Voluntary HIV Testing

and
Counseling
Ms.Somsri Tantipaibulvut
Anonymous Clinic
Thai Red Cross AIDS
Research Centre

Supported by
SEARCH Regional HIV/AIDS Training A Training Grant
8th January to 9th February, 2007 From
 VCT – The Evidence
• The V(voluntary ) encourages people to
present at services they may otherwise
avoid.
• The C(counselling)is more effective than
the simply providing health information.
• The T(testing) – quality, same day tests
are cost effective and increases uptake
and demand for VCT.
 What is HIV/AIDS Counseling
• HIV/AIDS counseling is confidential
communication between a client and a care
provider aimed at enabling the client to cope
with stress and take personal decision relating to
HIV/AIDS
• The counseling process includes the evaluation
of personal risk transmission, the facilitation of
preventive behavior, and evaluation of coping
mechanisms when the client is confronted with a
positive result
 Aim of Counseling
Help each individual to take charge of his/her
own life by
: Developing the ability to make wise and
realistic decisions
: Altering own behavior to produce desirable
consequences
: Providing information
 The classic VCT model

• “Individual VCT”

• “Group information giving”

• “VCT for couples”

 Brainstorm Activity

Discuss.....

What are the advantages?

What are the disadvantage?

 Model of VCT
• Classic model
• Opt in model
• Opt out model
• Shared confidentiality model
• HIV screening
 VCT Models
• Free-standing VCT
• Integrated into health care services-
- Integrated into general hospital services
- Attached to specialized clinics, such as STD,TB, or
antenatal clinic
- NGO is provided space to provide VCT within a
hospital
- Attached to research projects
- Private sector, Owned by individual or companies
• Mobile (outreach) VCT
• Home testing
 Free-standing VCT
• Advantage –
- Separate from medical services
- Community links
- Dedicated counselors
- Post-test support
- Flexibility of opening times
• Potential disadvantages-
- Possible stigma
- Sustainability/funding
 Integrated into Health care
services
• Advantage –
- ↓ Cost
- Ease of replication/scaling-up
- ↓ Stigma-test support
- ↑ Liaison with medical interventions
- ↑ Access for woman
- ↑ Access for young people
• Potential disadvantages-
- ↑ Workload
- ↓ Access for men and couples
- ? ↓ Quality of counseling
 Mobile (outreach) VCT

• Advantage –
- Anonymity
- Easy access
- Access for “hard to reach groups”
- Access for remote and rural
• Potential disadvantages-
- Poor follow up and post-test support
- Logistic/maintenance problems
 Home testing
• Advantage –
- Privacy
- Access for “special groups”
- Cheap (for health system)
• Potential disadvantages-
- No pre-test counseling
- No/limited post-test counseling
- Coercion
- Poor quality control
- Single test
- Difficult to perform
Informed consent
Confidentiality
Legislation to prevent discrimination
Quality control
 Voluntary counseling and
testing
• Client-initiated HIV testing to learn HIV
status
• Pre-test counseling on an individual basis
or in group settings with individual follow-
up
• UNAIDS/WHO promote knowledge of HIV
status among any population that may
have been exposed to HIV through any
mode of transmission.
 Diagnostic HIV testing
• Indicated whenever a person shows
signs or symptoms that are consistent
with HIV-related disease or AIDS to aid
clinical diagnosis and management
 Diagnostic HIV testing (cont’d)
• Includes HIV testing for all tuberculosis
patients as part of their routine
management
 Routine counseling and
testing
• Routine C and T is a step toward
“normalizing” HIV
• Less conspicuous
• Addresses many of the barriers to HIV
testing as it becomes the “standard of
care”.
• WHO/UNAIDS recommend that a routine
offer of HIV testing be made to all persons:
– Being assessed for STIs
– In antenatal care
– Asymptomatic persons seen in health care
settings where HIV is prevalent and ARV
treatment is available
• For provider-initiated testing, patients
retain the right to refuse testing, i.e. to ‘opt
out’ of a systematic offer of testing.
• The basic conditions of confidentiality,
consent and counseling apply but the
standard pre-test counseling is adapted to
simply ensure informed consent, without a
full education and counseling session
 Mandatory HIV screening

• UNAIDS/WHO support mandatory screening

for HIV and other blood borne viruses for:
– blood that is destined for transfusion or for
manufacture of blood products.

• Mandatory screening of donors is required:

– prior to all procedures involving transfer of bodily
fluids or body parts, such as artificial insemination,
corneal grafts and organ transplant.
• UNAIDS/WHO DO NOT support
mandatory testing of individuals on public
health grounds.

• Mandatory testing is done in association

with resettlement, immigration, military
recruits
 Mandatory testing
• UNAIDS/WHO recommend that such
testing be conducted only when
accompanied by:
– counseling for both HIV-positive and HIV-
negative individuals and
– referral to medical and psychosocial services
for those who receive a positive test result.
• Sound policies provide a supportive
framework for the provision and scaling up
of HIV testing
• Sound public health practice and respect
for basic human rights are mutually
reinforcing
• Thus the voluntary nature of testing must
remain core to the provision of HIV testing
services.
Anonymous counseling &
testing
It is not the same as:

Voluntary counseling & testing

or
Confidential counseling & testing
 Voluntary Counseling and
Testing (VCT)
• The ideal concept for HIV testing to ensure
maximal benefit with least risk from testing
• It has been a law in Thailand since 2002.
• It is not unique for HIV/AIDS but should be
applied to any test with potential
psychosocial consequence.
 Counseling skills
• Construct and predictive validity
• Maintenance of skills through
practice
• Validity across cultures and
genders, but difference style
inuse
 Counseling skills

• Different theories and different

patterns of use of skills
• Micro-skills social learning model
• Micro-skills are useful with others
system of training
• Micro-skills and integration
 Counseling skills

Counselling micro-skills are

essential for effective
communication and the
development of a
supportive client-
counsellor relationship
 Counseling skills
HIV Prevention Counseling is a
counselor-led and Client-focused
exchange designed to help
individuals make behavior
changes that will reduce their risk
of acquiring or transmitting HIV
 Counseling skills
• active listening
• Questioning
• Silence
• Non-verbal behavior
 Pre-test counseling

Apply knowledge of basic counselling microskills to

the context of HIV pre-test counselling

Integrate clinical risk assessment, HIV prevention

education and counselling into HIV pre-test
counselling

Assess an individual’s coping strategies and

psychosocial support system

Facilitate provision of informed consent by the client

To ensure that any decision to take the test is fully
informed & voluntary

To prepare the client for any type of result, whether

negative or positive or indeterminate

To provide client risk reduction information &

strategies, irrespective of whether testing happens

To provide options for PMTCT

To provide an entry point to treatment & care

An individualised risk reduction plan

Facilitate the client to enact the plan

Facilitate coping skills acquisition

Facilitate improved support mechanisms
to client: interpersonal & familiar
 General principal
Establish relationship with client

Find out why the client has come to the centre

(information, counselling and testing)?

Information on HIV
• Correct any misconceptions – give simple
factual information
• Discuss HIV transmission including the 4
principles – ESES
Help client assess own level of risk & draw up own
risk reduction plan

Explain the HIV test

Talk about the advantages & disadvantages of the test

for the individual
Discuss the importance of spouse or partner
disclosure (& the counselling assistance that can be
provided for this)

Summarise the session for the client

Obtain informed consent

Reaffirm right to decline testing

If client decides to test:
• Inform client about the procedure for test
• Length of time for results –
immediate/delayed
• Amount of and manner in which blood
(venipuncture, finger prick, etc) will be
taken
• Remember to show client blood tube/slide
collection form & labels which have their
code
Some flexibility is required
e.g. If the client is distressed on initial presentation
you will need to address this first
 Post-test counseling
• Apply a knowledge of basic counselling
techniques used in VCT
• Understand the basic requirements for the
provision of HIV results
• Conduct a post-HIV test counselling
session for a negative result
• Conduct a post-HIV test counselling
session for a positive result
• To prepare the client for the result
• To help client understand and cope with
the result
• To provide further information to the client
(if necessary)
• To refer the client to other services (where
required)
• To discuss with the clients strategies to
reduce HIV transmission
• Cross check all results with client file and
blood samples
• Provide results only “face-to-face”
• Be aware of the manner in which you call
clients from the waiting area
• Provision of written test results is not
advised
• Subject to misuse (for both positive and
negative results)
• Testing for employment, insurance –
special precautions
• Sharing results with partners – best done
at the VCT service
 General Principles

• Be calm when you call the client in for their

result
• Be direct in giving the result
• Give an explanation of their result
• Allow enough time for results to sink in
 Negative result provision
• Check for possible exposure in window
period – including any risks, which may
have occurred since pre-test counselling
• Reinforce information on transmission,
safer sex/drug use.
• Exploration of constraints to practice of
such
 Negative result provision
• Referral for anxiety i.e. ‘worried wells’
• - easily reassured
• - HIV phobia, hypochondriasis
• Clients may be negative but in the process
of sero-conversion and hence may be
highly infectious!
 Counselling Issues Related to
Negative Results
• Clients may worry that others will know they
have taken the test and make judgements
about their personal life or health
• Clients may fear that employers or insurance
companies will discriminate against them
even though the results are negative
• Clients may understand that they need to
modify their behaviour but may worry that
their partners will not want to change
• Clients who had high risk behaviour may
believe they are immune from HIV
Frequent HIV Negative Testers
• Often engage in high risk behaviours
• Have deep seated anxiety and belief that
they are HIV positive
• Should be reassured, if not responding
then refer to specialist for psychological/
psychiatric/mental health follow up
 Checklist for Provision of HIV
Negative Results
• Cross check client ID, blood samples and
records
• Check for possible exposure in window
period and inform client of need for any
retest and when this should occur
• Reinforce information on HIV transmission
and personal risk reduction plan
• Referral for anxiety i.e. “worried wells”
 Positive Result Provision
• Build Relationship: greeting/small talk
• Confirm the client is ready to collect the test
result:
– • Psychosocial Condition: Check what
was going on with the client before
coming here and while waiting for the
test result?
– • Comprehension: Ask if the client would
like to summarise what was discussed
last time
– • Coping Strategies: Ask what they
would do if the test is negative?………
What would they do if positive?
 Positive Result Provision
• Some clients may react with severe shock
and distress
• Others may show no emotion:
– Blocked affect
– Previously tested
• Allow enough time for results to sink in
• Let the clients acknowledge their fears
 Managing Emotional Responses
• Crying: Let the client cry, this allows them to vent
their feelings
• Anger: Stay calm, let the client express their
feelings, acknowledge that these feelings are normal
• No response: due to shock, denial or helplessness
• Denial: client has difficulty in accepting result
• For all responses encourage the client talk about
their feelings.
Encourage the client to ask questions
 Positive Result Provision
• Clarify misinformation about meaning of
result and it’s implications
• Assess supports available for client (refer
if necessary)
• Assess coping strategies
• Assess short-term arrangements for
leaving clinic, getting home etc.
 Positive Result Provision

• Discuss disclosing status to partner

• Provide information on:
– Health, rest, exercise, diet
– Safe sex
– Infection control issues
• Ask the client if they have any questions
• Offer follow up session
• Provide written information to read later