General principles and background
A priority measure to impact on the HIV epidemic and related STI epidemics is to diagnose people as early as possible after acquiring infection and link them to appropriate prevention, treatment, care and support services. As recommended in international guidelines, the organisation of HIV/STI testing activities should be approached within a public health and human rights perspective. Testing should therefore be accessible, voluntary, confidential and contingent on informed consent.
In Belgium, a strategic mix of HIV/STI testing services within both healthcare and community facilities is provided. In addition, there are three low-threshold screening centres in Antwerp, Brussels and Liège which offer the possibility of free and anonymous HIV testing for populations at high risk1. Since 2016, non-medical providers are allowed, under certain conditions, to perform HIV rapid tests2. There is also the HIV self-test that can be purchased in Belgian pharmacies.
Belgium has no national HIV testing policy. In 2019, clinical guidelines have been developed on the diagnosis and management of gonorrhoea, syphilis and chlamydia in primary care3. To guide primary healthcare practitioners in offering HIV/STI testing, an interactive screening tool “Testing STIs in a sexual health consultation” has been issued4. Finally, there are the STI screening strategies within HRCs, both for people living with HIV as for PrEP users.
Compared to other European countries, Belgium has a relatively high and stable HIV testing rate with more than 700 000 HIV tests per year. In 2019, 1.2 new diagnoses have been established per 1000 tests. More than half of the HIV diagnoses were made by general practitioners, followed by internists and gynaecologists. For now, no national data are available on the contribution of community-based HIV testing to the new diagnoses. Due to significant barriers to HIV testing and migration flows, many people living with HIV in Belgium are diagnosed late in the course of the disease (<350 CD4/mm3). At population level, late diagnosis is responsible for the existence of a "hidden" epidemic which drives the further spread of the epidemic.
Concerning the testing rate of STI, a rising trend can be observed. For chlamydia this raised from 30 tests per 1000 inhabitants in 2017, to 37 tests/1000 inhabitants in 2019 and for gonorrhoea from 25 tests/1000 inhabitants in 2017 to 35 tests/1000 inhabitants in 2019. In men, for chlamydia there was an increase from 12 tests/1000 inhabitants in 2017 and 17 tests/1000 inhabitants in 2019, for gonorrhoea from 12 tests/1000 inhabitants in 2017 and 21 tests/1000 inhabitants in 2019. For syphilis, the RIZIV/INAMI data also show a rising trend in the number of treponemal tests. These rising trends may be linked to more opportunistic and targeted testing for STI as well as the implementation of screening programs among risk groups such as men who have sex with men5.
The objective of the testing pillar is to improve the frequency, regularity and targeting of HIV/STI testing in key populations in order to increase the rates of early diagnosis, improve early uptake of sustained treatment and prevent transmission.
The testing pillar aims to cover the full procedure from screening to an eventual HIV/STI diagnosis, including informed consent, counselling, partner notification and linkage to appropriate prevention care and support services.
The responsibilities and competencies for HIV/STI testing are distributed over the federal and regional health authorities. The cost of the HIV tests that are prescribed by a medical doctor are reimbursed according to the rules of RIZIV/INAMI. The confirmation of reactive screenings tests is exclusively performed in the ARLs which are financed by RIZIV/INAMI. The cost for the STI tests is also reimbursed according to the rules of RIZIV/INAMI.
Furthermore, RIZIV/INAMI finances the three low threshold screening centres, and provides subsidies to HIV/STI testing programs for sex workers in Flanders, Brussels and Wallonia. The regional health authorities and the municipalities also contribute to the financing of these socio-medical health centres for sex workers.
The organisation of HIV/STI testing activities in community facilities is financed by the regional health authorities. It concerns mainly project-based funding for which the assignments are determined in periodic calls fitting within the regional policy framework concerning health promotion and prevention.
Through a participatory process, relevant stakeholders in the testing field agreed on the following priority areas and actions.
Priority area 1: Increase awareness and knowledge of healthcare providers, community health workers and key-populations of the indications for HIV/STI testing
1.1 Update, develop and implement informative initiatives for healthcare providers and community health workers on the indications for HIV/STI testing
1.2 Promote existing HIV/STI testing guidelines and recommendations for testing in primary care, in particular the KCE guidelines on diagnosis and management of gonorrhoea syphilis and chlamydia in primary care, and the screening tool “Testing STIs in a sexual health consultation”
1.3 Establish collaboration networks for training of lay-providers in community settings
1.4 Inform and educate key-populations on the indications for HIV/STI testing
Priority area 2: Increase accessibility and uptake of HIV/STI testing and tailor the testing approaches and services to the specific needs of the key-populations
2.1 Maintain an updated inventory of all available entry-points to HIV/STI testing both within healthcare and community settings
2.2 Improve the communication skills and intercultural competences of healthcare providers - in particular general practitioners - and community workers to pro-actively offer HIV/STI testing
2.3 Guarantee access to free and anonymous HIV testing
2.4 Further develop the legal framework for lay provider combined HIV and STI testing
2.5 Provide self-sampling kits for HIV and STIs to people in groups and communities with a high rate of HIV
2.6 Collect data on the purchase of the HIV self-test to assess whether its use can be better supported and promoted
2.7 Assess how the location-population approach for testing, in particular the UNAIDS fast-track city initiative, can be adopted and expanded in the Belgian context
2.8 Establish, in collaboration with relevant policy makers, a comprehensive HIV/STI testing policy, covering the combination of all existing testing approaches
Priority area 3: Implement evidence-based tools to identify undiagnosed people living with HIV and to address gaps in testing and prevention
3.1 Combine existing knowledge of different disciplines on the dynamics of the epidemic and the underlying behavioural patterns
3.2 Use modelling estimates and evidence on transmission networks as a mean to identify undiagnosed people living with HIV
3.3 Develop and implement practical tools to enable healthcare providers - in particular general practitioners - and community workers to identify undiagnosed people living with HIV
3.4 Enhance the acceptability of HIV/STI partner notification in the different key-populations by reducing barriers at structural, provider and user level
3.5 Facilitate the implementation of tools for partner notification
Priority area 4: Ensure that all diagnosed people with HIV and other STIs are promptly linked to prevention, care and (peer) support services without exception
4.1 Implement initiatives and develop guidance to support healthcare providers - in particular general practitioners - and community workers in test result management, including the delivery of HIV diagnoses
4.2 Improve the communication and collaboration between testing, care and support services
4.3 Define clear referral pathways from testing to care
Priority area 5: Consolidate a harmonized data collection of community-based HIV/STI testing
5.1 Harmonize the data collection of community-based HIV/STI testing activities
5.2 Improve the data quality
5.3 Integrate all applicable data to produce a meaningful national dataset that captures the testing activities of the various organisations
5.4 Coordinate the consolidation of national data collection.
Priority area 6: Gather and disseminate data to evaluate current STI screening practices and treatment strategies for key-populations, including PrEP users and people living with HIV
6.1 Continue to develop and improve surveillance activities to monitor STI within key-populations, including PrEP users an people living with HIV
6.2 Improve the evidence basis and evaluate the aim and impact of STI screening and treatment practices
6.3 Follow the new developments in the field of STI (rapid) testing and evaluate the performance and applicability of these procedures and assays.
1 Koninklijk besluit tot vaststelling van de voorwaarden waaronder het Verzekeringscomité overeenkomsten kan sluiten tot regeling van de tegemoetkoming van de verplichte verzekering voor geneeskundige verzorging in de prestaties voor specifieke vormen van aidsbestrijding (KB van 6 maart 2017, gepubliceerd op 23 maart 2017).
2 Koninklijk besluit houdende de toepassing van artikel 124, 1° van de wet van 10 mei 2015 betreffende de uitoefening van de gezondheidsberoepen teneinde een kader te scheppen voor de diagnostische oriëntatietests voor het humaan immuundeficiëntievirus (KB van 19 juli 2018, gepubliceerd op 19 september 2018).
3 Jespers V, Stordeur S, Desomer A, Carville S, Jones C, Lewis S, Perry M, Cordyn S, Cornelissen T, Crucitti T, Danhier C, De Baetselier I, De Cannière A-S, Dhaeze W, Dufraimont E, Kenyon C, Libois A, Mokrane S, Padalko E, Van den Eynde S, Vanden Berghe W, Van der Schueren T, Dekker N. Diagnosis and management of gonorrhoea and syphilis. Good Clinical Practice (GCP) Brussels: Belgian Health Care Knowledge Centre (KCE). 2019. KCE Reports 310. D/2019/10.273/21. Available through: https://kce.fgov.be/sites/default/files/atoms/files/KCE_310_Diagnosis_management_Gonorrhoea_and_Syphilis_Report.pdf
4 Jespers V, Stordeur S, Desomer A, Cordyn S, Cornelissen T, Crucitti T, Danhier C, De Baetselier I, De Cannière A-S, Dhaeze W, Dufraimont E, Kenyon C, Libois A, Mokrane S, Padalko E, Van Den Eynde S, Vanden Berghe W, Van Der Schueren T, Dekker N. Sexually Transmitted Infections in primary care consultations: development of an online tool to guide healthcare practitioners. Good Clinical Practice (GCP) Brussels: Belgian Health Care Knowledge Centre (KCE). 2019. KCE Reports 321. D/2019/10.273/60. Available through: https://www.sti.kce.be/en/
5 Vanden Berghe. W, De Baetselier. I, Van Cauteren. D, Moreels. S, Sasse. A, Quoilin. S. Surveillance van seksueel overdraagbare aandoeningen. Gegevens voor de periode 2014-2016. Brussel, België: Sciensano ; 2020. 26p. Depotnummer : D/2020/14.440/2