Country adoption of WHO 2019 guidance on HIV testing strategies and algorithms: a policy review across the WHO African region

OBJECTIVES: In 2019, the WHO released guidelines on HIV testing service (HTS).

We aim to assess the adoption of six of these recommendations on HIV testing strategies among African countries.

DESIGN: Policy review.

SETTING: 47 countries within the WHO African region.

PARTICIPANTS: National HTS policies from the WHO African region as of December 2021.

Primary and secondary outcome measures: Uptake of WHO recommendations across national HTS policies including the standard three-test strategy; discontinuation of a tiebreaker test to rule in HIV infection; discontinuation of western blotting (WB) for HIV diagnosis; retesting prior to antiretroviral treatment (ART) initiation and the use of dual HIV/syphilis rapid diagnostic tests (RDTs) in antenatal care.

Country policy adoption was assessed on a continuum, based on varying levels of complete adoption.

RESULTS: National policies were reviewed for 96% (n=45/47) of countries in the WHO African region, 38% (n=18) were published before 2019 and 60% (n=28) adopted WHO guidance.

Among countries that had not fully adopted WHO guidance, not yet adopting a three-test strategy was the most common reason for misalignment (45%, 21/47); of which 31% and 22% were in low-prevalence (<5%) and high-prevalence (≥5%) countries, respectively.

Ten policies (21%) recommended the use of WB and 49% (n=23) recommended retesting before ART initiation.

Dual HIV/syphilis RDTs were recommended in 45% (n=21/47) of policies.

CONCLUSIONS: Many countries in the African region have adopted WHO-recommended HIV testing strategies; however, efforts are still needed to fully adopt WHO guidance.

Countries should accelerate their efforts to adopt and implement a three-test strategy, retesting prior to ART initiation and the use of dual HIV/syphilis RDTs.