VCT DAR

Voluntary HIV Counselling and Testing: Evolution and Current Issues : 

Voluntary HIV Counselling and Testing: Evolution and Current Issues Regional Consultation Workshop on Strengthening Voluntary Counselling, testing and Antiretroviral (VCT/ART) Services within African Universities 25 – 27th June 2007 Dar es Salaam - Tanzania

Background : 

Background Test to Identify HIV Antibodies Developed Mid 1980’s Treatment not available – Counselling mainly educational People generally discouraged from being tested Nothing could be done High potential for discrimination, rejection Severe consequences and policies being considered

Original Views of Public Health : 

Original Views of Public Health Identify potential transmitters Disease control measure identifying partner notification Identify risk behaviour – risk populations

Lack of Dialogue : 

Lack of Dialogue Little discussion between stakeholder groups Medical Service Providers Public Health and Policy Makers Community Stakeholders and Affected Communities

Current Situation: 2007 : 

Current Situation: 2007 Scale Up of Effective Treatment Epidemic Continues to Spread – Greater need for emphasis on education, and health promotion. Not viewed as one epidemic but multiple Each epidemic may require a unique / different approach

Elements of a HIV Test Experience (traditional) : 

Elements of a HIV Test Experience (traditional) PRE-TEST SITUATION PRE-TEST ENCOUNTER WAITING PERIOD POST-TEST ENCOUNTER IMPACT OF AN HIV TEST EXPERIENCE A B C D E Repeat Testing

HIV Testing and Counselling: Best Practices : 

HIV Testing and Counselling: Best Practices Ensure information and risk reduction education Individualize Risk Assessment Give results in person Provide Information and make appropriate referrals Facilitate partner notification

HIV Testing and Counselling: Best Practices – not HIV specific : 

HIV Testing and Counselling: Best Practices – not HIV specific Build trust and rapport Ensure comfortable, safe environment Ensure confidentiality Impart non-judgmental attitude Self- determination Maintain professional boundaries

3 C’s that must be Respected : 

3 C’s that must be Respected Consent Confidentiality Counselling

Who does VCT : 

Who does VCT Trained Counsellors Physicians Nurses Social Workers Volunteers / trained peers Other Those who have time!

Current Situation : 

Current Situation Uptake of VCT low Low coverage of services Fear of stigma and discrimination Low Perception of Risk 80% of people living with HIV in low and middle income countries do not know they are HIV positive (UNAIDS, 2007) 12% men and 10% of women in Sub Saharan Africa have been tested and received their test result (UNAIDS, 2007)

Typology of HIV EpidemicsWHO and UNAIDS define different types of HIV epidemics as follows: : 

Typology of HIV EpidemicsWHO and UNAIDS define different types of HIV epidemics as follows: 1. Low-level HIV epidemics HIV prevalence has not consistently exceeded 5% in any defined sub-population. 2. Concentrated HIV epidemics HIV prevalence is consistently over 5% in at least one defined sub-population but is below 1% in pregnant women in urban areas. 3. Generalized HIV epidemics HIV prevalence consistently over 1% in pregnant women.

Scaling Up Access to HIV Testing : 

Scaling Up Access to HIV Testing “Scaling up access to HIV testing is both a public health and a human rights imperative” (K de Cock, WHO HIV/AIDS Director)

Approaches to HIV Testing and Counselling : 

Approaches to HIV Testing and Counselling Voluntary Counselling and Testing - Client-initiated Testing Provider-initiated Testing provider specifically recommends test to patients attending health facilities once pre-test information provided the test would be preformed unless patient declines

AIM: Provider-initiated HIV Counselling and Testing : 

AIM: Provider-initiated HIV Counselling and Testing Wider knowledge of HIV Status Increase access to HIV treatment and prevention Discussion: When is this approach appropriate? When may this approach not be appropriate?

WHO/UNAIDS Recommendations (1) : 

WHO/UNAIDS Recommendations (1) Patients have right to decline, not tested: against their will without their knowledge without information without receiving results Pre-test and Post-test information remain integral Discussion: Some feel these principles may be challenged. When?

WHO/UNAIDS Recommendations (2) : 

WHO/UNAIDS Recommendations (2) Patients should receive support to avoid potential negative consequences of knowing or disclosing HIV status What types of support may be put in place? Provider-initiated testing is not and should not be construed as endorsement of coercive or mandatory testing!

WHO/UNAIDS Recommendations (3) : 

WHO/UNAIDS Recommendations (3) Implementation of P-I testing should be undertaken in consultation with key stakeholders, including civil society groups (what works and what is ethical will vary with country/ context) Policy and legal frameworks should be in place to minimize potential harms What at a minimum should be in place?

WHO/UNAIDS Recommendations (4) : 

WHO/UNAIDS Recommendations (4) A system that monitors and evaluates implementation and scale up should be developed and implemented concurrently

Key issues (1) : 

Key issues (1) Should counselling and testing be viewed as a medical (patient) intervention or a public health, health promotion or community (client/consumer) intervention? Is counselling effective? When is counselling effective? When may counselling and testing not be effective? What is the impact of repeat negative testing and routine testing?

Key issues (2) : 

Key issues (2) 4. What must be set in place for counselling and testing to become more accepted and utilized? 5. In addition to considering the nature of the epidemic? What aspects of care and treatment need to be considered in determining approach to C & T?What structural, organizational, policy, ethical and cultural aspects need to be considered?

Slide 22: 

Best Practices? In what Context?

Slide 23: 

Thank you Now lets hear from the country experts! Ted Myers, Ph.D.    Professor and Unit Director    HIV Social, Behavioural and Epidemiological Studies Unit    Faculty of Medicine, University of Toronto,        e-mail: ted.myers@utoronto.ca

PRETEST : 

PRETEST The reasons why HIV testing and counselling is being recommended The clinical and prevention benefits of HIV testing and the potential risks, such as discrimination, abandonment or violence The services that are available in the case of either an HIV-negative or an HIV-positive test result, including whether antiretroviral treatment is available The fact that the test result will be treated confidentially and will not be shared with anyone other than heath care providers directly involved in providing services to the patient The fact that the patient has the right to decline the test and that testing will be performed unless the patient exercises that right The fact that declining an HIV test will not affect the patient's access to services that do not depend upon knowledge of HIV status In the event of an HIV-positive test result, encouragement of disclosure to other persons who may be at risk of exposure to HIV An opportunity to ask the health care provider questions.

Individual or group pre-test informationBasic prevention services for persons diagnosed HIV-negative: : 

Individual or group pre-test informationBasic prevention services for persons diagnosed HIV-negative: – Post-test HIV prevention counselling for individuals or couples that includes information about prevention services – Promotion and provision of male and female condoms – Needle and syringe access and other harm reduction interventions for injecting drug users – Post-exposure prophylaxis, where indicated

In the case of individuals whose test result is HIV-positive, the health care provider should: : 

In the case of individuals whose test result is HIV-positive, the health care provider should: Inform the patient of the result simply and clearly, and give the patient time to consider it Ensure that the patient understands the result Allow the patient to ask questions Help the patient cope with emotions arising from the test result Discuss any immediate concerns and assist the patient to determine who in her/his social network may be available and acceptable to offer immediate support Describe follow-up services that are available in the health facility and in the community, with special attention to the available treatment, PMTCT, and care and support services Provide information on how to prevent transmission of HIV, including provision of male and female condoms and guidance on their use Provide information on other relevant preventive health measures such as good nutrition, use of co-trimoxazole and, in malarious areas, insecticide-treated bed nets Discuss possible disclosure of the result, when and how this may happen and to whom Encourage and offer referral for testing and counselling of partners and children. Assess the risk of violence or suicide and discuss possible steps to ensure the physical safety of patients, particularly women, who are diagnosed HIV-positive Arrange a specific date and time for follow-up visits or referrals for treatment, care, counselling, support and other services as appropriate (e.g. tuberculosis screening and treatment, prophylaxis for opportunistic infections, STI treatment, family planning, antenatal care, opioid substitution therapy, and access to sterile needles and syringes).

Post-test counselling for pregnant women whose test result is HIV-positive should also address the following: : 

Post-test counselling for pregnant women whose test result is HIV-positive should also address the following: Childbirth plans Use of antiretroviral drugs for the patient’s own health, when indicated and available, and to prevent mother-to-child transmission Adequate maternal nutrition, including iron and folic acid Infant feeding options and support to carry out the mother’s infant feeding choice HIV testing for the infant and the follow-up that will be necessary Partner testing.

Typology of HIV EpidemicsWHO and UNAIDS define different types of HIV epidemics as follows: : 

Typology of HIV EpidemicsWHO and UNAIDS define different types of HIV epidemics as follows: 1. Low-level HIV epidemics Although HIV may have existed for many years, it has never spread to significant levels in any sub-population. Recorded infection is largely confined to individuals with higher risk behaviour: e.g. sex workers, drug injectors, men having sex with other men. HIV prevalence has not consistently exceeded 5% in any defined sub-population. 2. Concentrated HIV epidemics HIV has spread rapidly in a defined sub-population, but is not well-established in the general population. This epidemic state suggests active networks of risk within the sub-population. HIV prevalence is consistently over 5% in at least one defined sub-population but is below 1% in pregnant women in urban areas. 3. Generalized HIV epidemics HIV is firmly established in the general population. Although sub-populations at highrisk may contribute disproportionately to the spread of HIV, sexual networking in the general population is sufficient to sustain an epidemic independent of sub-populations at higher risk of infection. HIV prevalence consistently over 1% in pregnant women.

Basic prevention services for persons diagnosed HIV-positive: : 

Basic prevention services for persons diagnosed HIV-positive: – Individual post-test counselling by a trained provider that includes information about and referral to prevention, care and treatment services, as required – Support for disclosure to partner and couples counselling – HIV testing and counselling for partners and children – Safer sex and risk reduction counselling with promotion and provision of male and female condoms – Needle and syringe access and other harm reduction interventions for injecting drug users – Interventions to prevent mother-to-child transmission for pregnant women, including antiretroviral prophylaxis – Reproductive health services, family planning counselling and access to contraceptive methods

Basic care and support services for persons diagnosed HIV-positive: : 

Basic care and support services for persons diagnosed HIV-positive: – Education, psychosocial and peer support for management of HIV – Periodic clinical assessment and clinical staging – Management and treatment of common opportunistic infections – Co-trimoxazole prophylaxis – Tuberculosis screening and treatment when indicated; preventive therapy when appropriate – Malaria prevention and treatment, where appropriate – STI case management and treatment – Palliative care and symptom management – Advice and support on other prevention interventions, such as safe drinking water – Nutrition advice – Infant feeding counselling – Antiretroviral treatment, where available