“Testing” the Limits: HIV Counseling and Testing in

Clinics, Communities, and Beyond!

October 2006USAID Mini-University

asurdo@usaid.gov

Alison Surdo, HIV Counseling and Testing Advisor, USAID

Overview of Session

• What is HIV Counseling and Testing (CT), and why is it so important?• What are some of the approaches to providing quality CT services?

– Standards– Client-initiated services– Provider-initiated services

• Challenges & Solutions– Rapid testing– Referrals– Staffing– Aiding with disclosure and support– CT for children and families– CT for hard to reach populations

• Group discussion

What is Counseling and Testing?

• Refers to a service in which clients receive an HIV test combined with appropriate health information, counseling, support, and referrals

• HIV testing is the gateway to accessing care and treatment services and plays an important role in HIV prevention

• There are about 40 million people worldwide who have HIV, but less than 10% are aware of their HIV status

• In order to reach the Emergency Plan 2-7-10 goals, between 40 and 100 million people will need to be tested

• PEFAR progress so far: – In FY 2004 about 3 million persons received C&T– In FY 2005 about 4.6 million persons received C&T

Why is CT so important?

Standards

• Conditions—all HIV testing models must meet the “3 C’s”:*– Consent—testing is informed and voluntary– Confidentiality– Counseling

• Referrals and linkages—all C&T services must have a functioning referral system linking clients to appropriate care, treatment, support/prevention services

* UNAIDS/WHO Policy Statement on HIV Testing

Client-Initiated Counseling and Testing

• Typically occurs in community settings: traditional free-standing “VCT” sites, health centers, mobile units, and community-based programs

• Tailored pre and post test counseling for individuals and couples

• Referrals to other care, treatment, support, and prevention services

• Relies on clients coming and asking for an HIV test—self referral process

Considerations for Client-Initiated CT

• Most clients are HIV-, most HIV+ clients asymptomatic• Opportunity for early diagnosis, prophylactic and OI care,

timely enrollment in ART, prevention for positives• Prevention impact for HIV+ clients and discordant couples*• Data for prevention benefits for HIV- clients is variable, may

depend on quality of services*• Mobile and home-based CT are highly successful in

expanding access and improving uptake• Continuous promotion of services is key to continued uptake

*Weinhardt 1999, VCT Study Group 2000, S Allen 2003, KB Matovu 2005, DL Roth 2001

Provider-initiated CT in Health Care Settings

• Part of regular health services in TB, STI and other clinical or hospital settings

• Shortened pre-test session--information on the reasons for testing and confidentiality; consent obtained

• Post-test counseling on result, support, referrals Linkage to HIV care and treatment greatly facilitated

• The routine offer of CT leads to increased uptake and optimal case-finding for those in need of HIV care and treatment

Opt-Out vs. Opt-In

• Traditionally CT has been opt-in: patients had to give separate consent for an HIV test, often written consent

• Patients often declined an HIV test when asked to give separate consent

• Opt-out consent means that consent for an HIV test is included in consent for other medical care—patients are informed that the test is routinely offered and that they may refuse

• Opt-out consent is still voluntary• There is increased international support from PEPFAR, CDC,

WHO, and UNAIDS for opt-out consent in clinical settings where patients already consent to other routine health services

Challenge—Rapid Testing• Simple and rapid, perform as well as

traditional EIA, and are easier to use in resource-poor settings

• Most test kits not require extra lab equipment, electricity, cold chain, or highly trained lab technicians to perform testing

• Most kits require only a finger prick or oral sample

• Can be used within or outside of health facilities—easy to transport for mobile CT

• Dried blood spot technology can be used for quality assurance

• Yet many countries still rely on more complicated technologies— which hinders access to CT services

Considerations for Rapid testing

• Typically used in an algorithm• Not all the same—different tests are approved or validated for

use in different situations • What you should know when selecting rapid tests

– Which tests are appropriate for your situation—consider HIV prevalence, objective of the test, sensitivity and specificity

– What tests are approved for use in country– Is the test approved by the donor—e.g. is the test on the USAID

rapid test waiver: AAPD 05-01 or is it on the WHO bulk procurement list

– National rapid test algorithm/policies/guidelines

• Challenges:– Supply chain management/shortages– Ongoing quality assurance

Challenge: Ensuring Referral to Other Services

• Routine opt-out testing within HIV care and treatment sites greatly facilitates linkages– EGPAF pilot in Cote d’Ivoire: 97% of HIV+ patients had initial

medical assessment and dossier completed the same day, 45% started ART

– MoH pilot in Kenya: 87% of HIV+ patients were enrolled in care, 45% started ART

• Less data available on referrals from VCT and mobile programs– Establishing functional referral systems is the greatest challenge for

community-based CT

Tracking Referrals

• Standardized rather than informal- Informal oral/written referrals result in many lost to follow-up

• Document referrals• Information sharing

• CT sites give ART centers referral records

• ART centers return collected referral forms to CT sites

• Explore community-based approaches to facilitate referrals and follow-up on those lost in process

- Family referrals

- Home based CT services

• Explore methods to involve ART patient volunteers at CT sites

Challenge: Staffing

• Many countries face severe human capacity gaps in their health sector– Yet often national policy only allows health officers or nurses to

perform CT

– This leads to significant gaps in CT services

• Non medical lay counselors can perform quality counseling and rapid testing with proper training and supervision

• Several countries have successfully implemented lay counselors—e.g. Kenya, Uganda, Namibia, Cambodia

• Lay counselors can support client-initiated CT services as well as CT in busy clinical settings

Challenge: Aiding with Disclosure and Support

• Rates of disclosure remain low among CT clients*• Yet disclosure plays important roles in:

– Identification of and prevention within discordant couples– Access to HIV care for partners and family members with

undiagnosed HIV infection– Adherence support for ART

• Aiding with disclosure: – Couple HIV counseling and testing– Home based CT for families of HIV+ patients– Support groups and posttest clubs– Prevention with Positives programs

G Antelman 2001, C Kilewo 2001, S Maman 2003, Y Nebie 2001

Challenge: CT for Children

• With available care and treatment, many HIV programs are attempting to scale up CT for children

• Recent data indicates there are many children with undiagnosed HIV infection in high prevalence countries, despite PMTCT– In Uganda project, 19% of children <5 with HIV+ mother had

undiagnosed HIV infection*• Healthcare workers struggle with how to test children

– When and how to test– How to obtain consent

• Does parent approve• What to do when parent is not available or refuses• Whether to inform child

• Approaches for testing children:– Family CT for ART patients – Routine CT in hospital pediatric wards

J Were 2006

Challenge: CT for Hard to Reach Populations

• Special consideration is still needed for how to expand CT access to hard-to-reach populations– Rural populations often do not have local CT services or transport– High risk, stigmatized populations may not feel comfortable being

tested at regular health care sites• Mobile CT units are very successful for rural areas

– Usually associated with established CT programs or health clinics – In depth, client-initiated style counseling– Rapid testing typically used

• Outreach C&T is ideal for hard-to-reach populations—rural populations, commercial sex workers and clients, IDUs, MSM– CT services must be user-friendly for target population– Peer outreach workers can be used to encourage target population to

access CT– Mobile services can bring service to the target population

THANK YOU!