Expanding Human Immunodeficiency Virus Testing: Whole Society Participation and Multilevel Promotion
Human immunodeficiency virus (HIV) testing is the cornerstone of identifying individuals living with HIV (PLWH). Early diagnosis and timely treatment not only extend the lives of PLWH but also significantly reduce the transmission of HIV. As such, HIV testing is a critical component of public health strategies worldwide. Over the past decade, the global scale of HIV testing has expanded dramatically. In 2018, approximately 79% of the estimated 37 million PLWH globally knew their HIV status, a significant increase from 12% in 2005. In China, 68.9% of PLWH had been diagnosed by 2018. However, this figure falls short of the 90% target set in China’s implementation plan for containing the spread of HIV/AIDS (2019–2022). Expanding HIV testing remains an essential yet challenging priority for China’s HIV/AIDS prevention and control efforts.
Significant Increase in HIV Testing in China
China has made remarkable progress in scaling up HIV testing in recent years. The number of people tested for HIV surged from 128 million in 2014 to 241 million in 2018. During the same period, newly diagnosed cases through HIV testing increased from around 100,000 to approximately 148,000. This expansion has been driven by a combination of passive and active approaches to HIV testing, forming a comprehensive strategy for nationwide implementation.
Passive Approaches to HIV Testing
Passive HIV testing in China encompasses three primary methods. First, the implementation of HIV nucleic acid testing (NAT) at blood centers has become a national policy. Since 2016, NAT has been mandatory alongside the traditional enzyme-linked immunosorbent assay (ELISA) method. This dual approach has elevated China’s blood safety to an advanced level, with no reported cases of HIV transmission through blood transfusion or blood products.
Second, provider-initiated HIV testing and counseling have been widely promoted. Health providers recommend HIV testing as a standard component of care for individuals attending health facilities. Medical institutions, which account for over 50% of diagnosed HIV cases since 2013, have become the most important avenue for HIV detection in China. This approach increases the accessibility and convenience of HIV testing, particularly in key departments of medical institutions.
Third, HIV testing and consultation services are encouraged during pre-marital medical examinations and pre-pregnancy eugenic health examinations. In regions with high HIV incidence, personnel in commercial public places, such as entertainment venues and beauty salons, are recommended to undergo HIV testing every six months.
Active Approaches to HIV Testing
Voluntary counseling and testing (VCT) is one of the most effective strategies for active HIV testing. By 2018, China had established over 10,000 VCT clinics as part of its national HIV/AIDS program. VCT plays a crucial role in detecting HIV infections, with 27% of new HIV cases diagnosed in VCT clinics in 2017. Early diagnosis through VCT enables PLWH to start antiviral treatment sooner, improving life expectancy. Additionally, VCT ensures that individuals who test negative are linked to appropriate prevention services, contributing to the reduction of new HIV infections.
HIV self-testing (HIVST) is an innovative and reliable strategy to promote testing among high-risk populations. HIVST protects privacy and allows individuals to know their HIV status independently. In December 2016, the World Health Organization (WHO) issued guidelines endorsing HIVST as a supplement to existing testing services. China has embraced this approach by launching HIVST through drugstores and online platforms, supported by comprehensive follow-up services. From 2016 to 2019, anonymous urine testing for HIV through vending machines was assessed at 73 universities in 11 provinces. This initiative proved effective in increasing active testing among college students at high risk for HIV infection.
Challenges for HIV Testing in China
Despite significant progress, several challenges hinder the expansion of HIV testing in China. First, the proportion of PLWH who know their status remains low, particularly among key populations. By 2018, only 68.9% of PLWH in China were aware of their infection, far below the 95% target. Among men who have sex with men (MSM), a high-risk group, only 56.4% of those with HIV knew their status. Undiagnosed PLWH are a primary source of HIV transmission, underscoring the need for broader societal participation in HIV/AIDS prevention and control programs.
Second, the active testing rate in China is low. In 2018, active testing accounted for only 25% of all HIV tests. Promoting active testing is essential to combat HIV/AIDS, as emphasized by the themes of the 2018 World AIDS Day in China and globally: “Testing Actively, Understanding and Preventing HIV, Staying Healthy Together” and “Know Your Status.”
Third, delayed HIV diagnosis remains a significant issue. From 2010 to 2014, 35% to 42% of PLWH experienced delayed diagnosis, often presenting in the late stages of infection. This delay deprives individuals of early treatment opportunities. Additionally, the number of people aged over 50 diagnosed with HIV has steadily increased. From 2008 to 2014, the average time between infection and diagnosis for this age group was 6.8 years, with 70.6% having a CD4 cell count below 350 cells/mm³ at diagnosis. Addressing this issue requires targeted testing strategies for older populations.
Despite China’s substantial health funding for AIDS prevention and control, HIV remains the leading cause of death among infectious diseases. In 2020, 18,800 PLWH died, four times the number of deaths from COVID-19. Expanding HIV testing to enable earlier detection and treatment is imperative to reduce mortality and improve outcomes for PLWH.
Recommendations for Expanding HIV Testing Services
To address these challenges, several active measures are recommended to achieve China’s HIV/AIDS prevention and control objectives.
Promoting Awareness of Active Testing
The first recommendation is to promote the idea that everyone is responsible for their health and to disseminate educational materials about active testing. Public awareness campaigns should systematically address essential aspects of HIV testing, including who should get tested, where to access testing, available testing methods, and steps to take after a positive result. This approach encourages individuals to seek testing if they have engaged in risky behaviors.
Increasing Accessibility of HIV Testing
The second recommendation is to enhance the accessibility of HIV testing in the community. Social organizations play a vital role in reaching high-risk populations and following up with PLWH. Leveraging these organizations to improve community-based testing, particularly home testing, can significantly increase testing rates.
Integrating Online and Offline Testing Resources
The third recommendation is to combine online and offline testing resources. Establishing comprehensive online platforms that provide health information, testing locations, and results, alongside offline platforms that deliver HIVST kits and personalized VCT services, can create a seamless testing experience.
Exploring Innovative Testing Methods
The fourth recommendation is to explore innovative HIV testing strategies. Partner notification, which encourages PLWH to notify their partners about their status, has shown promise. A randomized controlled trial in Shenyang demonstrated that combining partner notification with HIVST and community-based organization services significantly increased testing rates among partners of HIV-positive MSM. Additionally, the “pay-it-forward” model, which incentivizes testing by allowing individuals to cover the cost of testing for others, has been effective in increasing acceptance of comprehensive HIV testing among MSM.
Social network-based testing, recommended by WHO’s 2019 Consolidated Guidelines on HIV Testing Services, is another innovative approach. This method targets key populations, such as MSM, injection drug users, and commercial sex workers, who are at high risk but have limited access to care services. By leveraging social networks, this strategy promotes timely detection of undiagnosed PLWH.
Conclusion
Early diagnosis of all individuals with HIV is a core strategy for AIDS prevention and a key component of China’s “Implementation Plan for Containing the Spread of AIDS (2019–2022).” Achieving the goal of 95% of PLWH knowing their status by 2030 requires a people-centered approach, increased awareness of active testing, expanded roles for social organizations, optimized VCT services, enhanced testing accessibility, and innovative testing strategies. Whole society participation and multilevel promotion are essential to meet these objectives and control the HIV/AIDS epidemic effectively.
doi.org/10.1097/CM9.0000000000001812
Was this helpful?
0 / 0