HIV testing is still the number one challenge in terms of controlling the HIV epidemic by 2030. Despite significant progress since the early 2000s tied to massive investments made by the President's Emergency Plan for AIDS Relief (PEPFAR) and the Global Fund to Fight AIDS, Tuberculosis and Malaria, it is now estimated that only 79% of people living with HIV (PLHIV) worldwide are aware of their status; the percentage drops to 64% for West and Central Africa (2018), far short of the “first 90” objective in the 90-90-90 target set by UNAIDS, according to which 90% of infected people would be aware of their status by 2020. HIV testing is the entry point for access to antiretroviral treatment, with individual advantages including reduced morbidity and mortality rates, and community-level advantages in terms of prevention through reducing the risk of transmission from PLHIV on antiretroviral treatment, and having a suppressed viral load.
Since the beginning of the 2010s and the emerging hope of an “AIDS-free generation”, international guidelines have focused on intensifying efforts to accelerate the response to HIV, in particular through the Political Declaration on HIV and AIDS: Intensifying Our Efforts to Eliminate HIV and AIDS, adopted by the United Nations General Assembly (2011); the introduction of the UNAIDS 90-90-90 targets or the adoption of Fast Track (or accelerating the pace of action) by the United Nations General Assembly, in order to eliminate the epidemic by 2030 (2016). Given the above, the level of funding is plateauing while the number of people on treatment and the related needs are ever increasing. For that reason, the main international donors – with PEPFAR and the Global Fund to Fight AIDS, Tuberculosis and Malaria leading the way – have committed to optimizing their resources. For the Global Fund, this approach led to the development of the New Funding Model (NFM), initiated in 2014, while for PEPFAR it resulted in the development of its strategic plan entitled ‘PEPFAR 3.0 – Controlling the Epidemic: Delivering on the Promise of an AIDS-Free Generation’, released in December of the same year. The strategic plan announces PEPFAR’s intention to adopt a new data-based approach, and the strategic targeting of geographical areas and populations to achieve greater impact for its investments.
Over the course of a decade, HIV testing strategies had focused on expansion through the decentralization of services, de-medicalization and the organization of door-to-door mass campaigns, or the systematic adoption of provider-initiated testing and counseling. But this strategic turnaround has involved the implementation of targeted strategies for better a better testing yield, namely higher positivity rates (the more people tested, the more people will test positive, therefore more people will be aware of their status).
This article presents the main findings of a study done as part of the DOD-CI (ANRS12323) project, which analyzed the evolution of PEPFAR’s HIV testing strategies since PEPFAR 3.0 was adopted, between COP 14 (October 2014 to September 2015) and COP17 (October 2017 to September 2018). The COP (Country Operational Plan) is a U.S. government-specific annual work plan used to approve annual bilateral funding from the U.S. government to combat HIV/AIDS in most countries. It sets out PEPFAR’s strategy for the following year (for example, COP14 provides the basis for determining funding priorities for fiscal year 2015, which runs from September 2014 to October 2015) for each country receiving funding; it sets out the objectives per geographical area and population group that each country must achieve. The study also looks at the impact and limits of this change in paradigm, from screening the general population to targeted testing. It was conducted in Côte d’Ivoire, a country where the epidemic is mixed (2.5% prevalence rate within the general population and higher rates within some vulnerable population groups), and was funded chiefly by PEPFAR (72%) and to a lesser extent by the Global Fund (17%; 2015-2017).
Significant variation in the objectives, year after year
Between 2014 and 2017, PEPFAR’s testing strategies changed significantly each year.
There have been significant changes in the numerical targets set by the donor. Between COP 14 and COP 15, the objective for the number of people to be tested has been cut in half. On the one hand, it is a matter of rationalizing resources and cutting out what was considered to be a waste of supplies. On the other hand, this drastic reduction was influenced by new UNAIDS estimates, which show a drop in the number of PLHIV in Côte d’Ivoire (from 450,000 in 2013 to 370,000 in 2014). For COP 16, testing has become a programming priority, given that UNAIDS estimates showed the number of PLHIV to had increased to 460,000. COP 17 features plans to prioritize and intensify HIV testing efforts, in keeping with the debate on accelerating the fight against the epidemic formalized at the highest level in the United States General Assembly’s political declaration on HIV/AIDS adopted in June 2016 (‘Fast Track’). The number of people to be tested, and the number of people with positive test results jumped by a factor of close to five in a space of two years, between COP 15 and COP 17. These disruptions have created a substantial gap between the objectives set and the outcomes achieved (Figure 1).
During that period, the disaggregation of objectives became ever more specific with targets for age, gender, point of entry, HIV status and key populations. The method used to set the objectives has also changed. Since COP 16, PEPFAR’s Office of the U.S. Global AIDS Coordinator (OGAC) has been using the Data Pack system to set targets, leaving little place for data from programming and experience on the ground. The system, based on epidemiological estimates, supported greater year-to-year variation and less flexibility for local actors.
Since COP 14, the HIV testing yield has become an increasingly important performance indicator, even though the results show it has decreased, overall, and the results have been systematically lower than the objectives set (Figure 2).
Figure 1. Objectives and results of HIV testing activities funded by PEPFAR in Côte d'Ivoire (COP 13 to COP 17)
Figure 2. Yield of HIV testing activities funded by PEPFAR in Côte d'Ivoire (COP 13 to COP 17)
PEPFAR also made substantial changes in the geographical areas targeted. With COP 14, PEPFAR stopped supporting sites with little or no yield, which accounted for 39% of the testing sites in Côte d'Ivoire at that time. In addition, it categorized regions as “high yield” or “low yield” areas, in which testing was kept to a minimum. In addition, testing at prenatal consultations was halted for pregnant women in five of the 19 health regions where PEPFAR had a presence. One year later, with the release of COP 15, more subtle divisions of the health districts were made (which remained relatively unchanged until COP 17), based on the percentage of people with an HIV infection out of the total number of people who tested positive for HIV and also based on the degree to which the objectives had been achieved (districts categorized as “maintenance/sustainable”, “scale up/aggressive scale up” and “scale up to saturation/saturation”).
Population group targets
In terms of the targeted population groups, COP 14 brought an end to testing the general population and introduced a closer focus on key population groups and some priority population groups before PEPFAR gradually expanded its targets. For example, men over the age of 25 became one of the new priority population groups targeted by COP 17.
Consequences and lessons learned
Impact on implementation in the field
The frequency and speed of these strategic shifts were seen by implement NGOs as “top-down” in nature without any links to their reality on the ground. They were also viewed as an obstacle to their efficiency and effectiveness, in so far as the actors responsible for executing them did not have time to adjust their strategies within the allocated timeframe. Each strategic and geographical shift involves human and financial costs (the cost of training, reorganizing the teams on the ground, re-establishing work methods with new partners, etc.) which may have resulted in fatigue or even indifference on the part of health workers receiving contradictory directives in a short space of time.
Supremacy of numerical targets in the face of uncertain data
PEPFAR’s increasingly heightened focus on achieving ever more specific numerical targets is problematic on a number of levels.
This approach is at odds with the uncertain nature of the epidemiological estimates used by PEPFAR to set its objectives. The increasingly specific disaggregation required by the donor (per district, age, gender, status, etc.) does not align with with the lack of quality epidemiological data available at the health district level, and with key population estimates (size, prevalence and geographic location). The study to assess HIV’s impact on the people of Côte d'Ivoire (CI-PHIA), was funded by PEPFAR and carried out in 2017, three years after the first geographic breakdown designed to generate more accurate data. Despite the size of the study (about 10,000 households), the HIV prevalence rates could not be determined at the district level.
The pressure on results and the number of HIV-positive patients to be tested as a condition for access to funding led some implementing NGOs to adopt circumvention strategies or even to inflate their statistics. Many actors regret what they see as the “dehumanization” of the fight against HIV/AIDS in light of the focus on numbers.
The limits of test positivity rates as a main indicator of the effectiveness of testing strategies
Today, the emphasis is on yield, in other words the obligation of achieving a high rate of positive tests, which would be more cost-effective given that it would make it possible to diagnose more new HIV cases for the same cost. But the results point to a failure, as the yield has diminished over the years. This drop in the yield is also indicative of the fact that the PLHIV that are easiest to reach have already been diagnosed, while those PLHIV who are unaware of their status are fewer in number and require greater efforts. The substantial resources used to improve the yield have made testing methods more difficult to implement. For example, requiring the development of detailed maps, the implementation and use of tools to evaluate the risk for an individual who wants to be tested, or refusing to test those outside the target group and who want to know their status, poses ethical problems for the implementing NGOs with respect to access to testing. This approach, which focuses on yield, may compromise progress on the “first 90” objective in a context where most undiagnosed PLHIV are part of the general population.
From 2014 to 2018, PEPFAR appears to have taken a trial and error approach. The financial crisis of the early 2010s initially resulted in the implementation of strategies focused on rationalizing resources and the need to develop high-yield strategies (COP 14 and 15). On the other hand, the goal of achieving the 90-90-90 objectives by 2020 and the “acceleration plan” have clearly shown the need to quickly broaden the scope of HIV testing, by concentrating on increasing the number of new HIV diagnoses (COP 16 and 17).
The targeted testing implemented as part of PEPFAR 3.0 was fragmented, accelerated and disconnected from HIV testing services due to a number of factors. These included the annual COP system, which persisted despite PEPFAR’s longevity; program alignment based on objectives tied to imperfect data with ongoing adjustments; and a lack of clearly identified approaches to HIV testing in the context of a mixed epidemic, oscillating between resource rationing and broadening testing coverage. This trial and error approach raises the issue of the real and long-term effectiveness of strategies that are reviewed annually and create an ever-wider gap between the reality of implementation actors on the ground and the objectives set in Washington.
- Bekelynck, Anne, et Joseph Larmarange. “PEPFAR 3.0’s HIV Testing Policy in Côte d’Ivoire (2014 to 2018): Fragmentation, Acceleration and Disconnection”. Journal of the International AIDS Society 22, no 12 (2019): e25424. https://doi.org/10.1002/jia2.25424.
- PEPFAR, The Office of the U.S. Global AIDS Coordinator (OGAC). “PEPFAR 3.0. Controlling the Epidemic: Delivering on the Promise of an AIDS-free Generation”. A/GIS/GPS, 2014.