Debates about HIV testing:
Debates about HIV testing Until recently…
Central place to counseling, as a result of HIV "exceptionalism:"
commonly accepted public health measures are questioned,
fears of discrimination are highlighted,
hence protecting individual rights is paramount
VCT, the "3Cs": emphasis on C
Current controversies:
Traditional VCT has resulted in slow uptake (6 million vs 180 million tests) and most people do not know they are infected
Potential availability of treatment shifts the cost-benefit debate
Ethical, technological, and human elements
Heated debates at the 2006 HIV AIDS conference
CDC Guidelines: counseling optional
WHO's work on PITC guidance
Changing models of HIV testing :
Counseling typically involves:
Face-to-face session with trained counselor
Pre-test: Information about HIV (illness, test, meaning, avoid transmission)
Obtain consent
Post-test: Identify ways to reduce risks
Refer where appropriate
Rapid testing changes the conditions of pre-/ post-test counseling
Time and resource limitations reduce counseling
Individual vs group information
Different models of testing
Diagnostic testing, diagnostic screening at health facilities
Home-based VCT
Testing campaigns
Multiple approaches to the provision of testing—some examples
Botswana: Since 2004, opt-out testing in prenatal care settings
Uganda: Revised policies; several models co-exist: VCT, routine offer at health facilities, home-based VCT
Netherlands: Opt-out testing in prenatal care clinics
NYC: Calls to skip counseling before the test, concentrate on post-test
Changing models of HIV testing
Highlights of a review of the evidence 1- Clients:
1. In most settings there is a gap between intentions to test and completion of testing:
Very high "acceptance" but lower completion--1/3 or more did not return for results
Fear a main reason for not testing
Many express wish/ intention to test but change their minds
Disclosure and partner involvement are very low
2. Perceptions of risks and consequences of HIV are key:
Individual notions of risk do not match objective assessments: denial, excessive fears or unjustified optimism, correct and incorrect information coexist
Emotional connotations of information, test results, and disclosure
3. Gender differences
In motivations to test: fears, risk perceptions, reasons (partner's symptoms)
In consequences of disclosure
Highlights of a review of the evidence 1- Clients
Highlights of a review of the evidence 2- Providers:
1. Variations in the quality of counseling
The usual problems of resource-poor settings: training, workloads, time, space
Provision of testing and counseling not always systematic
Providers try to predict responses of clients
Client characteristics influence provision
2. Counselors on the front lines—how do they cope
Emotional issues, fears of stigma
Fears of contamination
Helplnessness, doubts, burnout
Good rapport with providers makes a difference
3. Interventions that may help
Reduce practical obstacles—cost and convenience
Frame messages in a personal manner, adapt to context, consider gender
Protect and support providers (eg. Treat Train and Retain initiative)
Highlights of a review of the evidence 2- Providers
Questions for future consideration-1 :
1. What is the impact of stigma on testing and counseling?
Stigma as the biggest obstacle to testing--even in health care settings
Difficult to quantify: cognitive rather than behavioral measures “conceptual inflation,” "layering" of stigma
Violence and abuse: contradictory and insufficient results
Does routinization of testing help reduce stigma?
2. What is the effect of counseling on the uptake of testing?
Does more counseling lead to more testing?
Does skipping pre-test eliminate an obstacle or a protection?
Questions for future consideration-1
Questions for future consideration-2 :
3. Do ethical practices influence uptake?
Informed consent: cross-cultural differences vs. core elements
Subtle effects of pressure and relationships with providers
Absolute privacy vs. "shared confidentiality"—how do valuations vary across settings, and how does this influence testing uptake
4. New approaches: can we generalize from available evidence?
Home-based VCT: high consent, no major problems of coercion
Testing campaigns: higher than expected response
Opt-out does not elicit opposition; routine testing acceptable, less anxiety
In which settings is routine the right approach?
How much treatment should be available?
Questions for future consideration-2 Adapt guidelines to epidemic and resources
Put in place the services to the best of current knowledge
Monitor and compare what happens