HIV Counseling and Testing
What Is HIV Counseling and Testing?
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A counselor works in her tent-based counseling room at a mobile
counseling and testing event in Nigeria, with support from USAID's
Global HIV/AIDS Initiative Nigeria (GHAIN).
Source: A. Surdo |
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HIV counseling and testing (HCT) refers to the process by which
an individual, couple, or family receives HIV testing and counseling
on HIV prevention, treatment, care, and support. There are many
approaches to HCT, but generally, the intervention includes four
activities: pretest counseling on the testing process; risk-behavior
assessment; each participant’s informed consent; and post-test
counseling based on the test result(s).
HIV counseling and testing is the gateway to treatment, care, support,
and prevention interventions for those who have HIV. It is
also a critical opportunity for HIV prevention counseling, particularly
for couples where one partner is HIV positive (known as
sero-discordancy) and for others with a high risk of acquiring HIV.
For those who test negative, counseling focuses on prevention
messages tailored to the client's or patient's risk behavior(s) and
provides referrals to prevention interventions, such as male circumcision
clinics and support groups.
USAID supports
the efforts of the U.S. President’s Emergency Plan for AIDS Relief
(PEPFAR) to dramatically expand HCT services in many countries
across the globe. Due to PEPFAR and other efforts to scale up HIV
care and treatment, those who learn that they are HIV positive have
increasingly been able to access these services, often at an earlier
stage of the disease. Technologies such as HIV rapid testing have allowed
HCT to be expanded beyond health facilities and into communities
and homes. Implementing different approaches to HCT,
such as community-based and provider-initiated HCT, has greatly
expanded coverage, access, and acceptance of testing (see pages 2–
3). While most clients learn their status individually, access to HCT
for couples and families is increasing. (see page 2).
Through HCT, counselors and health care workers provide clients
and patients with information, tools, and access to interventions,
which enable them to protect themselves from acquiring or transmitting
the virus. HCT also brings greater awareness to a community
about HIV/AIDS. It allows people to talk, ask questions, and
learn. HCT can inspire greater community involvement in meeting
the needs of people living with or affected by HIV/AIDS.
| Twenty-five years into the HIV epidemic, more than 80 percent
of people living with HIV in low- and middle-income
countries do not know they are HIV positive. (UNAIDS and
WHO, 2006) |
Benefits of HIV Counseling and Testing
Some of the key benefits of learning one’s status include:
- Awareness of and knowledge about HIV
- Individual or couple-based HIV prevention counseling to identify and reduce risky behaviors
- Education on HIV prevention strategies
- Access to and education on correctly and consistently using condoms
- Linkages to HIV care and treatment
- Linkages to other relevant services, such as sexually transmitted
infection treatment, family planning, and prevention of
mother-to-child transmission programs
- Planning for the future
Activities Made Possible by USAID
USAID has worked with partners to support a wide range of HIV
counseling and testing activities.
Some are:
- Support for a variety of HCT approaches, including couples HCT,
community-based HCT, and HCT in clinical settings
- Training and support for HIV counselors and other staff
- Social marketing campaigns to promote HCT and enhance
community acceptance of HIV/AIDS activities
- Engagement of other donors and local host-country governments
to coordinate HCT efforts
- Development of HCT guidelines, policies, and protocols
adapted to the specific country and cultural context
- Evaluations of new HIV rapid testing kits and technologies
Because of these and other PEPFAR-funded activities, 57 million
HCT sessions were made available to men, women, and children
from 2003 to 2008.
Types of HIV Counseling and Testing
USAID supports programs that offer two approaches to HIV counseling and testing: community-based and provider-initiated
programs in health facilities. Each approach has a specific purpose and focus. Together, these strategies reach more
people and increase access to HIV prevention, care, and treatment interventions.
Community-Based HIV Counseling and Testing
Through the 1990s, client-initiated voluntary counseling and testing (VCT) was scaled up as an HIV prevention intervention
in communities throughout the world. Until recently, it has been the most common way for people to learn their status
and gain knowledge and tools to help them engage in safer behaviors. VCT has often taken place at sites that are
either free-standing or co-located with other health services, and has been implemented by a variety of providers and organizations.
Outreach services such as mobile VCT arose out of the need to offer access to HCT services to difficult-to-reach
populations such as those at increased risk (e.g., sex workers and injection drug users) and populations in remote
or rural areas with limited access to facility-based services.
Community-based HCT as a general approach remains an important component in efforts to achieve universal access,
help mitigate HIV transmission, and link individuals to additional prevention interventions.
An example of community-based HCT is the Global HIV/AIDS Initiative Nigeria (GHAIN) campaign, funded by USAID
and implemented by Family Health International. The goal of GHAIN was to enhance access to HCT for hard-to-reach
populations, such as youth, orphans and vulnerable children (OVC), transport workers, and sex workers.
To reach OVC and youth, GHAIN partnered with community-based organizations (CBOs) in order to provide HCT and
additional prevention services. HIV-positive peer counselors provided prevention education services in youth-friendly
stand-alone HCT centers. These centers were able to reach a wide range of youth because they targeted those both in
and out of school. The CBOs were also able to establish care and support groups for people living with HIV/AIDS, and
through these support groups, services were provided to OVC at the community level.
To better target HCT services to transport workers, GHAIN partnered with the National Union of Road Transport
Workers (NURTW), an umbrella trade union of all transport workers in Nigeria. Through this partnership, community
outreach activities in motor parks provided access to HCT and other prevention services to NURTW members.
Additionally, USAID has successfully targeted sex workers in Nigeria by providing rapid testing with same-day results at
junction towns and brothels.
Upcoming Priority in Community-Based HCT: Counseling and Testing for Couples
With a large portion of HIV infections occurring within stable relationships, couples HCT (CHCT) is extremely important.
In CHCT, partners attend counseling and testing sessions together and learn their results together. CHCT creates a
safe environment for couples to discuss concerns; provides information on HIV prevention, transmission, and treatment;
eases tension and reduces blame; and allows for joint decision making. In order to conduct a successful CHCT session,
counselors must be adequately trained and equipped with the appropriate skills to address the variety of issues that
may arise.
When testing couples together, there are three possible outcomes: concordant positive, where both are HIV positive; concordant
negative, where both are HIV negative; and discordant, where one partner is HIV positive, and the other is not.
Couples with each respective outcome require specific information, referrals, and/or linkages during post-test counseling.
Discordant Couples
HIV-negative partners in a discordant relationship are at a very high risk for contracting HIV. Without taking prevention
measures, HIV transmission is likely. Effective CHCT encourages and supports the couple to adopt preventive behaviors,
facilitates disclosure, and also aims to mitigate harmful relationship dynamics and reduce potential HIV-related stigma and blame.
Concordant Couples
CHCT is beneficial for concordant-negative and concordant-positive couples. Concordant-negative couples can learn
how to keep themselves HIV negative by utilizing different prevention methods, including the reduction of sexual partners
outside their relationship and the use of condoms. Concordant-positive couples can learn how to prevent HIV transmission
on various levels, including to their future children and within their community. It may also be possible for the couple
to start antiretroviral therapy (ART).
Many USAID partners support CHCT as part of a comprehensive HCT program.
Provider-Initiated HIV Counseling and Testing
Provider-initiated testing and counseling (PITC) occurs in health facilities as either a routine part of medical care or for
purposes of clinical diagnosis. In PITC, health care providers explain that it is a regular part of the facility’s medical care to
routinely offer HIV testing. The main purpose of PITC is to allow clinical decisions to be made or medical services to be
provided that would not be possible without knowing an individual’s HIV status.
The PITC model is often used in health care settings, such as tuberculosis (TB) clinics, sexually transmitted infection (STI)
clinics, prenatal clinics, and medical wards with high prevalence of HIV, TB, and/or STIs. In regions with a high HIV/AIDS
prevalence, PITC may also occur in other in-patient wards, out-patient departments, and primary care clinics.
An example of PITC is the USAID-funded Health Alliance International program in Mozambique. In accordance with the
Mozambican Ministry of Health’s approach of integrating HIV care into general services, Health Alliance International
launched PITC in 2005. In the initial rollout of the program, prenatal nurses were trained and made responsible for the
start-up and integration of provider-initiated testing and counseling. Along with the prenatal nurses, health staff in TB clinics
and pediatric nurses caring for at-risk children were also trained. Health staff from participating facilities were trained
to follow HCT codes of conduct, including ensuring confidentiality of results. In 2008, clinics throughout Mozambique
began to offer PITC routinely.
The program continues to grow, with an increasing number of health facilities offering HCT to all patients. Clinics are
even paying closer attention to patients by hiring people exclusively dedicated to providing counseling and testing. This
strategy, along with the integration of services, has proven to reduce stigma and discrimination, increase HIV diagnosis,
and improve referral of patients to appropriate follow-up services.
Upcoming Priority in Provider-Initiated Testing and Counseling: HCT for Children
Universal access to HCT for children remains a significant challenge. There are a number of reasons why HCT services
for children are absent in many programs, including:
- A lack of clear policies on the age of consent and disclosure
- Reluctance of health care providers to test children
- Insufficient training on counseling of children
- Lack of appropriate testing technologies
- Concerns over sustainability of supplies
Despite all of the challenges, it is still important to provide HIV counseling and testing to young children. If a child tests positive
for HIV at an early age, ART can be initiated when it is most effective, and counselors can provide age-appropriate prevention
information. If this information is given before a child becomes sexually active, it may impact future behaviors related
to HIV transmission. If the child tests negative for HIV, counselors and family members have an opportunity to educate the
child on how to stay protected against HIV.
USAID is currently supporting field work assessments to examine best practices for providing HIV testing for children
and their family members, including determining how and when to tell children about being HIV positive and what support
services are needed to help health care providers and families address the psychological, medical, and social challenges
of growing up with HIV infection.
In many settings where HCT is provided, HIV rapid tests are used because they are highly accurate, offer results in under 30
minutes, require little or no additional equipment or reagents, often do not require a cold chain, and create less medical waste.
Moreover, since they do not require a blood draw or other complex procedures, they can be performed by a wide range of
staff. This technology allows for HCT to be more readily accessible with faster results, minimizing loss to follow-up and helping
ensure that those who are tested receive their results. In addition, rapid tests are ideal for use in low-resource settings and
community-based settings outside health facilities. Examples of testing locations ideal for rapid test use include rural health
posts, train stations, work places, mobile clinics, and homes.
To promote the expansion and proper use of rapid tests, USAID has strict guidelines on their use in USAID-funded programs.
USAID and PEPFAR have compiled a list of approved rapid HIV test kits for use in U.S. Government-funded HCT programs.
USAID also has provided funding to the Centers for Disease Control and Prevention to validate new test kit products on the
market to ensure high quality and accuracy. View a list of approved HIV rapid test kits. |
International HIV Counseling
and Testing Workshop 2008
The International HIV Counseling and Testing Workshop was held in
Lusaka, Zambia, January 21–24, 2008. The theme of the workshop
was “Towards Universal Access to HIV Counseling and Testing.” The
workshop was designed to share state-of-the-art technical updates
and best practices in scaling up HCT services, identify key challenges
in achieving universal access, encourage partnerships, and determine
priority areas where further research is needed. One hundred seventy seven delegates from 27 countries participated in the workshop
to discuss future directions toward the goal of universal access.
Some key recommendations from the meeting include:
- Strengthen the prevention counseling component of HCT for
HIV-negative clients, HIV-positive clients, and couples
- Develop testing policies to encourage the use of rapid test kits
- Promote and scale up targeted HCT, especially for high-risk
groups, while working toward universal access
- Develop proactive policies related to age of consent and disclosure
to support the expansion of testing of children, partners,
and families
- Develop policies to support task shifting to alleviate human
resource strains
Seeing Results
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A mobile van is used to provide HIV counseling and testing by Right
to Care, a USAID-funded program in South Africa.
Source: A. Surdo |
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Right to Care
USAID’s partner, Right to Care, has initiated a successful HCT campaign
in South Africa called Proudly Tested. Proudly Tested is a combination
of access programs targeting higher education institutions,
shopping malls, and workplace HCT services. Between October and
December 2008, Right to Care counseled and tested more than
20,000 people through this program.
Right to Care also has been successful with its unique tracking and
referral system for HCT services called TherapyEdge VCT. This data
management software program helps ensure easy transfer of patient
information between HCT sites and treatment clinics for those who
are found to be HIV positive, facilitating referrals into care.
The U.S. Agency for International Development works in partnership with the U.S. President's Emergency Plan for AIDS Relief.
March 2010
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