PITC Presentation by MSD


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  • HIV testing and counselling is essential for identifying women who can benefit from treatment either immediately or later, or from interventions to prevent HIV in their infants. Entry to such programmes is initially determined by the proportion of HIV-infected pregnant women identified, often through an HIV test in antenatal care settings. Testing coverage in pregnant women is low in many of the 10 countries with the highest estimated numbers of HIV-infected pregnant women (Fig. 15). The seven countries with the highest PMTCT antiretroviral treatment coverage have relatively high percentages of pregnant women receiving an HIV test. In more than 70 surveyed low- and middle-income countries that reported data for 2005, only 10% of pregnant woman received an HIV test. In sub-Saharan Africa the percentage was 9%, while there was higher coverage in Latin America and the Caribbean (46%) and in Eastern Europe and Central Asia (75%). The high coverage in Eastern Europe was considerably influenced by the large proportion of women attending ANC who received HIV testing in the Russian Federation (about 90%).
  • We all know that tuberculosis patients in settings of high HIV prevalence have high rates of HIV coinfection. Ensuring that TB patients receive HIV testing and counselling should therefore be a high a priority for the health sector. In 2005, only 7% of TB patients were tested for HIV worldwide, of whom 23% tested HIV-positive. In countries with generalized HIV epidemics, only 13% of all TB patients were tested for HIV, of whom 48% were HIV-positive. Testing patterns vary between regions. Only 10% of TB patients were tested for HIV in sub-Saharan Africa, which carries 80% of the global HIV burden of TB, whereas 26% of TB patients were tested for HIV in Latin America and the Caribbean and 38% were tested in Europe and Central Asia. Of the patients tested for HIV in TB programmes, approximately 51% were found to have HIV in sub-Saharan Africa, whereas the corresponding values were 17% in Latin America and the Caribbean and 19% in Asia. Globally, 86% of the estimated number of HIV-positive TB patients are not tested for HIV during their treatment. Not offering HIV testing to all TB patients in countries with generalized HIV epidemics wasted the opportunity to inform approximately 460 000 HIV-positive TB patients of their status and ensure their access to comprehensive HIV treatment, care and support. It is not all doom and gloom though: data suggest that since 2003 there has been a threefold increase in both HIV testing of TB patients and detection of HIV/TB coinfection. A rapid expansion of HIV testing among TB patients, linked to provider-initiated testing and counselling, has recently occurred in some African countries. For example, in Rwanda in 2004, 46% of TB patients were tested for HIV and by late 2006 this had increased to 81%. In Kenya in 2005, 32% of TB patients were tested for HIV; this had increased to 64% by 2006. In Malawi in 2005, some 48% of TB patients were tested for HIV, of whom 69% were found to be HIV-positive. Nevertheless, a total coverage of HIV testing and counselling for TB patients of 7% is totally inadequate, as TB patients are already in the health care system, and every undiagnosed HIV infection in a patient with TB represents a major missed opportunity for HIV prevention, treatment and care.
  • Too little, too late: HIV testing in the UK At the end of 2005 an estimated 63 500 adults aged 15 to 59 were living with HIV in the UK, of whom, 20 100 (32%) were unaware of their infection. Two in five (40%) HIV-infected Black and Minority Ethnic adults were diagnosed late and they were ten times more likely to die within a year of their HIV diagnosis than those with higher CD4 counts (6.4% compared to 0.67%). Only a minority of those diagnosed late had very recently arrived in the UK.
  • Shown here are data from the Kisumu District Hospital in western Kenya. During the period January to April 2004 over 3,000 antenatal women in these clinics. In the first half of the year women were offered HIV testing using an opt-in VCT model requiring women to opt for the services.   After July 2003 a policy of routine HIV testing with patient notification was instituted at the clinic. Not to be tested required active refusal. Using this opt-out approach to testing HIV test acceptance rates increased from between 10 and 30% in the early part of the year to between 50 and 90% currently.   These findings are compelling and suggest that in antenatal settings routine testing should be instituted to increase the uptake of testing. We are in the process of strengthening and replicating this model to other sites.
  • PITC Presentation by MSD

    1. 1. Provider-Initiated HIV Testing and Counseling: An Introduction Dr Esther Tan, MSD
    2. 2. Background & Objective of Ppt <ul><li>Ppt purpose is to introduce UN health care providers to the PITC concept </li></ul><ul><li>PITC, while encouraged by the UN Medical Directors, have yet to be formally implemented by many UN health services </li></ul><ul><li>Hopeful that the information presented here will inform future task of launching PITC in the UN </li></ul>
    3. 3. Presentation Outline <ul><li>Evolution of HIV Policies </li></ul><ul><li>WHO Guidelines on PITC </li></ul><ul><li>Discussion Questions </li></ul><ul><li>UN PEP Starter Kits </li></ul>
    4. 4. HIV Testing Policies – Evolution
    5. 5. Highlights of 1980s <ul><li>HIV tests become available </li></ul><ul><li>Govts focus testing on blood, immigrants, specific pop sub-gps (SW, IVDU, MSM) </li></ul><ul><li>Evidence emerges that mandatory HIV testing drives people underground </li></ul><ul><li>Three Cs – Confidentiality, Counseling, Consent seen as integral part of testing </li></ul>
    6. 6. Highlights in 1990s <ul><li>WHO issues guidelines on need for testing to be voluntary: Birth of VCT </li></ul><ul><li>Respect for human rights in HIV testing seen as legal obligation and good public health </li></ul><ul><li>Changes to the HIV testing environment : </li></ul><ul><ul><li>Low uptake of VCT </li></ul></ul><ul><ul><li>Increased availability of antiretroviral therapy (ART) </li></ul></ul>
    7. 7. Highlights in 2000s <ul><li>Availability of HIV rapid tests with high sensitivity and specificity </li></ul><ul><li>Emergence of targets for number of people on ART – leading to high targets for HIV testing </li></ul><ul><li>WHO/UNAIDS issues new Guidance on HIV testing : Distinguishes between VCT and PITC </li></ul><ul><li>Emerging testing strategies : PITC, household testing, mobile testing..etc..increasingly common </li></ul>
    8. 8. Universal Access by 2010? 2005 G8 Summit at Gleneagles, Final Communiqué: “… working with WHO, UNAIDS and other international bodies to develop and implement a package of HIV prevention, treatment and care, with the aim of as close as possible to universal access to treatment for all those who need it by 2010 .”
    9. 9. HIV Testing – Then and Now
    10. 10. UN Medical Directors Position Statement (Oct 2008) <ul><li>“ Voluntary, confidential HIV/AIDS counselling and testing and provider initiated counselling and testing in UN staff members should be encouraged by medical staff during all contacts with staff members , particularly in duty stations where HIV is prevalent , and ARV treatment is available.” </li></ul>
    11. 11. WHO / UNAIDS: Guidance on Provider-Initiated HIV Testing and Counseling in Health Facilities (May 2007)
    12. 12. Background and Rationale <ul><li>Sub-Saharan Africa: Only 12% men, 10% woman had been tested for HIV and receive results </li></ul><ul><li>“ WHO/UNAIDS strongly support continued scale up of VTC, but recognize need for additional, innovative and varied approaches (including PITC)….” </li></ul><ul><li>“ Evidence…suggests that many opportunities to diagnose and counsel individuals at health facilities are being missed and that PITC facilitates diagnosis and access to HIV-related services.” </li></ul>
    13. 13. % of 15-49 yr old Africans ever tested and received test result Demographic and Health Surveys, MEASURE DHS, 2003-2005 Average: 10%
    14. 14. % of 15-49 yr old Africans who know their test result Demographic and Health Surveys, MEASURE DHS, 2003-2005 Average: 15%
    15. 15. Pregnant women who received an HIV test: data from the 10 countries with the highest estimated number of HIV-infected pregnant women, 2005 Average: 15-20%
    16. 16. HIV-positive tuberculosis cases identified through testing for HIV in 2005, Global TOWARDS UNIVERSAL ACCESS. Scaling up priority HIV/AIDS interventions in the health sector . Progress Report, WHO, Geneva, April 2007 Globally, only 14% of the HIV-positive TB patients identified through for HIV during their treatment TB patients should be offered HIV test
    17. 17. Unmet need for ARV in low- and middle-income countries, December 2006 No. of pp who need ARV and are not getting it
    18. 18. Lancet paper: Mortality in the months after starting ART in low- and high-income settings High mortality rate in first months of starting ARV
    19. 19. Mortality in patients on ART in low-income settings <ul><li>73% deaths occurred in persons starting therapy at CD4+ <100 per cu mm </li></ul><ul><li>38% deaths occurred in first month, 80% in first 4 months </li></ul><ul><li>Above points to late diagnosis , identification of HIV only at later stages of infection / AIDS </li></ul>Source: ART-LINC and ART-CC Groups, Lancet, 2006
    20. 20. UK: Late diagnosis in high-risk groups A Complex Picture. HIV and other Sexually Transmitted Infections in the United Kingdom: 2006 Health Protection Agency, London, 2007.
    21. 21. British Medical Journal Articles, June 30, 2000 <ul><li>Time to move towards opt-out testing for HIV in the UK , Hamill M et al. </li></ul><ul><li>Routine testing to reduce late HIV diagnosis in France , Delpierre C et al. </li></ul><ul><li>Reducing the length of time between HIV infection and diagnosis, Editorial </li></ul>
    22. 22. Importance of Encouraging Testing <ul><ul><li>Knowledge of HIV status is essential for: </li></ul></ul><ul><ul><ul><li>Expanding access to HIV treatment, care, and support </li></ul></ul></ul><ul><ul><ul><li>Improving HIV/AIDS treatment outcomes </li></ul></ul></ul><ul><ul><ul><li>Enhancing HIV prevention , including PMTCT </li></ul></ul></ul>
    23. 23. Definition of PITC <ul><li>Refers to HIV testing and counselling which is recommended by health care providers to persons attending health care facilities as a standard component of medical care. </li></ul><ul><li>While this type of testing can be routine under certain conditions, it should never be mandatory or compulsory . </li></ul>
    24. 24. WHO: Importance of Context <ul><li>PITC should be accompanied by </li></ul><ul><ul><li>Recommended package of HIV-related prevention, treatment, care and support services and </li></ul></ul><ul><ul><li>Implemented within framework of national plan to achieve universal access to ARV therapy for all who need it ( access to ARV therapy is not absolute prerequisite ) </li></ul></ul>
    25. 25. WHO Recommendations <ul><li>Recommend HIV test to: </li></ul><ul><ul><li>All patients, irrespective of epidemic setting , where there is clinical suspicion of underlying HIV infection </li></ul></ul><ul><ul><li>In generalized HIV epidemics , as standard part of medical care for all patients attending health facilities </li></ul></ul><ul><ul><li>In concentrated and low-level epidemics , more selectively </li></ul></ul><ul><li>“ Opt-out” approach to PITC </li></ul><ul><li>Giving simplified pre-test info </li></ul>
    26. 26. In All Epidemic Types <ul><li>HIV testing and counselling should be recommended to: </li></ul><ul><ul><li>Symptomatic patients : (all adults, adolescents or children with signs, symptoms or conditions that could indicate HIV infection, including tuberculosis) (i.e. Diagnostic Testing ) </li></ul></ul><ul><ul><li>HIV-exposed children or children born to HIV+ women </li></ul></ul><ul><ul><li>Men seeking male circumcision for HIV prevention </li></ul></ul><ul><li>This recommendation should ordinarily lead to the test being performed unless the patient declines </li></ul>
    27. 27. In Generalized HIV Epidemics <ul><li>HIV testing and counselling should be recommended to ALL patients regardless of the reason for presenting to the health facility (i.e. Screening ) </li></ul><ul><li>Implementation can be prioritized according to type of facility and HIV prevalence, eg: </li></ul><ul><ul><li>Medical wards and outpatient facilities </li></ul></ul><ul><ul><li>Antenatal, childbirth and postpartum health services </li></ul></ul><ul><ul><li>STI services..etc </li></ul></ul>
    28. 28. In Concentrated and Low Level HIV Epidemics <ul><li>HIV testing and counselling should not be recommended to all patients attending health facilities, only to symptomatic and perinatally exposed individuals </li></ul><ul><li>Consider PITC for </li></ul><ul><ul><li>STI services </li></ul></ul><ul><ul><li>Services for most-at-risk populations </li></ul></ul><ul><ul><li>Maternal health services </li></ul></ul>
    29. 29. DEFINING OPT-IN AND OPT-OUT <ul><li>Opt-in HIV testing . Requires health provider to provide counseling and a separate written informed consent, which patients must sign before being permitted to have an HIV test. </li></ul><ul><li>Opt-out HIV testing . Patients are informed either orally or via general medical consent that HIV testing will be included as part of the routine blood tests. Patients can decline the HIV test (opt-out). Assent is inferred unless the patient declines testing </li></ul>
    30. 30. Uptake of PMCT Testing by Testing Strategy, Kisumu, Kenya, 2003-04 Opt-In Opt-Out
    31. 31. Pre-Test Information and Informed Consent – What’s New? <ul><li>Pre-Test Information </li></ul><ul><ul><li>Can be individual or group info sessions </li></ul></ul><ul><ul><li>Minimum set of info should be provided </li></ul></ul><ul><li>Informed Consent </li></ul><ul><ul><li>Verbal communication adequate for obtaining informed consent (i.e. no need for written consent) </li></ul></ul><ul><ul><li>Consent always given individually, in private, in presence of health care provider </li></ul></ul>
    32. 32. Minimum Pre-test information <ul><li>Why HTC is recommended </li></ul><ul><li>Clinical and prevention benefits; risks: discrimination, abandonment, violence </li></ul><ul><li>Services available for + and -, including ART </li></ul><ul><li>That results will be confidential </li></ul><ul><li>The right to decline, but that test will be done unless declined </li></ul><ul><li>That, if testing is declined, access to services that do not require knowing one's serostatus will not be affected </li></ul><ul><li>That, in case of positive test, disclosure is encouraged </li></ul><ul><li>Opportunity to ask questions </li></ul>
    33. 33. Post-Test Counseling <ul><li>All patients must be counseled when test results are given </li></ul><ul><li>Minimum set of info for those with </li></ul><ul><ul><li>HIV-negative results </li></ul></ul><ul><ul><li>HIV-positive results </li></ul></ul><ul><ul><li>pregnant women who is HIV-positive </li></ul></ul>
    34. 34. Post test counselling <ul><li>If HIV negative: </li></ul><ul><ul><li>Explain test result – incl. window period, and recommend to be re-tested if recent exposure </li></ul></ul><ul><ul><li>Give basic advice on how to prevent getting HIV </li></ul></ul><ul><ul><li>Provide condoms </li></ul></ul>
    35. 35. Post test counselling <ul><li>If HIV positive: </li></ul><ul><ul><li>Explain test result/give time to consider </li></ul></ul><ul><ul><li>Ensure understands result; Allow questions; Help cope with emotions </li></ul></ul><ul><ul><li>Discuss immediate concerns – map support network </li></ul></ul><ul><ul><li>Describe health and social services available and refer/provide </li></ul></ul><ul><ul><li>Give information on how to prevent HIV, safer sex, condoms </li></ul></ul><ul><ul><li>Advice on nutrition, cotrimoxazole, ITN </li></ul></ul><ul><ul><li>Encourage HTC for partners and children </li></ul></ul><ul><ul><li>Assess risk of suicide and violence and discuss steps to ensure safety </li></ul></ul><ul><ul><li>Arrange time and date for follow up </li></ul></ul>
    36. 36. Post test counselling <ul><li>In Pregnant Woman who is HIV-positive: </li></ul><ul><ul><li>Childbirth plans </li></ul></ul><ul><ul><li>ARV for preventing mother-to-child transmission and own health </li></ul></ul><ul><ul><li>Nutrition, iron and folic acid </li></ul></ul><ul><ul><li>Infant feeding and support </li></ul></ul><ul><ul><li>Infant testing and follow up </li></ul></ul><ul><ul><li>Partner testing </li></ul></ul>
    37. 37. Frequency of Testing <ul><li>Depends on continued risks taken by patient, availability of human/financial resources and HIV incidence in setting </li></ul><ul><li>Re-testing every 6-12 months may be beneficial for those at higher risk of HIV exposure </li></ul>
    38. 38. US Testing Policy <ul><li>For patients in ALL health-care settings: </li></ul><ul><ul><li>HIV screening recommended for all patients using “opt-out” screening </li></ul></ul><ul><ul><li>Persons at high-risk should be screened at least annually </li></ul></ul><ul><ul><li>Separate written consent not required : general consent for medical care sufficient </li></ul></ul><ul><ul><li>Prevention counseling not required for diagnostic / screening test </li></ul></ul>
    39. 39. US Testing Policy <ul><li>For pregnant women: </li></ul><ul><ul><li>HIV screening included in routine panel of prenatal screening tests for all using opt-out approach </li></ul></ul><ul><ul><li>Separate written consent not required : general consent for medical care sufficient </li></ul></ul><ul><ul><li>Repeat screening in 3 rd trimester recommended in locations with elevated rates of HIV infection among pregnant women </li></ul></ul>
    40. 40. Discussion Questions
    41. 41. For Discussion <ul><li>What is level of HIV infection in local population in your mission? </li></ul><ul><li>What is level of HIV infection among staff population in your mission? </li></ul><ul><li>In your mission, who oversees and manages issues of HIV testing and counseling of staff? </li></ul>
    42. 42. For Discussion <ul><li>Do you think the following are difficult to implement? What are the barriers? </li></ul><ul><ul><li>HIV testing of all staff with clinical suspicion (e.g. TB positive) </li></ul></ul><ul><ul><li>“ Opt-out” approach </li></ul></ul><ul><ul><li>Verbal consent only without written consent </li></ul></ul><ul><ul><li>Providing minimum pre-test info (eg with no pre-test counselling) in eg group sessions or through provision of a leaflet </li></ul></ul>
    43. 43. For Discussion <ul><li>What do you think is the main barrier to HIV testing among staff in your mission? </li></ul><ul><li>What do you think is the level of stigma and discrimination in the UN staff population? </li></ul>
    44. 44. UN PEP Starter Kits
    45. 46. General Principles <ul><li>PEP = Post Exposure Prophylaxis , </li></ul><ul><ul><li>Full PEP involves set of services provided to manage the specific aspects of HIV exposure and to help prevent HIV infection in exposed persons </li></ul></ul><ul><ul><li>Includes first aid, counseling (assessment of risk of exposure, HIV testing, course of anti-HIV medication, follow up) </li></ul></ul><ul><li>Must initiate ASAP after exposure, ideally within 2 hours or less, not >72 hours post-exposure </li></ul><ul><li>Adherence to a full 28 days course of ARV critical </li></ul>
    46. 47. UN PEP Starter Kits Contents <ul><li>ARVs: 5 days of a two-drug treatment (Zidolam 1 tab bd) </li></ul><ul><ul><li>Full course is 28 days – must ensure continuity </li></ul></ul><ul><li>Pregnancy test kit </li></ul><ul><li>Emergency oral contraception (“morning-after” pill): </li></ul><ul><ul><li>1st tablet to take ASAP and no later than 5 days after exposure, 2 nd tablet 12 hours later </li></ul></ul><ul><li>Patient Registry Form : filled and signed by treating physician who will monitor care </li></ul>
    47. 48. Eligibility <ul><li>PEP Starter Kits (not full!) available to all staff with a UN agency contract, and their spouses and dependent children who are exposed to HIV because of: </li></ul><ul><ul><li>Sexual assault </li></ul></ul><ul><ul><li>Occupational exposure </li></ul></ul><ul><ul><li>An accident, criminal assault or security incident </li></ul></ul><ul><li>Not meant for exposure through voluntary activities outside work </li></ul>
    48. 49. 5 Patient Information Sheets
    49. 50. 5 Patient Information Sheets
    50. 51. Specific Info for Providers
    51. 52. Specific Info for Custodians
    52. 53. Report Use of Kits to UNMS <ul><li>Notify UN Medical Services via email ( [email_address] ) </li></ul><ul><li>Accompanying information required: </li></ul><ul><ul><li>Organization of person </li></ul></ul><ul><ul><li>Duty station of person </li></ul></ul><ul><ul><li>Gender of person </li></ul></ul><ul><ul><li>Reason for use of kit </li></ul></ul><ul><ul><ul><li>e.g. occupational exposure, sexual assault, criminal assault…etc </li></ul></ul></ul>
    53. 54. Thank you