Expanding Human Immunodeficiency Virus Testing

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Expanding Human Immunodeficiency Virus Testing: Whole Society Participation and Multilevel Promotion

Did you know that nearly one-third of people living with HIV (PLWH) in China still don’t know they’re infected? That’s a staggering gap—and it’s why expanding access to HIV testing is one of the most critical steps in stopping the spread of the virus. For PLWH, early diagnosis means earlier treatment, longer lives, and a lower risk of transmitting HIV to others. For public health, it’s the key to reaching the global goal of ending AIDS by 2030.

While China has made significant progress in HIV testing over the past decade—doubling the number of people tested from 128 million in 2014 to 241 million in 2018—there’s still a long way to go. A 2021 study by researchers from the NHC Key Laboratory of AIDS Immunology (China Medical University), National Clinical Research Center for Laboratory Medicine, and other institutions highlights both China’s progress and the challenges ahead in expanding HIV testing to reach every person who needs it.

China’s Progress in HIV Testing

China’s strategy combines passive testing (offered as part of routine care) and active testing (chosen voluntarily by individuals). Here’s how it works:

Passive Testing: Making Testing Routine

  1. Blood Safety: Since 2016, all blood centers must use nucleic acid testing (NAT) plus the existing enzyme-linked immunosorbent assay (ELISA) to screen donations. This dual approach has eliminated HIV transmission via blood transfusions or products—raising China’s blood safety to an advanced global level.
  2. Provider-Initiated Testing: Doctors now recommend HIV testing as a standard part of care for patients visiting hospitals or clinics. Medical institutions have frequent contact with PLWH, so this method has become the top source of diagnoses: since 2013, hospitals have accounted for over 50% of all HIV cases found in China.
  3. Preventive Exams: HIV testing is encouraged during pre-marital and pre-pregnancy health checks. In high-incidence areas, workers in commercial venues (like entertainment or beauty salons) are advised to test every six months.

Active Testing: Empowering Individuals

Active testing relies on two key tools:

  • Voluntary Counseling and Testing (VCT): China has built over 10,000 VCT clinics by 2018. These clinics offer free, confidential testing and counseling—and in 2017, they diagnosed 27% of new HIV cases. VCT links people to treatment if positive or prevention services (like PrEP) if negative.
  • HIV Self-Testing (HIVST): This innovative method lets people test at home, protecting their privacy. The World Health Organization (WHO) endorsed HIVST in 2016, and China followed with its own guidelines in 2017. Today, you can buy HIVST kits at drugstores or online, with follow-up support for self-testers. A 2016–2019 study of 73 universities in 11 provinces found that anonymous urine testing via vending machines boosted active testing among high-risk college students—proof that creative solutions work.

Key Challenges for HIV Testing in China

Despite progress, three critical gaps remain:

  1. Low Diagnosis Rates: Only 68.9% of PLWH in China knew their status in 2018—far from the 95% target set by the UN’s 2030 Sustainable Development Goals. For men who have sex with men (MSM), the number is even lower: just 56.4% of HIV-positive MSM know they’re infected. Undiagnosed PLWH are the biggest source of new transmissions, so closing this gap is urgent.

  2. Low Active Testing: In 2018, only 25% of HIV tests were “active”—meaning people sought testing on their own. The 2018 World AIDS Day theme (“Know Your Status”) emphasized active testing, but uptake remains low.

  3. Delayed Diagnosis: Between 2010 and 2014, 35–42% of HIV diagnoses were delayed—meaning people waited years to get tested, often until they were in late-stage infection. Older adults are particularly affected: from 2008–2014, the average time from infection to diagnosis for people over 50 was 6.8 years, and 70.6% had a low CD4 count (a sign of advanced disease) at first test. This delay costs lives: in 2020, 18,800 PLWH died from AIDS—four times the number of COVID-19 deaths in China that year.

Recommendations to Boost HIV Testing

To fix these gaps, the study’s authors offer four actionable steps:

  1. Promote Personal Responsibility: Educate the public on who should test (e.g., anyone with risky behaviors like unprotected sex), where to test (hospitals, VCT clinics, home kits), and what to do next (treatment if positive, prevention if negative). This will encourage more people to take charge of their health.

  2. Boost Community Access: Social organizations play a key role in supporting high-risk groups—use them to expand home testing and follow-up care. For example, community groups can deliver HIVST kits to MSM or injection drug users who may avoid traditional clinics.

  3. Integrate Online and Offline Services: Build platforms that combine online info (test locations, results) with offline support (kit delivery, counseling). This makes testing more convenient for busy or marginalized people.

  4. Innovate with New Methods: Try strategies like partner notification (encouraging PLWH to tell their partners, which increases testing) or pay-it-forward (where people cover the cost of a test for someone else). A 2021 trial in Shenyang found that partner notification plus HIVST and community support doubled testing among MSM partners. The WHO also recommends using social networks to reach high-risk groups (like MSM or commercial sex workers) who may avoid traditional care.

The Path Forward

Expanding HIV testing isn’t just a public health goal—it’s a moral one. China’s “Implementation Plan for Containing the Spread of AIDS (2019–2022)” lists early diagnosis as a top priority, and reaching 95% diagnosis by 2030 will require everyone’s help: governments, hospitals, social organizations, and individuals.

The key is to put people first: make testing accessible, private, and easy to understand. By promoting active testing, using social networks, and supporting community groups, China can close the diagnosis gap—and move one step closer to ending AIDS.

This study was conducted by Qing-Hai Hu, Jun-Jie Xu, Yong-Jun Jiang, and Hong Shang from the NHC Key Laboratory of AIDS Immunology (China Medical University), National Clinical Research Center for Laboratory Medicine, The First Affiliated Hospital of China Medical University, Key Laboratory of AIDS Immunology (Chinese Academy of Medical Sciences), Key Laboratory of AIDS Immunology of Liaoning Province, and Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases. It was published in the Chinese Medical Journal in 2021.

doi.org/10.1097/CM9.0000000000001812

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