman and Pakistan) reported a total of 32 Needle and Syringe Programs and three countries (Lebanon, UAE and Tunisia) reported six opioid substitution therapy sites. Similarly only Iran, Lebanon, Morocco, Pakistan and north Sudan report having reached sex workers with HIV prevention services; whereas only Lebanon and Pakistan reported having reached MSM. This lack of HIV prevention, treatment and care services for key populations at risk can partially explain the limited access to HIV testing. Moreover, the involvement of civil society organizations including PLHIV and their capacity to target at-risk populations is limited and requires strengthening in the Region. The EMR context also presents significant barriers to accessing HIV testing, including difficulty in addressing sensitive areas of HIV prevention such as sex outside of marriage and same-sex behavior, lack of comprehensive harm reduction programs for IDUs and high levels of stigma and discrimination in healthcare settings and the general public.
HIV tests reportedly conducted in health services such as TB, STI and HIV care clinics are most likely conducted without the consent of the clients, as suggested by the review of policies and field observation. There is a need to instill the principles of PITC and to scale up the services while observing the principles of voluntariness, confidentiality and consent ensuring that a positive HIV test does not have negative implications on the clients.
The HIV testing and counseling process itself is cumbersome to people seeking to know their HIV status, particularly in countries which do not make use of rapid HIV tests to ensure that clients can receive the test result and posttest counseling at the point of service on the same visit. The development of HIV testing algorithms, which support rapid testing and the provision of same-day results are needed in the region to increase access, knowledge of serostatus and linkage to care.
Despite the shortcoming discussed above, appreciable progress has been made in the last few years to increase access to HIV testing and counseling in the EMR, with a growing number of promising examples of programs targeting key populations at risk for HIV. The programs of Morocco reaching the sex workers, MSM and IDUs with HIV prevention, treatment and care services, including voluntary HIV testing and counseling, and those of Iran providing services to IDUs should be scaled up in other EMR countries. Other EMR countries have been experimenting with innovative approaches to increasing access to HIV testing and counseling and have lessons learnt to share, including Djibouti, Egypt, Lebanon, Pakistan, Sudan, Somalia, Saudi Arabia and others. The challenge now remains for the Region to reach consensus on policy and practice, to expand access to voluntary HIV testing and counseling including PITC, and share experience on approaches which are ethical, sustainable, accessible with respect to populations at risk and of high quality.
The authors would like to acknowledge the technical and information contribution of the team of Family Health International, Egypt to the review. Funding was received from WHO/EMRO.
Conflicts of Interest: None.