Voluntry councelling and testing by dr munawar khan
Voluntary Counseling and Testing (VCT) for HIV DR M MUNAWAR KHAN MBBS,DPA,MAS,MRSH
Objectives of HCT• HCT assists individuals and couples to: – Assess their HIV risk behaviors – Develop a risk reduction plan – Discuss testing of children – Access HIV testing – Adopt risk reduction behavior – Access medical and psychosocial referral services2
Objectives• Increase knowledge of and demand for VCT services by select target groups• Increased capacity of partners to implement social marketing interventions• Addressing issues related to decreased stigma of HIV-positive persons and the use of VCT services in high-prevalence communities
Definitions• HIV prevention (pre-test) counseling: An interactive process of assessing risk, recognizing specific behaviors that increase the risk for acquiring or transmitting HIV, and developing a plan to take specific steps to reduce risks
Anonymous Testing• No name is used• Unique identifying number• Results issued only to test recipient 23659874515 Anonymous
Confidential Testing• Person’s name is recorded along with HIV results – Name and positive results are reported to the State Department and the Centers for Disease Control and Prevention• Results issued only to test recipient
Deference Between HEALTH EDUCATION & COUNCELLINGHEALTH EDUCATION COUNSELLING •# A one on one interaction• #It is a one to many involving communication confidentiality, anonymity, privacy• #One deals with issues is general •#One has to deal with personal issues of the individual• #One shares statistical information, data and analyses to show trends •#Have to understand the and dangers of (i) individual to make an impact on epidemics (ii) risky specific attitude and behavior behavior.• #he interaction is •#e interaction can be very impersonal emotional
Elements: Voluntary testing for HIV,•Pre-test counseling,•Post- test counseling(mostly by lay counselors from communities) Counseling
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 Testing11
HCT: Foundation of HIV Prevention and Care ACCEPTING AND SUPPORT LIVING POSITIVELY COPING WITH HIV STATUS • FAMILY • NUTRITION • FELLOWSHIP • CLEAN WATER • HIV POSITIVE PEERS • REDUCED STRESS • WELLBEING MEDICAL CARERISK REDUCTION • STI & TB TREATMENT • TB & OI PROPHYLAXSIS••• BEHAVIOR CHANGE DISCLOSURE OF STATUS PARTNER REFERRAL TO VCT HCT • PEDIATRICS HIV DIAGNOSIS, CARE AND TREATMENT• CONDOM ACCESS PLANNING FOR FUTURE COMMUNITY INTERVENTIONS PREVENTION OF • FAMILY PLANNING MOTHER TO CHILD • SENSITIZATION • ORPHAN CARE TRANSMISSION • MOBILIZATION • FINANCIAL PLANNING • DESTIGMATIZATION
HIV Counseling & Testing• HIV Counseling: – Confidential dialogue between a client and a care provider aimed at enabling the client to cope with stress and make personal decisions related to HIV and AIDS.• Voluntary Counseling and Testing (VCT) – A combination of two activities– counseling and testing –into a service that amplifies the benefits of both.
IMPORTANCE of VCT• 90% of those infected do not know that they are infected.• Knowing one’s serostatus allows people to alter their behavior.• VCT provides an opportunity for prevention counseling and referral to care and support services. VCT is an entry point and not the end point.
IMPORTANCE of VCT Cont…• Effective prevention and care activities require people to know their HIV status.• VCT promotes and sustains behavior change (prevention).• VCT facilitates early referral to care and support services (including access to antiretroviral therapy).• VCT links with PMTCT, STI, and OI services.• VCT assists in stigma reduction.
Acceptance of Serostatus and coping Planning for Early future orphan management care; Will of OIs and STDs preparation Voluntary ReducesReferral to mother-to-social and Counseling childpeer support Testing transmission Normalizes Facilitates HIV/AIDS behavioral change Preventive therapy (TB & bacteraemia) and contraceptive advice
VCT: Foundation of HIV Prevention and Care LIVING POSITIVELY ACCEPTING AND COPING WITH HIV STATUS SUPPORT • NUTRITION • CLEAN WATER • FAMILY • REDUCED STRESS • FELLOWSHIP • WELLBEING • HIV POSITIVE PEERSRISK REDUCTION MEDICAL CARE:••• BEHAVIOR CHANGE DISCLOSURE OF STATUS PARTNER REFERRAL TO VCT VCT • STI & TB TREATMENT • TB & OI PROPHYLAXSIS• CONDOM ACCESS PLANNING FOR FUTURE COMMUNITY INTERVENTIONS PREVENTION OF • FAMILY PLANNING MOTHER TO CHILD • SENSITIZATION • ORPHAN CARE TRANSMISSION • MOBILIZATION • FINANCIAL PLANNING • DESTIGMATIZATION
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• Referral18
Goals of VCT (1)• Prevention of HIV transmission – From +ve tested people to -ve or untested partner/s – From +ve tested mother to child – From +ve or untested partner/s to -ve tested people• Early uptake of services – Counselling for positive living – Social support Medical care – Legal advice Family planning – Future planning Emotional care
Goals of VCT(2)• Societal benefits • Increase adherence – Normalisation of to: HIV – ARV therapy – Reduction of stigma – Preventive therapies – Promote awareness – ARV regimens for PMTCT – Support human rights – Infant feeding choices
Components of VCT• Determining clients • Explaining the test knowledge and obtaining informed consent• Giving accurate information • Discussing implications of HIV• Conducting result personalized risk • Assessing coping assessment ability• Developing a • Result notification personalized risk • Providing reduction plan psychological and• Demonstrating emotional support appropriate condom and referral as appropriate use
VCT as an Intervention Strategy• Effective in promoting behavioural change and providing psychosocial support.• Cost effective especially when it is targeted to couples and “high risk groups”.• Feasible as a component of comprehensive HIV prevention and care strategies in developing countries.• Facilitates the linkage to other HIV prevention and care activities.
Barriers to VCT (1)• Fear• No cure or treatment• Stigma• No need: I’m faithful• Partner with a negative HIV result• Gender inequalities• Lack of perceived benefit• Lack of access to care and support services
Barriers to VCT (2)Fear“I feel if I tested positive it would just devastate me. You know that, while I know I might be positive –I had herpes zoster - there are times I tell myself that its my father-in-law doing some black magic on me. If I went and had a test and they said ‘you have it’ then I know I would be dead in a week.”• Woman 28 years, Kara Counseling and Training Trust, Lusaka, Zambia
Barriers to VCT (3)No cure or effective treatment“I do not even want a test. What are you going to do about it if I come out positive? Are you going to give me medicines? If you tell me that you can give me medicines or that you will cure the disease then I can go for a test tomorrow.”• Man 30 years, Kara Counseling and Training Trust, Lusaka, Zambia
Barriers to VCT (4)Stigma:“ If you go for a test and the result comes out positive your family will not take care of you because you will be an outcast./outsider”• Woman 22 years, Kara Counseling and Training Trust, Lusaka, Zambia
Barriers to VCT (5)No need“Its not necessary since a test is only for those young ones who have not followed their parents’ advice of not indulging in things like careless sex.”• Woman 56 years, Kara Counseling and Training Trust, Lusaka, Zambia
Barriers to Access (Linked to Stigma and Fear)• Stigma/discrimination against PLWHA, as well as behavioral related stigma (IDU and SW) “I’m sure that 100 drug addicts all have the same thought. They’re afraid of being isolated, kept away, and losing the chance to go back to their family.” (Hanoi IDU)• Being recognized by friends or acquaintances• Issues related to Confidentiality• Fear of positive result, and with no cure for HIV/AIDS, there is no reason to get tested—hopeless and depression that would accompany.
Barriers to Access (More surprising)• Among sex workers the fear that testing will result in loss of income “We accept the fact that we might contract the disease, however we don’t dare to go for a medical examination because people might start rumors about our problem and keep away from us. Consequently, we will find it difficult to continue our jobs, to earn money, to feed our children. This is a reality”. (Hai Phong street-based sex worker)• Fear of being treated badly by health workers
Barriers to Changing Sexual Behavior Following VCT• Partner communication difficulties• Gender imbalances in sexual decision making• Difficulties in changing sexual behaviour• Desire to have children• Stigma• Economic deprivation
Pre-test Counseling• Transmission• Prevention• Risk Factors• Voluntary & Confidential• Reportability of Positive Test Results
Counseling is a Relationship• Client and counselor both bring: – Hope – Knowledge – Questions and answers – Personal experiences33
Seven Qualities of a Good Counselor• Self-confidence• Empathy• Acceptance• Genuineness• Trustworthiness• Confidentiality• Competence34
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 issues35
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 plan36
Counseling Skills• Remember to always: – Demonstrate professionalism and maintain rapport throughout the session – Convey to the client that his or her confidentiality will be strictly protected – Speak with the client at his or her level of understanding – Conduct an interactive session focused on risk reduction37
Counseling Skills (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 session38
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 information39
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 40
Ethical Principles• Counselors must be respectful toward the patient’s/client’s dignity and rights• Dignity – Acceptance – Non-judgment• Rights – Confidentiality – Privacy – Autonomy – Self-determination41
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 partner42
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 testing43
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 in44 mind
VCT Program Components-1• Type of counseling session – Individual – Couple – Family• Pre-test counseling – Introduction and orientation – Risk assessment – Discussion of testing children, if applicable – Options for risk reduction – Preparation for the test result45
PRE-TEST COUNSELLING• Review why they have come for the test in a relaxing manner• Review their knowledge of (i) condom use, (ii) sexually transmitted diseases, (iii) HIV/AIDS. Fill in the gaps in their knowledge.• Review and impress on them the consequences of risky behavior• Assess the degree of risk for the client• Slowly go over the nature of the test and the consequences of both a positive and negative result.
PRE-TEST COUNSELLING• In case of a positive result review the difference between HIV and AIDS. Stress the fact that the patient can still live a productive life for even as long as ten or more years and the prospects for therapy and cure are improving daily. Discuss their support system (family and friends)• In case of a negative result discuss the window period for antibody based tests and the need for retesting after about 4 months depending on risk assessment. Impress on them that a negative result does not imply immunity from infection, and the need for a change in behavior.• Obtain informed consent prior to the test.• Schedule the next meeting a week after the test date
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• Referral48
Post-test Counseling• Clarifies test results• Need for additional testing• Promotion of safe behavior• Release of results
POST-TEST COUNSELLING (TEST NEGATIVE)• Immediately reveal that the test was negative• Allow time for the relief and happiness to settle.• Reevaluate whether the person could be in the window period -- withing 3-6 months of having got the infection during which period negative results of tests based on detection of antibodies are not conclusive. If there is reason for concern that this may be the case, schedule an appointment for a retest in about 3-4 months and ask the patient to abstain from sex (or at least from unprotected sex) during this interval• Reassess the knowledge base and awareness of the patient• Reinforce risk reduction information• Explore sustainable changes in behavior
POST-TEST COUNSELLING (FOR DISCLOSING A POSITIVE RESULT)• Reveal test result directly but in a gentle tone and show empathy.• Allow time for ventilation of feelings. In majority of cases there is a emotional and physical breakdown. Allow the expression of grief through crying. Often there is denial -- it cannot happen to me, there must be a mistake in the test. Sometimes there is a silent acceptance but turmoil within.• Once the patient has calmed down sufficiently to the point that you no longer fear that they may do themselves harm, reassure them of all possible help in terms of medical care, psychological support, and referrals to specialists.• Schedule a meeting one week later to begin therapy
POST-TEST COUNSELLING FOR A HIV POSITIVE RESULT• Go over very carefully the difference between HIV and AIDS• Stress the benefits of a positive outlook to life in order to make the best use of the future and to stay productive.• Stress the need for a good, healthy, and balanced diet. (Lots of fruits and vegetables. Avoid spicy and heavy foods. Take vitamin and mineral supplements.)• Need for regular exercise that does not cause fatigue. 15-30 minutes of brisk walking.• Keep immune system strong. Avoid smoking, alcohol, drugs, and stress. Rest often to avoid fatigue.• Yoga and meditation help with maintaining a positive outlook and a healthy body• Explain the need for them to minimize risky behavior to avoid transmitting the infection to another person
POST-TEST COUNSELLING FOR A HIV POSITIVE RESULT• Review need To treat minor infections early and properly• Review the need for special attention to tuberculosis. Suggest regular screening for TB and for other opportunistic infections. Provide a referral service .• Build a support system consisting of friends and relatives. Encourage the patient to bring along one or more such persons to the counselling sessions. Develop a system of home based care for common infections and even for some of the simpler opportunistic infections• Advise confidentiality of status with associates at work and other casual associates. There is no need to advertise HIV status unless patient chooses to become an activist.• Establish the need for counseling, and continue to build trust and to provide effective and regular counseling.
Advancing HIV Prevention: New Strategies for a Changing Epidemic• Four priorities: 1. Make voluntary HIV testing a routine part of medical care 2. Implement new models for diagnosing HIV infections outside medical settings 3. Prevent new infections by working with persons diagnosed with HIV and their partners 4. Further decrease perinatal HIV transmissionMMWR April 18, 2003
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?55