touched upon only briefly in this chapter, while the primary discussion can be found in Chapter 9 on health systems strengthening. Finally, a multisectoral response to HIV also relies on other, non-health systems and operates in the broader context of the economic, social, cultural, and political environments, which are all part of the broader context of a multisectoral response to HIV. This broader context both contributes to and poses challenges for the effectiveness of the HIV response.

HIV COUNSELING AND TESTING

Early in the HIV epidemic, voluntary HIV testing programs were intended to increase the number of people aware of their HIV status and to serve as an entry point for counseling and other prevention services, both for those who were HIV positive and those who were HIV negative, with the aim of reducing HIV transmission and infection. Early programs faced such challenges as the fear of stigma and discrimination, complex laboratory methods, and a lack of available care and treatment services. With the introduction of more widespread access to care and treatment services and support for laboratory and other related services, HIV testing now serves as a crucial gateway to HIV care and treatment and to services for the prevention of mother-to-child transmission (PMTCT), while still serving the initial major purpose of providing counseling and an entry point to prevention services (Marum et al., 2012). Access to testing early in the course of HIV infection is of particular importance given that people living with HIV (PLHIV) who receive treatment later in their disease consequently have poorer outcomes (WHO, 2012d).

The following section presents the committee’s assessment of PEPFAR-supported HIV counseling and testing programs, with information on PEPFAR’s funding history and activities as well as on the effects of these activities, including achievements and challenges. This section focuses primarily on testing services because it was difficult to comprehensively assess the effects of counseling services, such as discussions that take place before and after an HIV test with the purpose of increasing knowledge, conveying prevention and risk reduction messages, providing supportive counseling, and facilitating referrals to services. There is very little information available to track this component of counseling and testing in terms of how PEPFAR-supported activities have been implemented and what the outcomes of these activities have been.

PEPFAR Guidance for Supported Activities for Counseling and Testing

PEPFAR does not issue specific programmatic guidance on counseling and testing, but instead refers programs to the World Health Organization



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