Audit of standards of care for HIV testing

Outcome and structural indicators are routinely collected through the HIV monitoring, coordinated by ECDC within the framework of the Dublin Declaration on Partnership to fight HIV/AIDS in Europe and Central Asia. However, process indicators, particularly those relating to clinical practice, are not captured systematically. A pilot clinical audit was therefore conducted to assess selected process indicators and examine the implementation of HIV testing standards at the individual clinic level.

This report presents findings from both data sources for three participating countries: Greece, Poland and Romania. Country-level data were drawn from the Dublin Declaration monitoring, while clinic-level data were collected through a retrospective audit, conducted between October 2025 and January 2026 at 12 clinics (three HIV clinics and one tuberculosis (TB) clinic per country). The audit collected aggregated clinic information and individual patient-level data from medical records. 

The participating clinics varied considerably in size and patient populations. At HIV clinics, HIV positivity among those tested ranged widely, and the characteristics of those diagnosed with HIV differed by clinic, including the key populations represented. TB clinics reported high levels of HIV testing among those diagnosed with TB, although performance varied. 

At the country level, none of the three participating countries had achieved the UNAIDS target (95% of people living with HIV should be aware of their status). At the individual clinic level, substantial variation was observed in the proportion of people diagnosed with HIV late or very late, indicating ongoing challenges in timely diagnosis in all settings. 

With regard to testing policies, there are still significant shortcomings. While community-based testing is included in national strategies to varying degrees, none of the three countries includes home testing or self-testing in national guidelines. This suggests that there are missed opportunities to expand testing approaches to reach populations who may face barriers to facility-based services. 

In terms of testing strategies, most HIV clinics reported implementing targeted HIV testing promotion activities for key populations. In TB services, HIV testing coverage among those diagnosed with TB was generally high, with most clinics meeting or approaching the recommended target of 85%, although variation among clinics was observed. 

For consent practices, all three countries report policies supporting voluntary HIV testing. However, requirements for pre-test counselling and written consent remain in some settings. At the individual clinic level, practices varied, with only around half of clinics fully aligned with standards that no longer recommend these requirements. These findings highlight inconsistencies between policy and practice, as well as potential barriers to scaling up routine testing. 

With regard to diagnosis and linkage to care, most clinics reported having documented care pathways to HIV treatment and support services. However, performance against key timeliness indicators was variable. No clinic reached the target for confirmatory testing within five working days of a reactive test, and only a minority achieved the target for timely specialist assessment. Time to initiation of antiretroviral therapy (ART) also varied widely. Documentation of partner notification discussions was also incomplete in several settings, indicating further gaps in implementation. 

For monitoring and evaluation, most clinics reported submitting HIV testing data to national surveillance systems. However, reporting practices differed, with some clinics reporting only positive tests and others reporting all testing activity. While most HIV clinics reported core indicators using key demographic variables, incompatibility of reporting practices may limit comparability and completeness of data. 

Overall, the findings from this pilot audit highlight variability in the implementation of HIV testing standards both between and within countries. While some clinics and national systems meet specific targets, shortcomings persist in a number of areas, particularly in the expansion of testing approaches, the streamlining of consent procedures and improvement of timeliness in the area of diagnosis and linkage to care. 

This audit demonstrates the feasibility of combining country-level monitoring data with clinic-level audit data to provide a more detailed understanding of how HIV testing standards are implemented in practice. Although the results of this audit are not intended to be generalisable beyond the clinics included, they do provide valuable insights which can be used to inform future audits and quality improvement efforts. 

The audit findings have been shared with participating clinics to support local reflection and improvement. Expanding the number of participating clinics in future audits would strengthen the robustness and representativeness of findings. Further development of the audit process, including increased automation and stronger institutional support, could facilitate regular, cyclical assessments and contribute to ongoing improvements in HIV testing services.