Experience of MARPs with HIV testing

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Experience of MARPs with HIV testing
counselling in Asia Pacific region

• Bill OLoughlin

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Source of information

• Literature review
• Documentation reports etc
• Key informant interviews
• Field trips
• Structured around papers supported by
  interviews. Not a formal review of Gov't policies
  programs.

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Small amount of documentation

• Small number of peer reviewed published papers
  with significant attention to TC in this region
• Small number of reports, documents etc
• Nothing on Pacific
• Increase in information in recent years - but
  still indicates history of neglect, lack of
  attention to topic of TC still significant
  problems with quality of TC services

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Overview of Presentation

• 3 Cs consent, confidentiality, counselling
• Factors affecting access to T C
• Specific MARPs Female CSWs, IDU MSM
• Recommendations - main

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3Cs

• Informed consent
• Confidentiality
• Counselling
• Pre-test
• Post-test

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Informed Consent

• Poor understanding of rights of people/patients
  people dont assert themselves, HCWs practices
  not challenged
• Guidelines on TC VCT not followed e.g.
  routine testing pregnant women without informing
  them
• Compulsory testing groups/settings policy e.g.
  IDU rehab, custodial

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Confidentiality

• Widely disregarded commonly known
• Causes lack of trust of health system staff
  Value of using health services Vs fear of HIV
  stigma/discrimination not come for services
  including testing
• Training of HCWs monitoring practices with
  client input leads to improvement

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Counselling

• Foreign concept practice to HCWs clients
• A set of questions rather than encouraging client
  to decide and learn not health education
  encouraging behaviour change
• Popularity of peer based approaches
• Lack of empathy, information in result giving
• HCWs lack skills need training, models, ME

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Pre-test counselling

• General focus on preparation for results
• Insufficient attention on information
  especially myths/misconceptions, on preventing
  transmission

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Post-test counselling

• Common failure to properly counsel a positive
  diagnosis
• Little sexual health information
• Poor information on treatment, prevention MTCT
• Discomfort HCWs with MSMno discussion sexual
  transmission male/female partners
• HIVve women not informed family/husband told
  instead

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Outcome of ve result

• Low rates return for results fear HIV stigma,
  also low general education level/HIV knowledge
• Stigma sex work/IDU/MSM interact with HIV
  creates powerful fear of knowing coping with
  HIV status

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Factors affecting access to TC
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History of lack of attention to TC, especially
at National levels

• National level no national forum, little
  support for guidelines, lack central service
  technical capacity, lack models/trials on TC
• Slow roll out of VCT services including few
  anonymous free sites
• Little known about peoples testing behaviour,
  acceptability of models/approaches

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Attitude of TC provider

• Doctor/Patient relationship imbalance of
  respect/deference. Drs expect to be obeyed not
  questioned. Few people refuse test if Dr suggests
• HCWs have low knowledge of HIV, including many
  misconceptions, also own fears of HIV
• Quality of public health system influences HCW
  capacity attitude resources/training

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Level of basic HIV knowledge

• Low levels of basic comprehensive knowledge on
  HIV can have HIV education still keep
  misconceptions
• Poor education about level of risk e.g. in high
  prevalence areas/groups
• Knowledge influences willingness to be tested
• Increased HIV knowledge less stigma

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Care after testing

• People will go for testing if they can see they
  will be cared for afterwards
• Local HIV care support poorly developed
• Limited access to ARV
• Access to health care already difficult for
  MARP due to stigma, cost, bureaucracy etc
• Often a ve diagnosis only causes increased
  stress Thai CSW NGO

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Stigma Discrimination

• Accounts of death murder/suicide show HIV
  stigma real
• Sex work/IDU/MSM stigma already HIV adds to
  this
• Involve PLWHA in health/education systems
• Dynamic link stigma HIV attitudes to testing
  reduce stigma increase testing make testing
  more attractivereduce stigma of HIV

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Stigma Discrimination cont

• Comparative lack of attention to effective
  strategies to reduce SD
• PLWHA initiatives late/under-resourced
• SD programming limited budget/limited
  understanding of/lack of capacity building/ME
  for real impact

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Women HIV TC

• Lack of knowledge perception of risk e.g.
  pregnant women ignorant of MTCT prevention of
  women in high risk areas unaware of risk
• Gender husbands permission for health service
  use, fear reaction if ve, education levels
  influence willingness be tested
• Overall strategies must address gender context

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Specific MARPs

• Female commercial sex workers
• MSM
• IDU

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Female Commercial Sex Workers

• Limited attention to studies on FCSWs TC
• Nothing on male clients.
• Treated as vectors of transmission not as people
  with occupational, sexual/reproductive health
  concerns
• Limited understanding of the factors that
  influence their use of TC services
• General failure to have properly provided VCT to
  FCSWs

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Men who have Sex with Men

• Few studies on MSM TC MSM HIV
• Little MSM HIV education low awareness of HIV
  risk amongst MSM few testing
• High levels discrimination in health system
  discomfort HCW, fear in MSM
• Higher interest/rates of testing if accepting of
  sexual social identity if access to MSM
  friendly services

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Injecting Drug Users

• Lack of knowledge about IDU TC although
  studies on risk behaviours no research on
  experiences of testing2006
• Unlikely that IDUs see TC as worthwhile
  context their lives social political meanings
  of drug use stigma discrimination of drug use
  HIV lack confidentiality poverty
  disincentives to use health services poor
  HIV/TC services no drug/HIV treatment

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Recommendation

• Need National Testing Counselling strategies
  policies guidelines, pilot models, resources
  available for implementation, capacity
  development, data collection ME.

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Recommendation

• Comprehensive HIV education for all especially
  MARPs addressing all aspects HIV transmission
  and treatment, ensure attention to
  misconceptions, and place HIV risk in local
  context.

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Recommendation

• For MARPs ensure affordable local good quality
  care and support, designed for comprehensive
  approach to specific health promotion, prevention
  and treatment needs of these populations as
  this will influence their willingness to be
  tested.

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Recommendation

• To improve testing practices of MARPs it requires
  attention to the structural barriers created by
  the stigma and discrimination associated with
  the factors or behaviours that make them
  vulnerable to HIV - finding effective
  strategies to remove or reduce them.

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Recommendation

• Provide resources and capacity development to the
  health system staff, systems, resources
  medicines - to properly provide VCT. Develop
  models that involve peers/PLWHA in service
  delivery. Ensure ongoing training, quality
  control ME.

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Conclusion

• TC VCT not been supported in region
• Quality of VCT been poor
• Reasons for guidelines consent,
  confidentiality, counselling still powerfully
  inhibit or motivate people re testing
• Consequences of inappropriate HCW attitude
  information in giving HIVve diagnosis, lack of
  care support can be severe life threatening,
  facilitate spread of HIV.