Clinicians or Counselors Challenges to the Scaleup of ProviderInitiated HIV Testing and Counseling

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Clinicians or Counselors? Challenges to the
Scale-up of Provider-Initiated HIV Testing and
Counseling
Alison Surdo, HIV Counseling and Testing Advisor,
USAID
October 2007 USAID Mini-University asurdo_at_usaid.go
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Outline

• Evolution of HIV Counseling and Testing
• Why Health Facilities
• Why Provider-Initiated Testing and Counseling
• Why Opt-out
• Acceptability
• Challengeswhat are we seeing in the field?
• Personnel
• Space
• Three Cs
• Cost
• Linkages to care
• Role of PITC in prevention
• Guidelines

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Evolution HIV Counseling and Testing

• HIV counseling and testing (HCT) was initially
  scaled up in Africa as a prevention intervention
  known commonly as VCT
• As different models for HIV counseling and
  testing have been developed, HCT has come to
  represent a range of interventions and approaches
  
• Traditional VCT focuses on walk-in clients and
  offers an individualized counseling session,
  tailored to personal risk behaviors
• Post-test counseling focuses on risk reduction
  and positive living

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Evolution of HIV Counseling and Testing (2)

• Typically, uptake of VCT is low
• In Sub-Saharan Africa, 12 of men and 10 of
  women have been tested and received results
• In the era of expanded access to prevention,
  care, and treatment, significant scale up of HCT
  is necessary to increase the percentage of
  persons who know their HIV status

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Why Health Facilities

• High prevalence, missed opportunities
• Health facilities represent a key point of
  contact with those most in need of HIV services
• 30-70 of TB patients in sub-Saharan African
  countries are co-infected with HIV
• Up to 30-50 of STI patients are co-infected with
  HIV, depending on the country and STI
• In high-prevalence countries, HIV prevalence in
  hospital wards can be over 60
• Yet there are many missed opportunities
• In Uganda, among adults offered HIV testing in a
  hospital, 83 were unaware of their HIV status,
  even though 88 had been to a health unit in the
  past 6 months (Nakanjako, 2006)

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Why Provider-Initiated Testing and Counseling
(PITC)

• Providers need HIV diagnosis in order to provide
  quality care for their patients
• Very low uptake of HIV testing when patients are
  referred from a clinic to VCT site
• Poor data transfers/monitoring between VCT sites
  and clinics

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Why Opt-Out

• Patients often decline an HIV test when asked to
  give separate consent (opt-in approach)
• Opt-out consent means that consent for an HIV
  test is included in consent for other medical
  carepatients are informed that the HIV test is
  routinely offered and that they have the right to
  decline
• Opt-out consent is still voluntary

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Acceptability of PITC

• Acceptability and uptake for PITC in healthcare
  facilities appears high in industrialized
  countries (Obermeyer, 2007)
• Acceptability and uptake of HIV testing in
  antenatal clinics in number of low-income
  countries has been high (Bolu, 2007)

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Where to Provide PITC

• All epidemics (concentrated and generalized)
• STI clinics
• TB clinics
• MCH/PMTCT settings
• Generalized epidemics
• In-patient wards
• Out-patient departments or primary health care
  clinics

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PITC What it IS and what it is NOT

• PITC is
• Routinely offered within a clinical setting by a
  healthcare provider
• Offered to all new patients within that clinic
• Informed consent with pre-test information
• Ensured confidentiality of test results
• Results with appropriate post-test counseling
• PITC is not
• Provider recommending a patient go to VCT
  (offsite or co-located)
• Mandatory
• Providing testing without the three Cs Consent,
  Confidentiality, Counseling

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Challenges
What are we seeing in the field?
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Clinicians as VCT Counselors?

• Without specific protocols or training materials
  for PITC, countries use VCT materials to train
  health care workers
• This is problematic because
• VCT and PITC have different purposes and focus
• VCT is more time-consuming than PITC, not
  feasible in busy clinical settings
• VCT training is lengthy and in-depth

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Role of Lay Counselors

• In many busy clinical settings, lay counselors
  can play a role in PITC
• Lay counselors can provide high quality services
• The use of lay counselors is linked to higher
  proportion of patients receiving HIV testing
• Lay counselors can provide a range of counseling
  support functions at health facilities
  adherence, disclosure, nutrition

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Space

• Many busy clinical settings are already space
  constrained
• Where should counseling take place?
• Balance needed between privacy and feasibility
• No one-size-fits-all approach, but the
  recommended client flow is for patients to
  receive PITC either between registration and
  clinical consultation, or within the clinical
  consultation

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Linkages to other HIV Services

• Linkages to HIV care and treatment should be
  facilitated by PITC
• Referrals needed for other prevention and support
  (e.g. VCT sites, prevention with positives
  programs, post-test clubs)
• Referrals for HCT for sexual partners and family
  members
• Referral monitoring/follow up needs to be
  strengthened

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Monitoring and Reporting

• Implementation of PITC is difficult to
  standardize due to variable hospital or clinic
  conditions
• Countries do not have recording systems in place
  for PITC
• Leads to either informal record keeping or use of
  VCT record systems for PITC
• Standardized data collection systems are needed
  for PITC
• Monitoring and Evaluation guidelines needed for
  PITC

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Cost

• Costs with PITC include staff training, cost of
  tests, cost of quality control measures
• Little data is available on the cost
  effectiveness of PITC
• Cost effectiveness is related to goals of PITC
  program increasing those in care and treatment,
  infections averted, or both?

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Role of PITC in Prevention

• Traditional VCT model has some prevention
  benefits, and there should be population level
  benefits to scaling up HCT
• Yet PITC significantly reduces the amount of
  individualized counseling
• Can PITC serve two goals?
• Identifying those most in need of care,
  treatment, and support
• Prevention of HIV infection/transmission

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Available Guidance
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Available Guidance (2)

• Several countries have either developed national
  PITC guidance or incorporated it into their
  national VCT guidance
• WHO/PEPFAR developing updated Monitoring and
  Evaluation Guidelinesincluding VCT and PITC
• WHO/CDC is developing a Provider-Initiated HIV
  Testing and Counseling in Clinical Settings
  training package

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Resources

• WHO PITC Guidelines
• http//www.who.int/hiv/en/
• CDC MMWR on Routine Testing in Health Facilities
  
• http//www.cdc.gov/mmwr
• UNAIDS Reference Group on HIV and Human Rights
• http//www.unaids.org/en/