Slide 2
The objectives of this presentation are to first review the reasons for
VCT in these settings; describe studies that have demonstrated the
effectiveness of VCT; and finally, discuss the components of voluntary
counseling and testing.
Slide 3
HIV/AIDS is a worldwide pandemic of unprecedented proportions.
Low-resource settings, primarily in the developing world, bear the
greatest burden of disease in terms of absolute numbers, proportions of
adults and children infected and disease and death secondary to HIV.
Nevertheless, these statistics alone would not warrant widespread HIV
counseling and testing unless it can be demonstrated that VCT has benefits
for those who receive counseling and testing. For individuals who are
found to be HIV-infected, there are several benefits of knowing their HIV
status, even in the absence of access to antiretroviral drugs. In most
limited-resource areas, there are medications available to treat or
prevent some of the most common opportunistic infections, such as
tuberculosis. These opportunistic infections are the major causes of
morbidity and mortality in persons with AIDS. Knowing the HIV status can
also help prevent mother-to-child transmission of HIV by the availability
and use of shorter and less expensive antiretroviral regimens and by
changing the mother’s practices of feeding her newborn. Individuals
found to be infected with HIV can also be educated about protective
practices to reduce the risk of transmission to others. Knowledge of HIV
status can help infected individuals plan for the future, including plans
for childbearing and care for their families. Finally, as antiretroviral
drugs become available in these settings, diagnosis of HIV will be
essential to have access to these therapies.
Slide 4
Studies in developed and developing countries have shown that people
who are counseled about HIV prevention, whether or not they are
HIV-positive, reduce risky behaviors. For those who are not infected, but
have high-risk behaviors, this counseling can reduce their risk of
acquiring HIV.
Within communities affected by HIV, the widespread availability of
voluntary HIV counseling and testing can help reduce fear and ignorance
about HIV that lead to the stigma surrounding this infection. VCT programs
can also promote community support of infected persons and help mobilize
communities to encourage behavior changes that will reduce risk of HIV
infection.
Slide 5
A number of studies in limited-resource settings have now demonstrated
that HIV counseling and testing are effective in reducing HIV risk
behaviors and also can reduce actual rates of HIV or other sexually
transmitted infections. A prospective cohort study of HIV education,
counseling and testing of over 1400 childbearing women in Rwanda resulted
in an increase from 7% condom use before the intervention to 22% condom
use one year later. Gonococcal or GC prevalence decreased from 13% to 6%
among HIV-positive women and HIV seroconversion rates declined from 4.1 to
1.8 per 100 person-years in women whose male partners also received
counseling and testing. Unfortunately, there was a lack of risk reduction
seen in HIV-negative women whose partners’ status was unknown. In the
former Zaire, VCT in 149 serodiscordant couples also resulted in
significant increases in consistent condom use, from less than 5% to
greater than 75% at 18 months of followup and a low rate of HIV
seroconversion.
Slide 6
In India, VCT of heterosexual men attending sexually transmitted
infection clinics resulted in a reduction of sexual risk behaviors and an
HIV seroconversion rate of 6.1 per 100 person-years, significantly lower
than the 18% per year incidence estimated from a previous study in the
same population.
In Thailand, HIV-positive individuals reported fewer sex partners and
more consistent condom use after VCT when compared to HIV-positive persons
who were questioned before VCT and did not know their status.
Slide 7
Finally, a randomized clinical trial of VCT versus basic health
information was conducted in Kenya, Tanzania and Trinidad involving over
3100 individuals and 586 couples. In both couples and individuals, VCT was
associated with a greater reduction in unprotected sex than basic health
information alone. A recent comprehensive meta-analysis of VCT concluded
that HIV testing resulted in risk reduction in persons who were
HIV-positive and in serodiscordant couples.
Slide 8
VCT is a cost-effective preventive measure, particularly in high
prevalence settings. In a separate analysis of the randomized clinical
trial of VCT, the cost of VCT per disability-adjusted-life-year was 13 US
dollars in Kenya and 17 US dollars in Tanzania. This cost compares
favorably with other common health interventions, such as management of a
sick child, treatment of acute respiratory infections, or immunizations
against measles, polio, diptheria, pertussis and tetanus. The World Bank
recommends using preventive interventions costing up to 50 US dollars per
disability-adjusted-life-year saved.
Slide 9
There are several factors that may increase the effectiveness of VCT
programs. The counselor should believe that VCT can make a difference for
the individual, the family and the community. Counseling should be
nonjudgmental and supportive. It should be interactive, so that the client
feels involved and not lectured to. The counselor should make eye contact
with the individual being counseled and should ask open-ended questions,
which allow the person other options than simply yes and no answers. The
person’s culture, level of education, age, and gender should be
considered so that the language used is easy to understand and not
offensive. It is important to target personal, and not general, risk
behaviors in order to engage individuals in their own care and to develop
risk reduction plans which are uniquely applicable to them. Finally,
although the majority of studies carried out show that people can make
some changes in sexual behavior to reduce HIV transmission, long-term
changes are difficult without both members of a couple being involved and
aware of their HIV status. Furthermore, many studies have shown that a
significant proportion of couples in steady relationships have
serodiscordant HIV test results, and the uninfected partner’s risk of
becoming infected is high unless safer sexual practices are used. When a
person is unable or unwilling to discuss HIV test results with a sexual
partner, adoption of safer sexual practices is less likely to occur. The
studies that show the most consistent reduction in risky sexual behavior
are among couples who attended VCT sessions together. Couple counseling
and testing can enable a couple to negotiate changes in sexual behavior
together, to plan for the future and to avoid blaming each other.
Slide 10
For HIV counseling and testing to be effective, several important
elements should be included. Basic information about HIV can be provided
in many ways, including written material or group sessions. Individual HIV
prevention counseling, however, requires a private, interactive approach
between a counselor and an individual to help identify specific and
personal behaviors that may place her at increased risk for acquiring or
transmitting HIV. The entire process should be voluntary. Accepting or
refusing testing should not have detrimental consequences for the
individual or to the quality of care offered to her. If the woman feels
coerced or forced to undergo counseling and testing, the counseling is
unlikely to be effective and may drive her away from needed care. Because
of the stigma that is associated with HIV in many areas, information about
the use of HIV counseling, testing and other services should remain
absolutely confidential. Services should be provided that are appropriate
to the client’s culture, age, language, literacy level and gender,
because these factors may affect how they seek, accept and understand
these services. Informed consent ensures that the person receiving
counseling understands the information she is given and freely agrees to
undergo testing.
Slide 11
During VCT, the counselor should provide information about HIV,
including dispelling any rumors or myths about the disease, and counsel
about prevention. Also, the counselor should use diagnostic tests to
detect HIV infection and refer the person for additional care and support
she may need.
Slide 12
VCT has traditionally involved a two-step process. Before testing a
person, the counselor should tell her about HIV, describe the test and the
implications, assess her risk of infection, discuss ways to prevent
infection and determine the woman’s coping strategies and support
systems, especially if the test is positive.
If the person accepts testing, she should be counseled after she is
given her results. This post-test counseling will differ according to the
results of the test. If the woman is HIV-negative, the counselor should
discuss the behaviors that increase the woman’s risk of becoming
infected and ways to reduce that risk. If the woman is HIV-positive,
counseling should focus on providing the woman with emotional support and
helping her deal with the diagnosis. She may feel a range of emotions from
denial and anger to despair. She may even think about killing herself.
Although these emotions are normal, counseling will help the woman deal
with them and help her accept her HIV status. It is also important to
discuss with the woman, when and who she should tell that she is
HIV-positive. Telling other people will increase the amount of emotional
and practical support she needs, but may increase her risk of being
abandoned or abused, so it is important to assess the risk of whether that
will happen.
Post-test counseling should also address prevention of HIV transmission
to others and plans for referral for ongoing HIV care and other services
needed. In many areas, peer support groups and post-test clubs have been
developed in association with VCT to help people cope by sharing
experiences and providing mutual support. After counseling, provide any
followup counseling support or referrals as needed. With the increasing
availability of rapid tests that allow clients to receive the HIV test
results on the same day the test is done, both the pretest and the
post-test sessions are conducted on the same day. The effectiveness of
more condensed prevention counseling sessions combined with the use of
rapid testing is currently under study.
Slide 13
In areas with limited-resources, there may be a need to target
counseling and testing resources to settings that serve individuals who
may be at increased risk for HIV. These settings include sexually
transmitted infection, postabortion care and adolescent clinics, drug and
alcohol treatment centers, tuberculosis clinics, prisons, and clinics
targeting men who have sex with men. Also, because interventions to
prevent mother-to-child transmission of HIV are more available and so
critically needed, pregnant women and clients at family planning clinics
should also be a primary focus for receiving voluntary counseling and
testing services.
Slide 14
Information about HIV should address what HIV and AIDS are, how HIV is
transmitted and how HIV can be prevented. Correcting any myths and
misconceptions about HIV is also important. It may be helpful to ask,
“Are there other things you have heard about HIV or AIDS that seem to be
different from what I am telling you? Are there specific things you have
heard about HIV or AIDS that you want to ask about?” Provide information
about HIV testing that includes how it is performed, what different test
results mean and the importance of obtaining the test results. Individuals
should be educated about the benefits of HIV testing and given information
about how and where to obtain further information or services pertaining
to HIV or HIV prevention.
Slide 15
Pregnant women need additional information about HIV, such as how the
disease will affect the pregnancy. Women with HIV, particularly those with
more advanced disease, may be at greater risk for certain adverse
pregnancy outcomes, such as preterm labor and low birth weight. Pregnant
women should be counseled about the risk of mother-to-child transmission
and how they can reduce that risk. Short-course antiretroviral regimens,
such as single dose nevirapine, alternatives to breastfeeding or
modification of breastfeeding practices, and screening and treatment of
sexually transmitted infections are all ways they can reduce the risk of
transmission. Disclosure is a concern for all individuals found to be
HIV-infected, but pregnant women may be especially vulnerable to abuse and
abandonment.
Although many women think that condoms are used only to prevent
pregnancy, encourage them to use condoms while they are pregnant to
prevent sexually transmitted infection transmission. Pregnant women should
also plan for the future, particularly, who will care for their children
when they become sick or if they die.
Finally, in areas where it is legally and safely available, pregnancy
termination is an option and should be discussed.
Slide 16
The second major component of voluntary counseling and testing is
prevention counseling. This component should focus on the individual’s
unique circumstances to help her identify and acknowledge her personal
risks for HIV. Help her change any behaviors that place her at risk for
acquiring or spreading HIV by first identifying her personal barriers to
change and helping overcome these with skill-building exercises, such as
demonstrating proper use of condoms on anatomic models or role playing to
help develop communication and negotiation skills around protective sex
practices. HIV prevention counseling is usually done in the context of HIV
testing, but does not require that testing be available for it to be
effective. In rural Uganda, a community-based counseling service offered
HIV counseling about safer sex and distributed condoms but did not offer
testing. Visitors to the clinic rose by 500% in 2 years and distribution
of condoms increased considerably.
Slide 17
During the first session, there should be a general risk assessment or
risk screening to help determine which individuals need more in-depth HIV
prevention services. The factors listed on this slide help to identify
people who may be at increased risk of HIV. For example, young single men
and women and mobile populations often have less stable sexual
relationships which put them at greater risk because of unsafe sexual
behaviors. Women who have conditions such as sexually transmitted
infections, which increase risk for transmission and acquisition of HIV,
or tuberculosis, which often co-exists with HIV, have an increased
likelihood of having HIV. In populations with high HIV prevalence, these
characteristics will be less useful and all sexually active individuals
should be considered at risk.
Slide 18
There are also certain signs or symptoms that may indicate the presence
of HIV infection or AIDS, including oral thrush, fevers of unknown cause,
chronic diarrhea, significant and unexplained weight loss, and generalized
enlargement of lymph nodes.
Slide 19
There are a number of infections or cancers that are strongly
associated with HIV infection. Tuberculosis is the leading HIV-associated
opportunistic infection in developing countries. Active tuberculosis is
more common in HIV-infected individuals than in uninfected persons. Almost
80% of cervical cancer cases occur in women living in low-resource
settings. HIV-infected women have higher rates of cervical dysplasia, a
precancerous condition, and without adequate screening and treatment for
dysplasia, are at increased risk for invasive cervical cancer. Other
infections and cancers linked to HIV are seen at very advanced stages of
HIV infection when the immune system is very damaged. But, it is most
beneficial to identify HIV early in the course of infection when there is
an opportunity to prevent development of some of these other conditions as
well as to better prevent HIV- and tuberculosis-transmission to others.
Slide 20
In those found to be at increased risk for HIV, more individual
assessment is important to help them identify, understand and acknowledge
specific behaviors and circumstances that place them at increased risk for
acquiring HIV. This is most effective when open-ended questions are used
to get information about use of condoms; sex with high-risk partners, such
as bisexual men; sex in high-risk situations, such as while under the
influence of alcohol or drugs or with coerced or forced sexual activity;
and injection drug use and sharing of drug equipment.
Slide 21
The most common HIV tests detect antibodies to HIV in serum or plasma.
Standard tests use a screening enzyme immunoassay or EIA. Reactive or
positive results are generally confirmed with Western Blot, which detects
specific antibodies to the virus. This testing sequence has a sensitivity
and specificity greater than 99.9%. More recently, rapid HIV tests have
been developed that generally provide results in 10–15 minutes. They are
also simple and relatively inexpensive. These tests are very sensitive but
are less specific than standard assays, and positive results therefore
require confirmation. Similarly, there is now the ability to test for HIV
using specimens other than blood, such as urine or saliva, which greatly
simplifies collection of specimens. Because of somewhat lower specificity,
positive results with alternative specimens also require confirmation. The
ability to use alternative specimens for HIV testing may increase the
acceptability of HIV testing to people who want VCT services.
Ways to confirm the results of any test may vary depending upon the HIV
prevalence in the population tested, the presence or absence of symptoms
of HIV and the local availability of specific types of tests. For example,
a symptomatic person living in a high prevalence area who has a reactive
screening test may be considered HIV-infected, particularly if resources
for additional testing are limited. In all other situations, reactive
screening tests should be confirmed with standard serology or with a
second and different screening test.
Slide 22
There are other ways to test for HIV, using culture or DNA or RNA
amplification. DNA-PCR, or polymerase chain reaction, is used to detect
infection in newborns who are still antibody-positive because of passage
of maternal antibodies across the placenta or infants with acute HIV
infection before antibodies have developed. RNA-PCR is valuable to help
predict the course of disease, because persons with higher HIV-RNA levels
have a more rapid rate of progression in the absence of antiretroviral
treatment. With appropriate treatment the HIV-RNA level (or viral load)
declines to very low or undetectable levels, and this test is therefore
useful for monitoring therapy. All of these tests are quite expensive and
labor intensive and are not appropriate in most VCT settings.
Slide 23
Special issues to consider in HIV testing include the possibility that
an individual tested has recently been infected and has not yet developed
detectable antibodies, often called the “window period.” Antibodies
generally take 8–12 weeks to develop. Therefore, retesting should be
encouraged in those who have negative test results and have had recent
high-risk behaviors. In areas such as Africa, where infection with HIV-2
is common, a test that can detect both HIV-1 and HIV-2 should ideally be
used. This test is particularly important if the individual has clinical
signs or symptoms or laboratory evidence that suggests HIV infection but
has negative, indeterminate or inconclusive results to HIV-1 testing. The
use of rapid tests can be especially useful in settings where followup is
difficult because the clients live far away from the counseling and
testing site, may not return for the results, or need intervention such as
women who are in labor without prior testing, or healthcare workers who
may need postexposure prophylaxis. People are much more likely to receive
their HIV test results when rapid tests are used. However, this also makes
it particularly important to ensure that the client is prepared to receive
a result in minutes to hours, rather than days or weeks.
Slide 24
An important part of HIV counseling is interpreting and explaining the
meaning of HIV test results. A test should be considered positive only
after both screening and confirmatory tests are positive. Given the high
sensitivity and specificity of testing, a positive result indicates that a
person is HIV-infected except in very rare circumstances. Similarly, a
negative test indicates the absence of HIV infection unless the individual
is in the “window period” or is infected with HIV-2 and has been
tested only for HIV-1.
Slide 25
An indeterminate test is defined as a reactive screening EIA and an
indeterminate Western Blot. This most often represents detection of
nonspecific reactions in serum from an uninfected person, but may also
indicate an evolving HIV antibody response in a newly infected individual
or infection with HIV-2 or with a different HIV-1 strain. In the absence
of recent and ongoing risk behavior, repeated indeterminate test results
at least 1 month apart do not represent HIV infection.
Slide 26
Voluntary counseling and testing should be an entry point for
prevention and care of HIV-infected persons and those at high risk for HIV
— VCT is a way HIV-infected people can get care and people at risk for
HIV can learn about prevention. Therefore, it is important to develop
links to a referral system with antenatal care clinics, other reproductive
healthcare settings and clinics providing medical care for persons with
HIV. Individuals with ongoing risk behaviors should have access to further
prevention counseling and assistance. VCT programs should enlist peer and
community support to help reduce stigma for HIV-infected individuals and
to encourage adoption of HIV risk reduction practices. Countries where VCT
is well established, such as Uganda, have a less stigmatizing attitude to
HIV. VCT programs should also assist HIV-positive individuals in coming to
terms with their infection and in planning for the future.
Slide 27
It is important to remember that when dealing with individuals in high
HIV prevalence areas or in specific clinical settings where clients have
increased behavioral risks for HIV, offering testing based on reported
risk factors will underestimate the number of individuals actually
infected with HIV. It is more appropriate in these settings to offer
testing to all individuals, when possible. On the other hand, in lower HIV
prevalence settings, it is most important to target VCT services to higher
risk groups, especially when resources for counseling and testing are
limited. As already discussed, voluntary counseling and testing is more
effective for risk reduction when both sexual partners in a relationship
participate and share their results. Post-test counseling of individuals
who test negative for HIV is critical, because they may assume that their
behaviors are safe or that they are protected against HIV, and therefore
may not only continue but may in some cases actually increase risky sex or
drug-using practices. Instead, a negative result should be seen as a
second chance to change behaviors that increase the risk for HIV. It
should be clearly stated that a negative test does not mean there is no
risk for HIV or that the person cannot become HIV-infected.
Slide 28
Special emphasis should be given to talking about drug and alcohol use
associated with sexual activity because drugs and alcohol lower
inhibitions and decrease the likelihood of condom use. Positive prevention
messages are also important because the majority of individuals, even in
areas of high prevalence, are not infected.
Slide 29
The most common barriers to voluntary counseling and testing should be
recognized, anticipated and confronted. Concerns about confidentiality not
only deal with the stigma attached to HIV/AIDS, but also relate to fears
of rejection, abandonment or abuse, particularly in women who are found to
be HIV-positive. These are not unreasonable fears. In one study in Rwanda,
HIV-infected women were more likely to suffer physical abuse and the
break-up of relationships, especially when the spouse was not
HIV-infected. In studies from low-resource settings many HIV-positive
individuals do not tell their HIV status to their partners because they
fear their partner’s reaction. Safety issues should be addressed both
during pretest counseling and when positive results are given. This will
ensure that HIV-infected women have the protection and the resources they
need to deal with their diagnosis. There are many examples of
discrimination against HIV-infected individuals in the workplace, school
and other areas of society.
Another common barrier to VCT is simply the fear of being HIV-infected,
particularly in low-resource settings where HIV may be viewed as a disease
without hope or help. Many people in high prevalence countries or in
higher risk groups may assume that they are already infected, and this
belief may discourage them from seeking VCT services. The counselor should
discuss what can be done when HIV is diagnosed, with emphasis on local
resources. Prophylaxis of opportunistic infections with simple inexpensive
generic drugs, nutritional interventions to maintain and enhance health,
management of common symptoms associated with HIV, prevention of perinatal
HIV transmission with short-term oral antiretroviral regimens and
alternatives to or modifications of breastfeeding practices are all
possible even in less developed areas of the world. These interventions
can be reviewed in order to help clients understand the benefits of
knowing their HIV status.
Slide 30
Many individuals resist HIV counseling and testing because they do not
believe they are at risk for HIV. This belief underscores the importance
of individualized risk assessment and personalized risk-reduction
counseling. HIV statistics have demonstrated that many individuals,
particularly women, are at risk not because of their own behaviors, but
because of their partner’s practices, of which they may not be aware.
Finally, a major barrier to VCT is the inability of many women to
change sexual behavior. In many cultures, it is difficult for a man and
woman, even if they are married, to talk openly about sex. Women usually
have little or no power in sexual decision-making. Women or their husbands
may wish to have children and, therefore, have unprotected sex, putting an
uninfected partner at risk. For some women, sex represents the only way
they can support themselves.
Slide 31
In summary, HIV voluntary counseling and testing has been shown to
reduce risk behaviors in both HIV-infected and -uninfected individuals and
in serodiscordant couples. Knowledge of HIV status can benefit not only
HIV-infected persons but can also motivate uninfected persons to reduce
risk. Greater efforts are needed to reach young people and couples.
Counseling and testing should be voluntary and confidential and should
include information about HIV and personalized prevention counseling,
whether or not testing is performed. Finally, the barriers to VCT must be
acknowledged and confronted in order to make this effective intervention
safer and more accepted.
