Background:  HIV counseling and testing (HCT) policies and practices in Sub-Saharan Africa largely conform to the WHO/UNAIDS principles of consent, confidentiality, and counseling, but HCT implementation has often been ahead of policy development over the last 15 years. Implementation and policies have varied across and within regions, however, 3 distinct eras are evident:  pre-1990, 1990 to 1995, and 1996 to 2005. In the pre-1990 era, HCT was confined to research and blood transfusion sites, counseling was minimal, and results rarely returned. Demand for HIV testing in the early 1990s led to the establishment of voluntary, anonymous HCT sites. National policies were nonexistent and services were based on institutional guidelines and tended to be client-initiated with long turnaround time and low post-test return rates. In the mid to late 1990s, rapid HIV testing with same-day results became available, with a shift to confidential HCT, improved post-test support, and targeting of couples. Over the last 5 years, pressure to increase access to HIV services, address HCT for children, and other gaps led to policy revisions. Innovations­—eg, provider-initiated and home-based approaches, use of non-medical workers, and finger-stick techniques—were adopted. Acceptance and demand for HCT is rapidly increasing in many countries and policy should allow for innovative approaches to meet the demand. For example, in 2 districts in Uganda, more than 170,000 persons received home-based family voluntary HCT in 2006, with over 98% acceptance rate. Likewise, in 2 major Uganda hospitals, routine HCT was provided to more than 90,000 persons in 2006 with over 96% acceptance. Programs targeting HCT for family members of HIV-infected individuals have shown high rates of previously undiagnosed HIV infection and discordance. Significant challenges remain in terms of great unmet demand for HCT (ranging from 95% in Nigeria to 70% in Uganda), linkage to prevention and care services, limited human resources, and supportive policies.

Conclusions:  To achieve WHO’s goal of universal access to HIV prevention, care, and treatment, millions of people in Sub-Saharan Africa will need access to HIV testing. This will require a major scale-up of HCT and care services, diversification of HCT approaches, improved diagnosis among children and infants, and progressive policies that support innovation while preserving quality.