HIV testing and counseling are important entry points for prevention and care needs. Measuring the number of people who access these services is therefore important to indicate the number of people who could potentially benefit from prevention and care. In addition, over time this indicator provides information on the number of new people tested.This indicator is designed to show how many people have been tested and received their results in the last 12 months.
This indicator can be used as a proxy for the coverage of HIV counseling and testing services. Estimates of coverage of counseling and testing services help to determine whether those services are achieving their threefold aims of providing an entry point for care and support, promoting safe behavior, and breaking the cycle of silence and stigma.
This indicator aims to give an idea of the reach of HIV testing services in the general population and of the percentage of people who now know their HIV status. It can also be constructed for specific sub-populations with high-risk behavior among whom counseling and testing services are being promoted.
In a general population or sub-population survey, respondents are asked whether they were tested in the last 12 months, and, if so, whether they have received the results.
The questionnaire prefaces the questions by saying, “I do not want to know the results of the test…”, in an attempt to minimize stigma-based fear of answering the questions truthfully.
The indicator needs to be stratified by how these services are delivered. Distinguishing how counseling and testing are provided is important to service delivery. In general, three service delivery methods should be considered: stand-alone or free-standing voluntary counseling and testing sites; counseling and testing units within health facilities to which people are referred (from tuberculosis, family planning and other health units, for example); and fully integrated counseling and testing services in which a provider can refer the person to a laboratory for a test, but the provider carries out the counseling.
Because testing and counseling services are often not performed within discrete units (that is, outpatient or inpatient departments) or departments, reports can potentially be duplicated for the same individual being tested in multiple units or those being tested multiple times during the 12-month period. In other cases, such as preventing the mother-to-child transmission of HIV and other HIV testing and counseling, services are performed in the same place. This too will lead to double reporting in the number of people tested. In addition, because of these various points of HIV testing and counseling services, linking testing to counseling through facility records may be difficult in some situations unless a strong records system is in place to track testing and counseling.
If a household survey is used, double counting can be minimized.
In areas where HIV is highly stigmatized, respondents may be unwilling even to admit to having taken an HIV test, since it may be counted an admission that they fear they may be infected. This is all the more true when the question is posed in the context of a questionnaire about risk behavior. On the other hand, in countries where testing has been heavily promoted as a “responsible” thing to do, some people may say they have been tested when in fact they have not. Despite these potential biases, the indicator is useful for getting a rough idea of the proportion of people likely to know their HIV status at all. Because the indicator is constructed to capture the percentage of respondents receiving an HIV test and receiving results in the last 12 months, the measure will reflect recent changes in testing services. Those people at higher risk for HIV should be targeted for repeat testing. Note, however, that in high-prevalence populations with good coverage of testing services, trends in the time-bound indicator can be expected to be affected by the fact that people who have tested HIV positive will not return for further testing in future years.
A breakdown of the indicator into its component parts (looking, for example, at people who received a test but never received their results) can point to gaps in program service provision and quality of care. Data on those who do not return for results or know their results may offer insight, for example, into levels of stigma and/or reluctance to learn their HIV status based on lack of available options for care.
Due to the difficulty in defining post-counseling and ethical issues in asking questions on post-counseling associated with HIV+ status, no information on post-counseling should be collected through population surveys. Additional information on post-test counseling should be collected through alternative methodologies such as facility-based surveys.
At the local level, program managers may be interested in collecting additional information, such as the number of people tested and counseled, the number receiving their results of those tested, and the number found to be HIV positive of those tested. It should be noted that this indicator is most useful for tracking the scale-up of counseling and testing services. For individuals who tested positive beyond the past 12 months, this indicator does not reflect the fact that they would not need to be re-tested every year. Thus, this indicator will not reflect on the number who know their status, but simply those tested in the last year.