HIV COUNSELING

&
TESTING (HCT)
Concept and Implementation
 Outline
• The Concept ,the need & different models of HIV
counseling and testing (HCT)

• The concepts,objectives, basic requirements, Guiding &

Ethical principles of VCT

• Barriers to VCT & how to remove.

• Special issues addressed in the new HCT guideline

• The concept & advantages of PITC
 HIV Counseling and Testing (HCT)
• Is an umbrella term that encompasses models of
counseling & testing
- for different needs
- in different organizational settings
• Is an essential component of a comprehensive
HIV/AIDS program to turn the tide of HIV
epidemic
 The Need for HCT
• Through HIV Counseling &Testing (HCT) -
people know whether they are infected with HIV or
not,
understand the implications of their HIV status
and make more informed choices for the future
Possible to identify patients in need of ART,
prevention ,care & support services
 To accesses different group of individuals.
To decreases morbidity and mortality rate.

• HCT is an entry point to HIV prevention,

care , treatment & support services
HCT- as an
entry point Eases acceptance of
Sero status and coping

Promotes Facilitates
planning for
future behavioral
orphan care change

Facilitates
HIV
referral
to social &
Counseling Reduces MTCT
peer support Testing
Normalizes
HIV/AIDS& Promotes early
reduces management of
stigma
OIs &STIs
Enables preventive
therapy &
contraceptive advice
Counseling & testing in Ethiopia
Historical Background
• 1984 - first HIV sera positive was detected

• 1986 - two AIDS cases were reported

• 1987 - National HIV/AIDS Control program

established by M o H

• 1987 - HIV/AIDS counseling & testing started

in Ethiopia; with two social workers in M o H

• 1987 -HIV testing started at EHNRI and Red Cross

• 1998 - National HIV/AIDS Policy developed

 ….. in Ethiopia
• 1998 - counseling and testing was made available in
private health care setups and NGOs
• 1999- National Strategic frame work (plan)
was developed & revised in 2004 (2004-2008)
• 2000 - VCT guideline first produced by NAC,
revised in 2002
• 2000 - VCT services started at government sites

• 2003-2005 Rapid scale up of VCT services in the

government health institutions
• 2007- the revised version of HCT guideline is developed
 HCT Approaches

- Client Initiated (VCT)

- Provider Initiated (PITC)

- Mandatory and compulsory HIV testing

- Testing for medical research and surveillance

 Service Delivery Models of HCT
• Stand alone/freestanding

• Integrated

• Outreach Mobile services

• Others
- Home/Family Based (pilot)
 Voluntary Counseling & HIV
Testing (VCT)
Definition:
• VCT is an HIV prevention intervention initiated
by the client, entered into by the client’s free will,
which provides the opportunity for the client to
confidentially explore & understand his/her HIV
risks and to learn his/her HIV status with the
support of a counselor
 VCT Definition cont…
• Through VCT, clients learn their HIV status.
Most people who access VCT find they are
not infected with HIV!
• Clients who go through VCT become
ambassadors for HIV prevention. They
reduce their risk and encourage partners,
family members and friends to access VCT.
Important Issues in the definition
Is a prevention intervention

Initiated by the client

Client’s free will

Confidentially explore and

understand his/her HIV risks

know his/her HIV infection status

 Objectives of VCT

• To assist individuals and couples to:

• assess their HIV risk behaviors and to explore
previous risk reductions options
• prepare and access for HIV testing
• develop a risk reduction plan.
• To facilitate referral services for clients
who have medical and psychosocial
needs
Objectives...

• Testing is initiated by a client seeking to

know his/her status for the purposes of
- prevention of HIV and
- future life planning

• Places more emphasis on counselling than

on testing,
– because one of the key purpose of VCT is prevention.
VCT is more
than just HIV
testing!

VCT provides
professional
counseling!
 VCT Guiding Principles
• Voluntary attendance

• Confidentiality

• High quality, reliable prevention counseling services

• Informed consent

• Linkage to prevention, care & support services

 Basic requirements for
VCT services
(Site Level)
• Adequate & trained human resources

• Availability of space (Suitable and privacy )

• Adequately equipped testing centers

• Established referral systems

• Promotion and advocacy for the service

• Monitoring and evaluation, including quality assurance

 Referrals

 Referral is critical for helping VCT clients access

other risk reduction, care and support services.

 VCT is more effective when it is linked with care

and support services.
 REFERRAL LINKS
Community

Health care • Counselor

provider • Self
• Peer
• Educator
Special group
Community (Military, CSW,
etc)
VCT Center

Ongoing Intra-organizational
Counseling Inter-organizational

Medical care Support

• TB • social Home-based
• STI • material care
• OI • legal
 Factors Influencing
Outcomes of VCT
• Content and quality of counseling

• Number of counseling sessions undertaken per day per

counselor

• Availability of Pre- test, post-test and follow-up counseling

• HIV testing methods employed in VCT sites (same-day

simple/rapid testing Vs ELISA)

• Associated with care & support services available to VCT

sites
 Factors influencing….
(cont’d)
• Anonymous & confidential testing and
reporting of results

• Age/emotional maturity of clients

• Socio-economic factors (may affect access

to treatment, prophylaxis)
Barriers to VCT
 Fear of testing positive

 Concerns about confidentiality

(stigma, discrimination, abandonment,…….)

 Lack of perceived risk for HIV

 Lack of perceived benefits in knowing HIV status

 Lack of information about VCT services

What can we do to remove these barriers?
 Removing barriers...
 Remember that most people test HIV negative

 Maintain confidentiality in all aspects of HCT services

 Maintain positive attitudes and work to prevent stigma

and discrimination
 Explain risks for HIV and benefits of VCT

 Create community awareness making sure available VCT

sites are fully utilized
 Special Issues addressed in the Ethiopian
National HCT Guideline
 Issues related to confidentiality
 Anonymous and Confidential
 Partner notification

• Role of the counsellor in protecting the HIV negative partner.

- if the client fails to disclose after repeated (3-5 sessions)
documented counseling sessions &

- if the counselor feels that the clients’ partner is at risk of

infection,

 the counselor can consult the supervisor/ senior/immediate

management staff for further action.
 Special Issues addressed …… (Cont’d)
Issues related to Provision of written HIV
test result
– VCT service should not provide written test result
because
 it compromise the confidentiality
 the result might be misused and miss interpretation

Issue related to the initiation of use of

“ /non-health professional counsellors”
– Non-health professionals can provide the VCT service
in health institutions
 the selection criteria is agreed
 implementation is on process.
 Special Issues addressed ……
(Cont’d)
 Issues related to age of consent
• Any client age 15 years and above requesting VCT should
be considered “mature enough “ to give full informed
consent.
• Young between 13-15 years who are married, pregnant,
CSW and street teenager are regarded as “mature minors”
and should be considered eligible to give consent for HIV
testing ,though
the counselor should make an assessment of their
readiness for HIV testing.
• Testing client below 13 years should be conducted with the
knowledge and consent of their parents or guardians.
Utilization of different approaches of HCT
- a paradigm shift
The Need for Paradigm Shift
• The raised awareness of the community about
HIV/AIDS, benefits of testing

• The better accessibility and acceptability of OI treatment

and ART

• Effectiveness of the comprehensive treatment of TB, STI

and other OIs to improve quality of life of the patients
– To put 100,000 PLHAs on ART.
• 5.1 million individuals need to be tested

 Avoid missed opportunities of testing by introducing

PITC (Provider Initiated Testing & Counselling)
Broadening entry points to testing

Past / current
Care & support

PMTCT OVC
limited VCT
Prevention

Bottleneck? ART

Current with hiccups

VCT
Care & support
Diagnostic for
symptomatic PMTCT OVC

Prevention
Routine offer
STI, TB, ANC ART
 Multiple Models of HIV Counseling and Testing Services

Different: Voluntary Counseling and Testing Service Delivery Options:

Purposes and Multiple Models Single

Objectives Setting
Prevention of Mother-to-Child Transmission
Messages Integrated Services

Psychosocial, Clinical, Stand Alone Services

Couple HIV Counseling and Testing
Developmental and Risk
Issues Outreach and Mobile
Services
Emphasis Counseling and Testing Services for Youth
Clinic Based Services
Target Populations
Counselor
Protocols Counseling and Testing for Vulnerable
Populations Health Care Worker
Skills and Training
Requirements Multidisciplinary Team
Family-Based Counseling and Testing

Routine Diagnostic and Clinical Testing

A strategic mix of different approaches to counseling and testing will likely have the
greatest benefits. 29
 Similarity Between PITC and VCT
• Are voluntary
• Require the consent of the client
• Test for the benefit of the client
• Require that the result be given to the client
• Are preferably done using a rapid test with
the same day result
 Differences between VCT and PITC

VCT PITC
Settings - Stand alone community sites - Health facilities
- Mobile units
- Health facilities

Clients/ - Come to clinic specifically for HIV - Come to clinics for a

Patients test variety of reasons
- Expect to get tested - Not necessarily expecting
- More likely to be asymptomatic HIV test
Providers - Usually trained counselors, not - Health care providers
necessarily trained as health care trained to provide
providers counseling/education

31
Differences between VCT and PITC
(Cont’d)
VCT
Primary - Primary focus is on
purpose of preventing HIV acquisition
HIV CT through risk assessment,
risk reduction and testing
Pre- and - Client-focused counseling
post-test - Usually one-on-one
counseling - Is equally important for
both HIV-positive and
negative clients to their
results for prevention of
HIV
PITC
- Primary focus is on diagnosing
HIV for appropriate HIV
management by providing referral
for HIV care, as well as prevention
- Provider recommends test as
standard practice for all
clients/patients
- Limited discussion about need
for HIV testing
- Little time given to those who
test HIV-negative
- Primary focus is HIV diagnosis
and management
32
Differences between VCT and PITC
(Cont’d)
VCT PITC

Follow-Up HIV-positive clients referred HIV-positive patients provided

to medical care services and with medical care and referred
other support services, some for additional support services,
of which are in the community some of which are located in the
community

33
 HIV Testing and Counseling in Clinical Settings
PATIENT EDUCATION (OPD)
Patient education provided while patient
waits. Options include: group education,
posters and brochures.
(Optional) Community education
provided in the form of mobilization
efforts, media campaigns, etc.
PITC
- PROTOCOL
INITIAL PROVIDER ENCOUNTER
Provider informs patient of the importance of HIV
testing:
• Many people in our community have HIV
• Diagnosis of HIV is important for proper medical care
• Treatment for HIV is now available
Provider informs patient of testing policy:
• All patients will be tested for HIV unless they refuse
Provider answers any questions

RAPID HIV TESTING PATIENT REFUSES HIV TEST

Rapid testing performed either by provider or lab.
PROVIDER GIVES PATIENT THE HIV TEST RESULTS
• Provider repeats benefits of testing
and reminds patient of available treatment
If patient continues to refuse:
• Recommends VCT site as an alternative
and/or
•Provider repeats message on importance of
HIV testing at future visit or while an inpatient

FOR PATIENTS WHO TEST NEGATIVE:
• Provider informs patient of negative test result
• Gives patient brief message about prevention
• Advises patient that partner needs to be tested
FOR PATIENTS WHO TEST POSITIVE:
• Provider informs patient of positive test result
• Supports patient in adjusting to result -
• Informs patient of need for HIV care and treatment
• Gives patient information about HIV prevention
• Advises patient that partner needs to be tested

REFERRAL
Provider refers patient to nearby VCT site for: REFERRAL
• Partner testing
• Refers to on-site supportive counseling or other counseling services
• Repeat testing if recent unprotected sex (window period)
• Provides patient with referral to local care, treatment and su
upport services
• Additional prevention counseling
34
Provider-Initiated HIV Testing &
Counseling (PITC)
• Is one of the models of HCT

• It takes place in clinical settings for the

purposes of HIV diagnosis and clinical care
management

• HCT is recommended & offered by Health Care

Worker using the test results to make medical
care decisions or recommendations
Reasons for Performing HIV Testing in Clinical
Settings
• HIV/AIDS is a serious disease that requires
care and treatment.
• Life-saving therapy for HIV is becoming more
available.
• WHO, UNAIDS, CDC and MOH/Ethiopia have
recommended that patients in clinical settings
be tested for HIV.

36
Routine Offer of HIV Testing
• According to the guidance on PITC in health
facilities suggested by WHO and UNAIDS:
– In countries of generalized epidemic, all clients
visiting health facilities should be offered an HIV
test
– However, this guidance needs to consider the
resource limitations of the specific health facility
in charge

37
Routine Offer of HIV Testing: Resource-Limited
Settings
• Routine offers should be made for the
following groups in resource limitation
settings:
– Patients with clinical signs and symptoms of
HIV/AIDS
– Patients with sexually transmitted infections
– Pregnant women attending antenatal clinics
– Any healthy individual going for a general medical
examination
• Since TB is one of the defining illnesses of
AIDS, all TB patients should be tested for HIV 38
Importance of Routine HIV Testing in TB Clinics

• To identify HIV-infected patients for diagnosis,

counseling and follow-up
• To refer HIV-infected patients to appropriate
treatment and care services
• To monitor trends in HIV infection of TB and
other HIV-related diseases by facility, region,
sex, age, etc.

39
Rationale for PITC
• Many people in Ethiopia do not know their
status.
• Routine HIV testing increases access to HIV
testing and, therefore, increases the number of
individuals who know their status, and identifies
those who need ARV treatment, care and
support.
• Many people prefer to be tested by a medical
provider within the context of a regular health
care visit.
40
Rationale for PITC (Cont’d)
• A separate visit to a facility just for an HIV test
can be time-consuming and inconvenient.
• Provider-initiated HIV testing and counseling
takes less time, as the focus is more on post-
test counseling and referral to appropriate
services.

41
Advantages of PITC
• Normalizes HIV counselling & testing in the clinics,
health care facilities and the community

• HIV testing becomes the standard of care

• Optimizes the use of human resources

• Identifies patients in need of ART & prevention services

• Increases uptake of HCT and ART services

Challenges of Incorporating PITC in Clinical
Settings
• Stigma eroding patients’ comfort or trust in the clinical site.
• Lack of human or material resources and infrastructure.
• The issue of HIV screening and ARV treatment of clinic staff.
• Coordinating with HIV treatment and referral resources in the
community will require planning.
• Clinic staff, particularly providers, may feel uncomfortable
talking with patients about HIV testing, and may not have
been tested yet themselves.

43
 Remember!!
VCT & PITC
• Are not mutually exclusive

• Are strategic mix of approaches

(often within the same facility) needed to:

- meet different needs in different

settings &

- increase opportunities for people to

know their HIV status.
 Key Points
• Countries will need a strategic mix of different models of HIV
counseling and testing to increase the proportion of people
getting tested for HIV.
• The primary focus of PITC is on identifying HIV-infected
patients and linking them to prevention, care, treatment and
support services.
• Providing patient education before the patient sees the
provider will help smooth the way.
• Determining the HIV status of clients is important for their
future medical care.
• Because information about patients’ HIV status is sensitive,
patient confidentiality must be protected.
• WHO, UNAIDS, CDC and MOH/Ethiopia have recommended
that patients in clinical settings be tested for HIV.

45