This is the first review of national policies on HTS for inclusion of lay providers. Similar reviews have been undertaken on HIV policy regarding self-testing [25], but to date there is no information regarding the role of lay providers in national HIV policies.
This review revealed that of the 50 countries analyzed, 58% either do not permit lay providers to perform HIV RDTs using fingerstick blood (the most common type of HIV RDT) or do not specify if they can, while 44% do not permit or do not specify whether lay providers can perform HIV pre- and post-test counseling. The regional comparison analysis showed that the WHO African region had the highest proportion of countries in which lay testing is permitted.
Thirteen of the 50 reviewed policies did not specify or explicitly outline the role of lay providers in providing HTS. While some of these countries may have provisions that allow lay providers to perform HIV testing and pre- and/or post-test counseling, the lack of explicit reference to the role of lay providers may introduce misunderstandings or misinterpretations by providers and national program managers. Furthermore, if lay testing is not explicitly sanctioned, systems to support training, supervision and provide quality assurance of lay testing may not be routinely and consistently applied. Countries should regularly review their national HIV testing policy to make sure it contains correct information, reflects national practice as well as lay provider training, testing and quality assurance.
The difference between reported GARPR data and that extracted from official HIV testing policies may be due to several reasons such as policies that had not been updated to account for lay provider use, incorrect information from the national representative regarding lay provider use in their country, or the policy may not have been clear regarding the role of lay providers in HIV testing.
GARPR data only asks if lay providers are permitted to perform RDTs in general and does not specify whether lay providers are permitted to perform the different types of RDTs (i.e. fingerstick whole blood or oral fluid). This specific information would have helped to give greater clarity on the role of lay providers and aided in our comparison of GARPR data to national HIV policy.
Of the 12 countries with differing information, half (n = 6/12) of them were from African nations. This difference demonstrates a disparity between reported data and national policy information. Greater care must be taken when reporting GARPR data to make sure it correlates with approved practice. It is suggested that in a bid to increase accuracy, the reporting of GARPR data could be accompanied by policy documents to support their reported data and help catalyze regular reviewing of national policy documents.
Through task-sharing, lay provider HTS have been widely implemented throughout Africa. Sub-analysis of data from the WHO African region suggests that there is a more supportive policy environment for lay provider HTS compared to other global regions. Task sharing to increase the scope of work for lay providers is important to scaling up HTS, as recent reviews have shown that it is acceptable, can be low cost and can increase uptake of HTS, particularly among key populations who are generally underserved [26]. Thus, based on the review of existing evidence, WHO recommends that trained lay providers can perform RDTs safely and effectively [26].
Limitations
Although we reviewed the most currently available HTS policies, some may be out of date or in the process of being updated. As we collected and analyzed national testing policies, it is possible that some information on lay provider testing was not specified in these, but instead included in national PMTCT guidelines, treatment guidelines or other national guidelines.
Although 50 national policies were collected, this did not match the number of countries reported in GARPR data (n = 124). A greater number of HIV testing policies would have made for a greater comparison and stronger analysis however this difference was explained by the difficulty in obtaining formal HIV policies, the lack of formal HIV policies from a number of the reporting countries and the time limitations that were placed on the analysis.
Data on whether lay providers are permitted to perform pre and post-test counseling was not collected as a part of the 2014–2015 GARPR reporting cycle. Therefore, we could not compare information from reviewed national policies with GARPR reports. Inconsistencies identified between national policies and GARPR reports highlight that the term lay provider may need further definition. It is possible that errors in reporting or missing information may have occurred because of differences in terminology.