HIV Testing and Counselling: New Directions

1. TESTING AND COUNSELLING: NEW DIRECTIONS Dr David Miller WHO/FCH/HIV/PRV TB/HIV Working Group, Montreux, 05.06.03

2. HIV/AIDS PRE- AND POST-TEST COUNSELLING: The ‘standard’ “opt-in” model

3. Primary Health Care Health posts Dispensaries Traditional Orphan care Secondary Health Care District Hospitals HIV Clinics Social/legal Support Hospice Community Care NGOs Churches Youth Groups Volunteers Palliative emotional and spiritual support self care Specialists and Specialised Care facilities PLHA Peer support The entry point Tertiary Health Care Home care A Care and Support Service Continuum Voluntary Counselling Testing

4. VCT MODELS EVOLVE

5. Requirements for successful VCT implementation • REALISTICtraining of counsellors (irrespective of background) in managing complex information processes and psychological reactions + counsellor support • ADAPTING testing and counselling models to the needs of local situations • Communicating HIV/AIDS knowledge and prevention messages • Community awareness, education and mobilisation - on test information, against stigma • Referral networks and Support services • Appropriate facilities - time, privacy, confidential information management, accessibility • Monitoring and evaluation

6. WE KNOW MORE ABOUT THE CHALLENGES IN VCT PROVISION... • Gender and sexual negotiation: • Men control VCT decision-making • Men control sexual behaviour decisions • Couples need to be engaged in Counselling and Testing • Quality of counselling determines quality of population response • Scaling up without diluting quality • Access to testing and counselling and uptake of results • Stigma and its impact on decisions to test and disclose

7. Making testing & counselling youth-friendly • New testing technologies - rapid tests • New treatment technologies • Finding new, ethical models of counselling and testing • Group information-giving • targetting services to users • outreach • telephone counselling • Matching models of testing and counselling to HIV prevalence • Examining and learning from alternative approaches to confidentiality

8. The Right to Know • New Opportunities • Increased access to care and treatment • Increased understanding of prevention • Reduced stigma and discrimination • New Imperatives • More PLHA need care and treatment • Maintained widespread ignorance about HIV status

9. TO REACH “3 BY 5”… 300+ million Tested?? 30 million found with HIV?? 3 million on ARVs

10. The Right to Know HIV testing and counselling must be implemented on a broader and radically larger scale to meet an increasing global demand for access to care and prevention services – NOW! This requires a change in emphasis from “opting in” to “opting out” – making the offer of HIV testing by health workers routine

11. The Right to Know: Guiding Principles Testing and Counselling must now be scaled up • Offering HIV Testing and Counselling should become standard practice wherever they are likely to enhance the health and well-being of the individual • To enable the greatest possible number to benefit from improvements in treatment, care and prevention options

12. NEW APPROACHES NEEDED… • Move away from the standard approach to ensure testing and counselling are available • For all who want to know their status • Wherever medically indicated in contexts of clinical care • As part of prevention for mothers and their infants

13. For those who want to know • Expanded, innovative approaches for young people • Priority service provision for vulnerable and marginalised populations (IDU, MSM, etc..)

14. HIV Testing & Counselling in the Context of Clinical Care • Offered whenever a patient shows signs or symptoms of HIV or AIDS, or where this will aid clinical diagnosis and management – the standard of care • Offered for all patients with TB

15. Preventing HIV among mothers and their infants • Offered to women in free-standing clinics or in linked services (e.g., family planning) • Routinely offered in ANC as standard of care in high-prevalence settings • Right of refusal and opportunity to do so

16. Expanding Access to HIV Testing and Counselling • Opt out from routinely-offered testing and counselling • Services must be linked to care, treatment and support programmes • Action on community denial, stigma, discrimination, gender inequality • Use rapid tests • Increase counselling competence in health care workers • Build counselling team approaches • Pre-test information by a variety of media • Work with PLHA • Operational research into various models’ effectiveness, costs and social impacts • T&C in TB services, STI treatment services for CSW and their clients, health services for MSM • Community education on benefits of exercising the right to know

17. The Right to Know: Guiding Principles Testing must be voluntary • Mandatory HIV testing is neither effective on a public health level not ethical • It denies individuals choice and violates principles including the right to privacy and the ethical duties to obtain informed consent and maintain confidentiality

18. The Right to Know: Guiding Principles Informed consent must be obtained • Providing pre-test information on the purpose of testing, and on available treatment and support once the result it known • Ensuring understanding • Respecting the individual’s autonomy Processes of obtaining informed consent will vary according to setting

19. The Right to Know: Guiding Principles Post-test support services are crucial • Results should always be offered to the person being tested • Also, appropriate post-test information, counselling and referral should be offered • Those testing positive should receive counselling and referral to care, support and treatment

20. The Right to Know: Guiding Principles Confidentiality must be protected • All medical records should be managed in accordance with appropriate standards of confidentiality – access only on a “need to know” basis for health care professionals with a direct role in patient management.

21. Primary Health Care Testing and counselling offered as indicated Secondary Health Care Testing and counselling offered as indicated Community Care Testing and Counselling Openly discussed Palliative emotional and spiritual support self care Testing and counselling offered as indicated PLHA Peer support One entry point Tertiary Health Care Home care A Comprehensive Care and Support Service Continuum Voluntary Counselling Testing

22. Testing and Counselling and TB services • ProTEST revealed the viability and impact of linking testing and counselling with TB (and STI) detection and care • A two-way lesson • Expand and strengthen HIV testing and counselling in context of TB services • Strengthen the TB component in the context of HIV detection and management services

23. Testing and Counselling and TB services • Lessons from ProTEST mirror lessons on service testing and counselling provision in other settings (and models), especially regarding capacity building of staff, use of rapid tests, quality assurance for counselling and tests, staff attitude and patient motivation, multi-service provision, and management • We need to encourage innovation, complementarity, collaboration • Testing and counselling cannot do without counselling! That’s what encourages/supports test-seeking and receiving results and encourages/supports changed behaviour

24. Thank You!