2023 Malawi HIV, Syphilis and Hepati ti s B Integrated Rapid Testi ng and Counselling Guidelines

HIV Testing Client Flow in the 2023 Registers 2023 HIV Diagnostic Algorithm for: Never tested, Last self-test (neg, pos, inc), Last professional test (neg, inc, exp infant) 2023 HIV Diagnostic Algorithm for Last Professional Positive Clients
Has the client ever been tested for HIV? If yes, was the most recent test:
Diagnostic Algorithm Recency Surveillance * Diagnostic Algorithm
 Self-test or professional test? Documented results are preferred, but reported results are acceptable.

Blood Draw 1
Blood Draw 1
* Syphilis and hepatitis B tests are done in parallel with
 Document previous test status in Initial Testing Register.
 Regardless of previous test status: all clients follow the full serial 3-test algorithm HIV test 1 in certain entry points. Recency testing is only
Syphilis done in selected facilities
HIV Test 1 HIV Test 1
Hepatitis B * R = reactive
LT = long-term
Rec = recent R = reactive
Most recent: Most recent: NR R NR= non-reactive NR R
Never tested Neg = negative NR= non-reactive
Self-test Professional test
I n f or me d Co ns e nt

Blood Draw 2
Blood Draw 2
Negative, Initial positive*, New Recency
HIV Test 2 HIV Test 2
Negative, Positive or Invalid
Positive, New inconclusive, Test
Exposed infant, Positive or NR R LT Neg NR R
Inconclusive re-test Rec

Blood Draw 3
Blood Draw 3
Initial Register
HIV Test 1 HIV Test 1 HIV Test 3 DBS for VL HIV Test 1 HIV Test 3
* Initial Positive: Clients with a
NR R NR R <
positive HIV test 1 result 1000 1000 NR R NR R
(entered in the Initial Testing +

Interpretation

Interpre tation
HIV Test 1 positive Register) who did not complete
͞Initial positive͟Ύ the full 3-test algorithm Long-term Recent
(confirmatory testing). This may Negative Inconclusive Positive (Ignore) Negative Inconclusive Positive
Infection Infection
happen with community-based
testing.
Confirmatory Register
HIV Test 2, 3, 1, Recency

Result Given

Result Given
New New Positive Inconclusive Positive
Negative None
Inconclusive or Exp. Infant Re-test Re-test
New inconclusive, New positive, Patients on ART
HIV negative
Inconcl. re-test Positive re-test (once per year)
Repeat whole 3- Start ART as soon Continue / start ART as soon as client is ready
 High risk event in last 72hrs: PEP, re- (No routine follow-up) Repeat whole 3-test algorithm after 2 weeks
test algorithm as client is ready (within 2 weeks). HIV exposed infant if client is <12

Referral

Referral
test after 4 weeks If repeat is still inconclusive: DBS for reference lab
after 2 weeks (within 2 weeks) months. All children under 24 months who start or
** Self- tests may be  Ongoing risk: re-test after 12 months DBS result provides final diagnosis, except:
Send DBS to Ref. If repeat is still HIV exposed *All children under 24 months who start or re-start ART re-start ART need a confirmatory DNA-PCR using a
distributed for use by  Client on PrEP: re-test 3-monthly If DBS is negative and client is on ART: interrupt ART, repeat
Lab if repeat Index register inconclusive: DBS infant if client is need a confirmatory DNA-PCR using a new DBS sample. new DBS sample. This should be collected on the
partners or others, regardless  Refer high-risk for VMMC, PrEP, etc. 3-test algorithm after 3 months.
inconclusive for reference lab <12 months* This should be collected on the day of starting ART. day of starting ART.
of the recipients own HIV
status. However, never give
self-tests for self-use by
clients with a previous
positive or inconclusive test Contact Register
result.
Syphilis Screening Hepatitis B (surface antigen) screening
2023 Diagnostic Algorithm 2023 Diagnostic Algorithm
Self-test Distribution
Register**

Need for HBV

syphilis te st
Ne ed for

test
Not eligible Eligible* Not eligible Eligible*

HIV Risk Assessment

Syphilis test

HBV test
Hepatitis B surface
Syphilis Rapid Test
antigen rapid test
Low risk Ongoing risk High risk
(moderate)
 No sex / abstinence  Any of the 6 substantial risk factors defining PrEP need, but client is NR R NR R
 Consistent and correct  Stable partner with not, or not consistently, using PrEP:

HBV infection
Ask: previous
treatment?

condom use with all unknown HIV 1. Current or recent STI: in last 6 months, self-report or clinical
Treated for syphilis Never treated for

risk
partners status without diagnosis Low High*
in the past syphilis before
 Consistent PrEP use* (any other high-risk 2. Transactional sex: paid or received money or goods for
partners) sexual partners condomless sex (incl. sex workers and clients)
 Stable known HIV  Born / breast 3. Condomless sex with a known HIV infected regular partner who is
negative partner who feeding from HIV not on ART or with viraemia 1000+ on their most recent VL result
Refer to lab for

HIV status***
confirmation

does not engage in risky infected mother on 4. Condomless sex with regular partner with unknown HIV status Lab tests for active Lab tests not
behaviour ART who has other high-risk sexual partners. infection** available*** HIV negative or
inconclusive HIV positive
 Stable HIV infected 5. Condomless anal intercourse with non-regular partner NR R
partner who is taking ART 6. Injecting drug use with needle sharing
with viral load <1000  Rape (regardless of HIV status of perpetrator)
copies/ml on their most  Condomless sex with non-regular partner (known pos. or unknown
Other tests and re- Full course of 3 Enroll in HBV clinic
recent result. HIV status) No syphilis treatment. Enroll in HBV clinic
test appointment HBV vaccinations for reporting.

Referral
Referral

 Occupational exposure: needle stick injury, etc. Other tests and re-test for diagnostic
Treat for Syphilis based on risk (unless already Start or continue
 Born / breastfeeding from HIV infected mother not on ART appointment based on risk follow-up /
assessment and completed in the ART for HIV and
assessment and guidelines treatment HBV
guidelines past)
*Consistent PrEP use means taking oral or injectable PrEP exactly as prescribed for the minimum required time before and after all risky acts (see PrEP guidelines)
* Eligibility for HBV testing: see Table 5 in Integrated Testing Guidelines for who and when to test for Hepatitis B.
* Eligibility for syphilis testing: see Table 5 in Integrated Testing Guidelines for who and when to test for syphilis.
** Table 5 shows high risk groups who should be referred for a course of 3 HBV vaccinations unless they have
But: condomless sex carries high risk of unwanted pregnancy ** Lab test for active infection: Clients with a previous syphilis infection usually have a positive rapid test for life, even previously completed 3 HBV vaccinations: FSW, TG, MSW, MSM, PWID, prisoners, PrEP clients, children 0-14 years born
ART and PrEP are and STIs if the infection was cured. Additional lab tests (RPR or VDRL) are needed to confirm a new, active syphilis infection. to HBV positive women, STI patients, general population at ongoing HIV risk or after high-risk event, health workers,

 !
very effective  Some STIs can not be cured and may cause ugly sores on *** Lab tests not available: Lab tests for confirmation of active syphilis infection may not be available at all sites. In sex partners of HBV index clients, sex partners of STI patients, presumed hepatitis patients, in-patients.
HIV prevention genitals, long-term suffering, cancer and death (hepatitis this case, refer for presumptive syphilis treatment to ensure that any potentially new syphilis infection is treated. *** HIV status must be ascertained for all HBV positive clients. Perform a new HIV test using the full 3-test algorithm
methods if used B, herpes simplex, HPV, HTLV) unless the client is already known to be HIV positive.
consistently  Even curable STIs are often missed, causing infertility,
stillbirth, nerve and brain damage, etc.