Provider-Initiated HIV Counseling and Testing Services Within Tuberculosis Clinics

1. Provider-Initiated HIV Counseling and Testing Services Within Tuberculosis Clinics Beth Dillon, MSW, MPH Centers for Disease Control and Prevention Global AIDS Program

2. Acknowledgement of Collaborators CDC-Kenya:Barbara Marston, Elizabeth Marum, Larry Marum, Margaret Mburu, Joseph Odhiambo, June Odoyo, Jane Tipton, Nicholas Wambua Kenya:Jeremiah Chakaya, MOH, Sylvia Ojoo, NACP, Judith Brown and Tomas Macharia, Nazareth Hospital, Allan Pamba, KEMRI, Alice Njoroge, Eastern Deanery, Anna Eden, Liverpool CDC-Uganda:Rose Apondi, Rebecca Bunnell, Moses Kamya Uganda:Zainab Akol, MOH, AllenKekibiina Mbarara Hospital, Rhoda Wanyenze, Makere University GAP-TB/HIV Team: Bess Miller, Naomi Bock, Abe Miranda, Patrick Nadol, Lisa Nelson, Reuben Granich, Tim Holtz and Kelly Stinson GAP-Prevention Branch: Caroline Ryan, Jan Moore, Alison Surdo, Lisa Belcher

3. HIV Counseling and Testing: Realities and Challenges • Large numbers of people will need to be tested in order to identify persons eligible for ARV treatment. • Access to testing will need to be expanded exponentially. • In scaling-up CT services, priority sites must be settings where infected persons who are eligible for ARV treatment are likely to be identified. • There are significant human resources limitations– particularly the availability of health care workers and trained counselors. • Given the large volume of patients seen in clinical facilities and human resource constraints, an integrated HIV CT service delivery model seems the most practical.

4. HIV Counseling and Testing: Realities and Challenges • Within an integrated model, the health care provider will need to be the point of service delivery: • Offer and recommend testing; • Provide results; • Time required for traditional “pre-test” counseling cannot be an obstacle in clinical settings to patient access to HIV testing, care, and treatment services. • Counseling and testing protocols will need to be streamlined to maximize efficiency. • A “quick start” approach to training staff may be needed and training time reduced to limit provider time away from clinical settings.

5. Clarification on HIV Counseling and Testing Service Delivery Models • Free-standing – Typically a VCT site operated by a community based organization, frequently offers support services, may offer STI or family planning services, linkage to care and treatment service is by referral • Imbedded – VCT services co-located in a facility, typically a health care facility, and operated somewhat autonomously from other clinical care services. • Integrated – HIV CT services incorporated into the routine clinical care services of medical departments and wards, and the health care provider is involved in delivering HIV CT. • Others – Mobile, Outreach, Satellite Sites

6. Multiple Models of HIV Counseling and Testing Services Voluntary Counseling and Testing Options: Multiple Models Single Setting Stand Alone Services Outreach and Mobile Services Integrated - Clinic Based Services Outpatient and Inpatient Utilize: Counselor, Health Care Worker or Multi-disciplinary Team Different: Purposes and Objectives Target Populations Psychosocial, Clinical, Developmental and Risk Issues Protocols Skills and Training Requirements Counseling and Testing in Antenatal Clinics Couple HIV Counseling and Testing Provider-initiated Counseling and Testing Counseling and Testing for Vulnerable Populations Family Based Counseling and Testing Counseling and Testing Services for Youth A Strategic Mix of Different Approaches to Counseling and Testing Will Likely Have the Greatest Benefits

7. VCT Individual chooses to seek HIV CT First user of the test result is the client who uses the information to make personal life decisions Counseling focuses of addressing risk behavior and risk reduction Anonymous or confidential services may be offered Provider-Initiated Individual is seeking medical care HIV CT recommended and offered by HCW First user of the test result is the health care worker to make a correct diagnosis and provide appropriate treatment Services provided are confidential and documented in medical record to ensure continuity of care Differences Between VCT and Provider-Initiated HIV CT Services

8. Provider-Initiated HIV Counseling and Testing Services— Definitions • Diagnostic – Patient presents with symptoms that may be attributable to HIV or has an illness associated with HIV, and diagnosis and clinical management of the patient is influenced by the diagnosis of HIV. • Routine – HIV testing is offered as part of the clinical evaluation of all patients in settings where HIV is prevalent. • “Opt-in” – HIV test is routinely recommended and offered to each patient and the patient explicitly consents to receive the HIV test. • “Opt-out” – HIV test is routinely recommended and provided to each patient and the patient is informed of his/her right to refuse the test

9. Programmatic Advantagesof Provider-Initiated HIV CT • Normalizes HIV CT in the clinic, health care facility and the community • HIV testing becomes the standard of care • Provides an alternative and feasible model for delivering HIV CT services in a clinical setting • Optimizes the use of human resources • Increases uptake of HIV CT services • Identifies ARV eligible clients • Improves management of TB and HIV disease

10. Facility, Provider, and Patient Advantages of Provider-Initiated HIV CT • Utilizes and builds on health care workers’ training, existing skills, and experience • Health care providers’ recommendations to patients for HIV testing are credible, influential, and effective • Offers services in the context of a trusted provider-patient relationship • Facilitates patient access to and acceptance of HIV CT services • Increases opportunity to provide comprehensive clinical care and to ensure continuity of care

11. Proposed Provider-InitiatedHIV Counseling and Testing Protocol • Consistent with WHO guiding principles and UNAIDS/WHO policy statement on counseling and testing • Provider initiates - recommends and offers the HIV test • Pre-test session is primarily information and education - presented in an encouraging and motivational manner • Accommodates “opt-in” and “opt-out” models of consent • Post-test counseling tailored to patient’s HIV test result • Option for auxiliary counseling/case management staff to serve as “physician/nurse extenders” for group pre-test information and supplemental post-test counseling, support, referrals and follow-up

12. Provider-Initiated HIV Counseling and Testing May Be Delivered in Group Setting or by Provider Notify Patient of Routine HIV Testing, Ensure Understanding and Benefits of Testing Patient Declines or Defers Testing Recommend and Offer HIV Test: Determine HIV Test History and Answer Questions Problem Solve Barriers to Testing Rapid Test Performed Develop Plan to Return for HIV Test Inform Test Result is Negative Inform Test Result is Positive and Provide Support Provide HIV Clinical Care Recommendations Address Partner Referral and Motivate Patient to Reduce Risk Address Disclosure and Partner Referral Address Support Needs and Provide Referrals May Be Delivered by Provider or Counselor

13. Groupor IndividualPre-test Information • TB and HIV co-infection common • HIV testing routinely offered/provided as a component of TB care and treatment • Advise that patient may choose to decline HIV test • Benefits of testing • Available clinical care services can improve health • Eligible for ARV treatment • PMTCT services • Plan for the future • Prevent the transmission of HIV to partner(s) • Counseling will be provided based on test results • Referral to clinical care and support services provided

14. “Opt-in” “As you may know, it is fairly common for persons with TB to have HIV. In order to ensure that you receive the appropriate and essential care and treatment services you need, it is important to know whether or not you have HIV. As part of your clinic visit today, I recommend that we perform the HIV test. May I have your consent for this test? What questions can I answer for you about this?”

15. “Opt-out” “As you may know, it is fairly common for persons with TB to have HIV. In order to ensure that you receive the appropriate and essential care and treatment services you need, it is important to know whether or not you have HIV. Unless you object, as part of your clinic visit today you will receive an HIV test. What questions can I answer for you about this?”

16. Post-test HIV-Negative • Health care provider delivers the test result to the patient, explains the meaning, and ensures an accurate understanding of the result. • Provider/counselor reinforces essential risk reduction measures for remaining uninfected. • Provider/counselor explains partner issues: discordance, risk of infection, importance of early diagnosis and treatment. • Provider/counselor develops plan for partner referral for HIV CT services.

17. Post-test HIV-Positive • Health care provider provides the test result, explains the meaning of the result, and offers empathy and support. • Provider explains TB and HIV clinical care recommendations, addresses immediate health care issues, and coordinates patient access to essential clinical services. • Provider/counselor discusses with patient the need for partner disclosure and referral for CT services. • Provider/counselor explores patient’s support resources, provides linkages to community-based resources, and provides referrals to preventative and public health resources (e.g. family planning, STI services, safe water vessels, bed nets).

18. Policies and Procedures • Collaboration between NACP and TB program • Counseling and testing information management • Medical record documentation and strengthening systems to ensure confidentiality • Ensuring continuity of care across clinical departments • Establishing referral systems and linkages to community-based services • HIV-positive health care workers working in TB clinics

19. Operational and Implementation Issues • Patient volume and provider workload • Patient flow – waiting room and group education, point of service • Space – privacy and confidentiality • Type of HIV tests and testing algorithm • Test quality control and reference laboratory services • Test kit procurement and inventory control • Where test will be performed and by whom • Supply chain of consumables

20. Provider Issues • Overcoming resistance, changing paradigms, and getting “buy-in” • Workload – additional responsibility without incentive • Lack of confidence in their ability to deal with “counseling” issues • Fear patients will have overwhelming emotional reactions • Discomfort talking about sexual issues associated with HIV • Concern that receiving HIV test results will overburden patient – stigma of HIV and TB • Simply not knowing where to start or what to say • Concern that ARV treatment will adversely impact compliance and adherence to TB treatment • Provider HIV anxiety – concerns about their personal and occupational risks – resistance to receive HIV test • Lack of acceptable and confidential HIV CT services and ARV treatment for providers

21. Provider Training • Estimate 3 day course - minimize time away from clinical duties while allowing enough time to fully obtain buy-in from and empower providers • Job aids - pictorial message based flip charts, cue cards, scripts, brochures • Course topics: • Background and rationale for provider initiated HIV CT • Reinforcement of existing skills and experience • Basic counseling skills • Protocol for provider initiated HIV CT • Role plays – recommending HIV, providing HIV negative and positive results • Review tests and testing algorithm • Clinical care recommendations • Enhancing continuity of clinical care across specialty clinics • Working with counselors and other multidisciplinary team members • Providing linkages to preventative health services, support and community resources

22. Conclusions and Recommendations • TB clinics serve large volumes of persons infected with HIV eligible for ARV treatment. • High HIV infection rates and mortality rates of co-infected persons make a compelling argument for HIV CT as a standard of care within TB clinics. • TB clinics and medical wards have highest priority for implementation of provider-initiated HIV CT. • Provider and patient experience with extensive treatment regimens, adherence issues, and DOT may have the potential to enhance ARV treatment services. • Through successful implementation of provider-initiated HIV CT, TB programs could lead the way in improving medical care and expanding access to ARV treatment, saving lives and changing the tide of the epidemic.

23. UNAIDS/WHO Policy Statement on HIV Testing • Diagnostic HIV testing is indicated whenever a person shows signs or symptoms that are consistent with HIV-related disease or AIDS to aid clinical diagnosis and management. This includes HIV testing for tuberculosis patients as part of their routine management.

24. Expectations from the President’s Emergency Plan for AIDS Relief • Seek new strategies to encourage wider HIV/AIDS testing • Integrate testing with other heath care—provide resources for diagnosis, care and treatment of HIV/AIDS through TB and STI Programs • Expand the range of settings in which confidential Counseling and Testing services are offered • Strengthen training of Counseling and Testing service providers to increase availability and ensure quality of services

25. Expectations from the Emergency Plan for AIDS Relief • Focus efforts to make HIV testing available to those at highest risk of infection. • Encourage support for programs that perform routine HIV counseling and testing in general TB and STI programs • Rapid expansion of ARV services, including strategies to build on existing health programs and target populations, for example TB, STI and hospital in-patients.

26. Summary What we have: • Mandate • Resources • Evidence • Framework • Responsibility What we need: • Institutional will • Conviction and commitment • Action