HIV Counseling and Testing (HCT)

Unit 2HIV Care and ART:

A Course for Healthcare Providers

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Learning Objectives

Define HCT, VCT, and PIHCT Explain the purpose and benefits of HCT as the

entry point to HIV prevention, care, and treatment

List the basic components of a HCT program and pre- and post-test counseling

Identify the skills and characteristics of an effective HCT counselor

Values Clarification Exercise

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HIV Counseling and Testing

HIV Counseling and Testing (HCT) is composed of two types of testing:VCT – Voluntary Counseling and Testing PIHCT – Provider Initiated HIV Counseling and

Testing

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Providing HCT In High & Low Prevalence Areas

High HIV prevalence in general population, >8% Universal access for HCT services recommended

Low HIV prevalence in general population, <1% HCT should target high-risk groups

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Neg Pos

Neg Pos

Sample

Neg Pos

Screening Test (Determine®)

Confirmatory Test (Capillus™)

Tie Breaker (Uni-Gold™or SeroCard™ )

Source: WHO 2004

HIV Testing Algorithm

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Sample

Neg Neg

Neg

Pos Pos

Pos

Test 1

(Determine®)

Test 2

(Capillus™)

Tie Breaker

(Uni-Gold™ or SeroCard™)

Parallel Test

Source: WHO 2004

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Knowing your HIV Status

HCT is a cornerstone for early access to prevention, as well as care and support

Why? “Think About It” exercise

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Objectives of HCT

HCT assists individuals and couples to:Assess their HIV risk behaviorsDevelop a risk reduction planDiscuss testing of childrenAccess HIV testingAdopt risk reduction behaviorAccess medical and psychosocial referral services

ACCEPTING AND COPING

WITH HIV STATUS LIVING POSITIVELY

• NUTRITION• CLEAN WATER• REDUCED STRESS• WELLBEING

SUPPORT

• FAMILY• FELLOWSHIP• HIV POSITIVE PEERS

MEDICAL CARE

• STI & TB TREATMENT • TB & OI PROPHYLAXSIS• PEDIATRICS HIV DIAGNOSIS, CARE AND TREATMENT

COMMUNITY INTERVENTIONS  

• SENSITIZATION• MOBILIZATION• DESTIGMATIZATION

PREVENTION OF MOTHER TO CHILD

TRANSMISSION

PLANNING FOR FUTURE

• FAMILY PLANNING • ORPHAN CARE• FINANCIAL PLANNING

RISK REDUCTION

• BEHAVIOR CHANGE• DISCLOSURE OF STATUS• PARTNER REFERRAL TO VCT • CONDOM ACCESS

HCT

HCT: Foundation of HIV Prevention and Care

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VCT Overview

Voluntary Counseling & Testing (VCT) is an HIV-prevention intervention initiated by the client at his or her free will

VCT provides the opportunity for the client to confidentially explore and understand his/her HIV risks and to learn his/her HIV infection status with the support of a counselor

VCT is composed of:CounselingTestingReferral

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VCT Models

Integrated within existing health services, i.e., general clinical care settings and specialized clinics, such as ANC, TB, STI

Free-standing VCT sites Mobile (outreach) VCT services Private VCT services Youth-friendly VCT services Workplaces

Seeking VCT: Logic Model

Community Education

Individuals/Couples/FamilyWant to Have HIV Test

Decision to Seek Testing

VCT/Pre- and Post-Test Counseling Risk Reduction

Ongoing Counseling(Preventive & Supportive)

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VCT Program Components

Type of counseling sessionIndividualCoupleFamily

Pre-test counselingIntroduction and orientationRisk assessmentDiscussion of testing children, if applicableOptions for risk reductionPreparation for the test result

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VCT Program Components (2)

HIV Test Post-test counseling

HIV negative test result• Negotiate risk reduction plan• Support for risk reduction plan• Negotiate disclosure & partner referral

HIV positive test result• Identify source of support• Negotiate disclosure and partner referral• Risk reduction issues

Referral

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What are the Concerns and Benefits of VCT?

To the individual To the couple, children, and family To the community

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Provider Initiated HIV Counseling and Testing

PIHCT is routine, confidential, HIV testing offered to patients visiting health institutions

Routine HIV testing (opt-out) at health institutions increases access to HIV testing

Many people prefer to be tested by a medical provider within the context of a regular health care visit

PIHCT takes less time as the focus is more on post-test counseling and referral

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Indications for Offering PIHCT

Patient reporting high risk behavior Patient with tuberculosis Patient presenting with STI Symptom complex suggestive of HIV/AIDS Pregnant women attending antenatal clinic Patients receiving in-patient care

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Difference between VCT and PIHCT  VCT PIHCT

Clients/Patients

Come to receive HIV testing Come with a medical problem

Expect to be tested Are not expecting testing

Mostly asymptomatic  

ProvidersTrained counselor may not be health personnel

Health care provider trained to provide counseling

Purpose of HCT Primary purpose is preventionPrimary focus on Dx, Mx of OI and HIV, and referral

Pre/Post-test Encounter

Client centered counseling Provider recommends testing

Result discussed with neg & pos Little time for negative results

Primary focus on pos result

Follow-upHIV positive referred to medical care

Care of HIV positive patient coordinated with Tuberculosis clinic

Counseling Skills for HCT

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Counseling is a Relationship

Client and counselor both bring:HopeKnowledgeQuestions and answersPersonal experiences

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Seven Qualities of a Good Counselor

Self-confidence Empathy Acceptance Genuineness Trustworthiness Confidentiality Competence

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Skills and Characteristics of Effective HCT Counselors

Believes that HIV prevention counseling can make a difference in preventing and controlling HIV for the individual, the family, and the community

Balances well-selected, open-ended questions with statements, summaries, and reflections that guide the session and maintain the focus on risk issues

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Skills and Characteristics of Effective HCT Counselors (2)

Uses active listening skills Feels and behaves comfortably when discussing

specific HIV risk activities Able to help a client develop a realistic and

relevant risk reduction plan

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Counseling Essentials

Remember to always:Demonstrate professionalism and maintain rapport

throughout the sessionConvey to the client that his or her confidentiality will

be strictly protectedSpeak with the client at his or her level of

understandingConduct an interactive session focused on risk

reduction

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Counseling Essentials (2)

Clarify important misconceptions, but avoid extended talk on issues not related to risk

Stay organized, and avoid counseling outside the protocol’s structure

Know that it is all right to tell the client that you will be covering something later

Avoid collecting data about the client during the counseling session

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Questioning Skills

Acknowledge that you have heard and understood the client

Blend reflective, guiding, and directive statements with well chosen open-ended questions

Ask questions that guide the client to consider their HIV risk, risk reduction, coping, and support

Ask appropriate follow-up questions Ask client to elaborate on unclear issues Ask client to clarify confusing or contradictory information

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Closing a Counseling Session

Remind client of pre-test information

Assess client’s emotional state

Give client space to ask questions

Schedule client for further sessions

Refer to appropriate services

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Referrals

Developing linkages with other services Referral directory of services Referring clients Developing a system for tracking referrals

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VCT Client

Pre and Post Test Counseling

Referral

Medical Examination (Clinical and Lab)

YES

NO

ART administration and follow up

ART counseling

VCT Client Referral

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Working With Couples

Make sure both partners have an understanding of HIV/AIDS

Review willingness to have HIV test

Explain the process of testing and receiving results

Discuss advantages and disadvantages of knowing results as a couple

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Working With Couples: Making a Plan

Review options for positive, negative, and discordant results

Explore the possibility of discordant results Identify others who may be affected by the

outcome Discuss testing their children

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Ethical Principles

Counselors must be respectful toward the patient’s/client’s dignity and rights

DignityAcceptanceNon-judgment

Rights Confidentiality Privacy Autonomy Self-determination

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Ethical and Legal Issues: Disclosure

Counselors cannot force disclosure of HIV status To whom and when is always the choice of the

patient Can encourage the partner to have an HIV test Can prevent the spread of HIV to the partner

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Ethical and Legal Issues: Children

Persons 15 years-old and above can give informed consent for testing

Children under 15 years-old may only be tested with consent of their parents or guardians

“Mature minors” between 13-15 years of age are allowed to consent for HIV testing

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Ethical and Legal Issues: Children (2)

Mature minors should be informed of their results like adults

Children 12 years-old and above should be informed after appropriate counseling, and with the involvement of their parents or guardians

Children under 12 should not be informed of results until they reach an age when they can understand and parents/guardians give consent

Counselors should carefully consider to whom they disclose results, with the child’s best interests in mind

Pre/Post-Test Counseling

Trainer Role Plays

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Pre-Test Counseling

What does the client understand about HIV? What does the client understand about HIV

testing? How does this information apply to the client?

Pre-Test Counseling in the PIHCT Setting

Trainer Role Play

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HIV-Negative Results

Give time and space for the client to express emotions

Explore the client’s reaction Review the meaning of the

test result (revisit the window period) Discuss prevention/risk reduction Refer for ongoing support/counseling at

appropriate site

Giving HIV-Negative Results

Trainer Role Play

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Giving HIV-Positive Results

Allow some time Discuss what this means Identify a coping strategy Emphasize risk reduction Link with support services

Giving HIV-Positive Results

Trainer Role Play

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Key Points

HCT is a cornerstone of early access to prevention, care and support

HCT is composed of Voluntary Counseling and Testing (VCT) and Provider Initiated Counseling and Testing (PIHCT)

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Key Points (2)

VCT is a HIV-prevention intervention initiated by the client at his or her free will.

VCT provides an opportunity to individuals and couples to work confidentially with a counselor to:Assess their HIV risk behaviors Develop a risk reduction plan Adopt risk reduction behaviorAccess medical and psychosocial referral services

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Key Points (3)

PIHCT is routine confidential testing of HIV offered to patients visiting health institutions by their providers

Effective counseling requires a number of qualities, characteristics and skills that can be developed and improved with practice.