HIV TESTING AND DIAGNOSIS: WHAT YOU NEED TO KNOW

Today, living with HIV is a very different experience from just ten years ago. Advances in prevention, treatment and care mean that people living with HIV and on effective treatment have a near-normal life expectancy. This article outlines the importance of HIV testing and diagnosis in ending the epidemic.

Why is HIV testing important?

WHY IS HIV TESTING IMPORTANT?

HIV testing is important because early detection and timely intervention are key in managing HIV effectively.¹ During the initial phases, HIV may be symptomless or flu-like, making reliance on symptoms alone insufficient.^1,2 These flu-like symptoms may include a fever (often accompanied with chills or night sweats), headaches, fatigue, swollen lymph nodes, and a persistent sore throat.^1,2 A skin rash or muscle and joint pain may also become apparent, as well as weight loss, mouth ulcers, and diarrhoea.^1,2 Clearly, these early HIV symptoms are also associated with other common illnesses and health conditions, so this emphasizes why regular testing is so vital.

HIV can be acquired through bodily fluids like blood and semen and is more easily transmitted in the early stages, making testing necessary not just for personal health but also to prevent unintentional transmission to others.^2,3 Testing is the first step towards early diagnosis of HIV and guiding people living with HIV towards treatment.^2,3

Innovation in HIV testing has brought us steps closer to the UNAIDS target of 95% of people living with HIV knowing their status by 2030.⁴ However, efforts are still underway; only 84% of all people living with HIV were aware of their status in 2021. In some regions, such as sub-Saharan Africa, this percentage is even lower.⁴

Awareness of HIV status is also lower globally among certain populations, such as sex workers, men who have sex with men (MSM), people who inject drugs (PWID), and transgender people, highlighting the need for increased testing access (facility and community-based) in high-incidence communities to meet the UNAIDS 2030 goal.⁴

Lower awareness of HIV status in these populations generally stems from the high levels of stigma and discrimination that they face due to their sexual orientation, gender identity, or lifestyle choices.²² Internalised or ‘self’ stigma is also common in these groups, leading to feelings of shame, isolation, and fear of disclosure.²² All these factors can create barriers to seeking HIV testing due to fear of judgement or mistreatment.²² In some parts of the world, stigma and discrimination can also extend into criminalisation (i.e. legal and religious barriers), and these individuals may also face higher rates of mental health challenges, including depression, which can also impact their ability to seek HIV testing.^41,42

Who should get tested for HIV?

WHO SHOULD GET TESTED FOR HIV?

Everyone should get tested for HIV, particularly people who are sexually active. The CDC recommends that everyone between 13 and 64 years old gets an HIV test at least once in a lifetime.^3,5

It is generally advised that some people get tested more often (i.e. every 3 to 6 months). These include high-incidence groups, such as: MSM, PWID, those with a history of sexually transmitted infections (STIs), people who have sex without the use of prevention tools such as condoms, and those who have had sex with someone living with HIV with a detectable or unknown viral load.^5,7 Having sex exclusively with someone with an undetectable viral load would cease the need for more frequent HIV testing. The World Health Organisation (WHO) states that people living with HIV who have an undetectable viral load, and take antiretroviral therapy (ART) as prescribed have zero risk of transmitting HIV to their sexual partner(s).⁴³ Zero risk means undetectable equals untransmittable, often abbreviated as U=U.

Children who have experienced HIV exposure during or after their birth are offered even more frequent routine testing.^7,8

The average age of HIV diagnosis varies globally, with some people diagnosed later in life than others. This is particularly notable in migrant populations, where language and cultural differences pose barriers to timely testing, leading to a late HIV diagnosis.⁶

7 common reasons to get tested for HIV

1. Early detection

HIV testing detects the virus before symptoms appear, or if you have a flu-like illness, a common reason for testing. Early diagnosis opposed to a late HIV diagnosis has many benefits; the sooner HIV treatment is started, the better the outcome.⁹ Starting ART early benefits individuals, society, and advances future HIV cure research.^10-12
2. Preventing HIV transmission

Knowing your HIV status stops you from unknowingly transmitting it to others.¹³ If you’re HIV positive and maintain an undetectable viral load by taking HIV treatment, you won’t transmit the virus.¹⁴ U=U highlights the importance of HIV testing for public health.
3. Eligibility for PrEP

A negative HIV test result alone does not make you eligible for pre-exposure prophylaxis (PrEP), but you can consult your sexual health practitioner to see if PrEP might be suitable for you. PrEP mainly helps those at an increased vulnerability to HIV — such as MSM, people who engage in condomless sex, PWID, and those with HIV-positive partners — to remain HIV negative.^15,16 However, PrEP can also help people beyond these specific groups. PrEP is for anyone who wants a HIV prevention option.
4. Routine health monitoring

Regular HIV testing is offered as part of comprehensive health screening. In some countries you will be screened for HIV in combination with other STIs, such as chlamydia, gonorrhoea, and syphilis, and this may also cover hepatitis B and C. In the U.K., eligible individuals can also receive non-routine vaccinations such as hepatitis B and HPV at no charge. PrEP users should undergo HIV testing every 3 months as well as regular kidney function tests.^17,18
5. Screening during pregnancy

HIV-positive pregnant individuals who are undergoing effective HIV treatment maintain an undetectable viral load. Treatment administered to their newborns for 2-6 weeks can reduce the risk of HIV transmission to 1% or less.^19,20 The risk of HIV transmission through breastfeeding is also less than 1% provided the mother has an undetectable viral load during pregnancy, although pregnant women with HIV should reach out to their healthcare practitioner for advice about feeding their baby.^19,21 ARDs should be used during pregnancy only if the potential benefit justifies the potential risk to the foetus.
6. Peace of mind

Uncertainty about HIV status after a potential exposure can cause extreme anxiety. A negative HIV test result provides peace of mind, reducing stress. For some, reducing the worry of HIV helps them to enjoy sex more. Utilizing preventative measures such as condoms and PrEP can also alleviate future HIV testing concerns.¹³
7. Fighting stigma

Regular testing helps normalise HIV testing, reducing the stigma associated with HIV as a whole. This fosters empathy and support for those living with HIV within the community.²²

How soon can HIV be detected by a blood test?

People commonly wonder, “how long does HIV take to show up on a test?” Whilst HIV tests are very accurate, they can’t detect the virus immediately after infection due to the ‘window period’, which roughly lasts between 2 and 12 weeks after exposure (depending on the test carried out).²³ The window period is the time between the exposure and when a test can detect HIV in your body.

How soon HIV tests can detect the virus depends on the type of test being used (more on this in the ‘Types of HIV tests’ section below) and on the type of blood taken. Using blood from a vein can detect the viral load faster than tests using blood from a finger stick, or orally.²⁴

How accurate is an HIV test after 2 weeks?

Testing after just 2 weeks would not give a reliable result due to the window period of HIV. Fourth generation tests can detect 99% of HIV cases 6 weeks after exposure, but testing at 4 weeks only identifies 95%.²⁶ Early testing should be followed by a confirmatory test at 12 weeks, considering the 2—12 week window period.^26,23 These tests detect both antibodies and the p24 antigen, offering higher sensitivity than third generation tests.

How quickly are HIV test results available?

HOW QUICKLY ARE HIV TEST RESULTS AVAILABLE?

HIV tests in order from fastest to slowest test result are:

Rapid HIV test: as little as 30 minutes or less using a finger stick or oral swab.²⁴
Home HIV test kits: home test kits such as OraQuick can get results in 20-40 minutes after an oral swab at home.²⁵
Nucleic acid tests (NAT): a few days. These are lab-based tests also known as RNA testing.²⁴
Antigen/antibody tests: detects HIV antibodies and the p24 antigen typically in a few days.²⁴

How and where to get tested for HIV

Globally, barriers to HIV testing may include not knowing where to get tested, perceived costs, low awareness of self-perceived risk, and gender inequities.^27,28

Barriers to testing vary greatly between countries, but there are many places to get an HIV test, including:

In clinics/doctor’s offices

The following types of clinics typically offer HIV testing (depending on the country):

sexual health or genitourinary medicine (GUM) clinics
gynaecologists (OB/GYN)
urologists
some primary care physicians (also known as family doctors and GPs)
some contraception and young people's clinics
antenatal clinic (if you're pregnant)
private clinics (where you will have to pay)
HIV testing centres run by charities or international humanitarian organisations (e.g Terrence Higgins Trust in the UK or Médecins Sans Frontières (MSF), who offer HIV testing and treatment globally)²⁹

Healthcare system disparities exist globally. In some countries like the U.S., HIV testing may involve costs or health insurance, while other countries provide free HIV testing services or affordable testing in clinics. Developing regions, like parts of sub-Saharan Africa, may face low testing coverage and awareness.³⁰ Socio-economic status often determines access to HIV testing (i.e. poverty, unemployment), and the concentration of health facilities in urban areas poses challenges to people in rural communities.³⁰

In the community

Community-based HIV testing, led by trusted leaders, enhances awareness and education about HIV and testing.³¹ Communities may expand testing availability and accessibility through clinics, mobile units, and community-based centres.³¹ For instance in Rotterdam, a high HIV-prevalent multicultural area in the Netherlands, ‘walk-in’ testing events were piloted by community leaders at a boxing school, a community centre, and at a community support organisation where mainly women with a migratory background socialise.³¹ HIV testing was provided along with an assessment of body mass index (BMI), blood pressure, blood glucose, and HIV education.³¹

At home using an HIV self test

Self-testing is available in some countries, allowing individuals to test for HIV in the privacy of their own home. This is particularly valuable for those who prefer a less medical environment for increased comfort or have limited access to testing services, such as those in rural areas.³²

Where to buy a home HIV test kit

You can buy HIV home test kits online (e.g. via the Terrence Higgins Trust in the UK or s.a.m health in Germany) or collect them at pharmacies, usually after answering a few questions about symptoms and sexual health history.³³

Globally, social enterprise MedAccess also collaborates with Wondfo (a point-of-care testing manufacturer) to offer its HIV self-test at a record low price of $1 for public sector purchasers in 140 low- and middle-income countries.⁴⁴ FDA-approved kits such as the OraQuick^® HIV Self-Test Kit are also an option with availability in the UK, India (via Ubuy), and Europe (including Germany, France, Italy, Spain, and Portugal).^25,45

Where to get a free home HIV test kit

Some sites may offer free home testing in partnership with hospitals, while others require payment. The Terrence Higgins Trust, for example, offers a free HIV home test finder for anywhere in the UK.³⁴ Some other countries may have their own free test initiatives from sites affiliated with local public health departments, such as knowyourownHIVstatus.com in Florida, USA.

Globally, Unitaid offer HIV self-testing in low- and middle-income countries such as Côte d’Ivoire, Eswatini, Lesotho, Malawi, Mail, Senegal, South Africa, Zambia, and Zimbabwe.⁴⁶ In 2015, Unitaid funded the Self-Testing Africa Initiative (STAR), and by November 2018, STAR had distributed 2.3 million HIV self-test kits in Africa.⁴⁶

HIV self-testing typically involves collecting a saliva or blood sample at home, which – depending on the product – can be either analysed at home or sent by mail for analysis in a laboratory.

Counselling services

The following types of counselling services typically offer HIV testing, depending on the country:

Local drug dependency services
Public health offices
Checkpoints
AIDS Action

Globally, different countries will have different accessibility to counselling services. In some low-income nations, people in rural areas may have no adequate voluntary counselling and testing services.³⁶ Some countries may also have strict privacy laws to protect an individual’s HIV status, but in others, such laws may not exist, and people may face significant stigma.^35,36

In countries with multiple languages, counselling could become very complex to deliver, and government policies also have a big influence. Many countries may have robust government-funded programmes, while others may rely more on NGOs and international organisations.³⁷

Types of HIV tests

TYPES OF HIV TESTS

HIV tests typically detect the virus by taking a sample of your blood – either with a conventional blood test or a rapid test (a pin prick). Oral swab tests using saliva are another available option.³⁸

Below is an overview of the different types of tests used, and how long HIV takes to show up in each different format:³⁸

Antibody HIV tests
Antibody tests look for antibodies of HIV in a person’s blood or saliva, and detect HIV 23 to 90 days after exposure.³⁸

Antibody test formats are most commonly found in self-tests and rapid tests (finger stick tests that will give you a result within minutes).³⁸
Antigen/antibody HIV tests
Antigen/antibody tests are performed by a lab on blood from a vein and look for both HIV antibodies and antigens. They detect HIV 18 to 45 days after exposure.³⁸

Antigens are foreign substances that cause a person’s immune system to activate. If a person has HIV, an antigen called p24 is produced before antibodies develop.³⁸

Note: there is also a rapid antigen/antibody test available that is done with a finger stick and detects HIV 18 to 90 days after exposure.³⁸
Nucleic acid HIV tests (NATs)
NATs look for actual virus material in the blood. A NAT can usually detect HIV 10 to 33 days after exposure.³⁸

Consider this test if you have had a recent or possible exposure to HIV, are experiencing early symptoms, and have tested negative with an antibody or antigen/antibody test.³⁸
Will HIV show up on a normal blood test?

A standard blood test in health clinics or hospitals does not include HIV testing, as it doesn't measure HIV antibodies, antigens, or genetic material.

Routine blood tests like the Complete Blood Count (CBC) (a test which measures different parts of the blood, i.e. red blood cells, white blood cells, and platelets) also does not detect HIV. Despite this, a CBC test can indicate an early sign of an infection. Potential signs of HIV in a CBC test could be a low platelet count, high eosinophil count, or low neutrophil count in more advanced HIV.³⁹

To get an HIV test, you must specifically request one via HIV testing services, as hospitals do not automatically test for HIV. However, HIV testing is part of routine testing for pregnant women.

Understanding HIV test results

UNDERSTANDING HIV TEST RESULTS

Your HIV test result reveals only your own HIV status, not that of your sexual partners. It is important that everyone potentially exposed to HIV transmission is tested separately and that nothing is assumed.

Below are factors to consider when interpreting positive or negative HIV results.

Negative HIV test results

A negative test result doesn’t always rule out HIV, as the window period varies between individuals and depends on the test type. This is why different types of tests are performed.²³

Positive HIV test results

A positive antibody test result requires a follow-up lab test which is used to confirm a diagnosis of HIV.²³

Confirmatory HIV tests are essential to rule out any false-positives, which can result from technical or biological errors, especially in self-test kits.⁴⁰

How to deal with an HIV diagnosis

HOW TO DEAL WITH AN HIV DIAGNOSIS

There's no right or wrong way to respond to an HIV diagnosis. Dealing with an HIV diagnosis can be challenging in many ways, but strong networks of support and effective treatment that allow a maintained quality of life are available.

Some top tips of how to deal with HIV diagnosis include:

Fully cooperate with your HIV healthcare team for optimal treatment and a personalised care plan.
Seek support from loved ones. Counselling or mindfulness may also help you cope better with your new HIV diagnosis; your mental health is important and you should never have to go through HIV alone.
If disclosing your HIV status is not feasible due to factors like criminalisation or stigma, prioritise your safety and well-being. Seek support from trusted individuals, such as close friends or healthcare professionals, who can offer guidance and assistance while respecting your privacy.
Maintain a healthy lifestyle with nutrition, sleep, hydration, exercise, and stress management to support your immune system and reduce medication side effects.

A new HIV diagnosis may bring significant challenges, but remember, it doesn't define you. You are still the person you've always been.

Remember the empowering benefits of U = U, or "Undetectable = Untransmittable." When you maintain an undetectable viral load through treatment, you not only protect your own health and the health of others, but you also break down barriers and prove that HIV doesn't control your future.

Your journey will serve as a source of strength and motivation for other people living with HIV.

Watch inspirational stories on how others have dealt with their HIV diagnosis.

Watch HIV stories now

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