Care of Women with HIV Living in Limited-Resource Settings Voluntary Counseling and Testing (VCT)

1. Care of Women with HIV Living in Limited-Resource SettingsVoluntary Counseling and Testing (VCT) Jean R. Anderson, MDDirector Johns Hopkins HIV Women’s Health Program

2. Objectives • Review reasons for VCT • Describe effectiveness of VCT • Discuss components of VCT

3. Reasons to Provide HIV Counseling and Testing • Knowledge of HIV status can benefit HIV-infected persons • Treatment and prevention of opportunistic infections • Prevention of mother-to-child transmission • Reduction of risk of transmission to others • Help in planning for the future • Access to antiretroviral therapies as these become available

4. Reasons to Provide HIV Counseling and Testing continued • Widespread availability and use of VCT can: • Reduce fear, ignorance and stigma surrounding HIV • Promote community response in support of HIV-infected individuals • Contribute to stronger community support for behavior change, such as safer sexual practices

5. Effectiveness of Counseling and Testing • Rwanda1 • VCT in urban Rwandan women • Decrease in GC prevalence from 13% to 6% (p < 0.05) • HIV seroconversion rates decreased significantly from 4.1 to 1.8 per 100 person-years (p < 0.04) in women whose partners also received VCT • Democratic Republic of the Congo (formerly Zaire)2 • VCT in serodiscordant couples • Increase in consistent condom use from < 5% to > 70% • Low rate of HIV seroconversion — 3.1 per 100 person-years Source: 1Allen 1992 2Kamenga 1991.

6. Effectiveness of Counseling and Testing continued • India1 • VCT heterosexual men attending STI clinics • HIV sero-incidence at baseline estimated at 18% per year • After VCT HIV seroconversion rate 6.1 per 100 person-years and reduction in sexual risk behavior • Thailand2 • HIV-positive individuals reported fewer sex partners and more consistent condom use after VCT than HIV-positive persons who did not know their status Source: 1Bentley 1998 2Muller1995.

7. Effectiveness of Counseling and Testing continued • Kenya, Tanzania, Trinidad • Randomized clinical trial of VCT versus health education alone • Sexual risk behavior significantly reduced in VCT group compared to health education only • HIV-positive individuals more likely to show significant changes in behavior Source: Lancet 2000.

8. Cost-Effectiveness of VCT • Cost per disability-adjusted-life-year (DALY) saved1: • $13 in Kenya • $17 in Tanzania • Comparison to other health interventions (per DALY saved) • Management of sick child — $30–50 • Measles immunization — $12–17 • Polio, diphtheria, pertussis, tetanus immunization — $20–40 • Treatment of acute respiratory infection — $12–50 • World Bank recommends interventions costing up to $50 per DALY saved. 1 Costs cited are in US dollars.

9. Factors That Increase Effectiveness of VCT Programs • Nonjudgmental and supportive attitudes • Interactive counseling • Eye contact • Open-ended questions • Using language which is easily understood and non-offensive • Target individual personal risk behaviors • Couple involvement in counseling and testing

10. Important Elements of HIV Counseling and Testing • Private • Voluntary • Confidential • Culturally sensitive • Requires informed consent

11. General Components of VCT • HIV information, including addressing false rumors and myths • Prevention counseling, including safer sex counseling • Diagnostic tests • Referral for further care and support, as needed

12. Development of Community Awareness Decision to attend for testing Pretest counseling HIV information The test process and implications of testing Risk assessment Prevention counseling Assess coping strategies Decision to test No Yes Post-test counseling HIV-negative News given Risk profile reviewed Prevention counseling reinforced Identify support for risk reduction HIV-positive News given Emotional support Assess risk for abandonment and abuse Discussion about referral for care Discussion about disclosure of HIV status Prevention of HIV transmission Source: UNAIDS Technical Report 2000. Followup counseling and support as required

13. Settings That Serve Individuals Who May Be at Risk for HIV • Sexually transmitted infection (STI) clinics • Postabortion care clinics • Adolescent clinics • Drug and alcohol treatment centers • Tuberculosis (TB) clinics • Prisons • Clinics targeting men who have sex with men • Family planning clinics • Antenatal care clinics

14. HIV Information • What is HIV? What is AIDS? • Information about HIV transmission and prevention • Address myths and misconceptions about HIV and AIDS • Benefits of HIV testing • Information about HIV testing • Meaning of test results • Importance of obtaining test results • Where to obtain further information or services

15. VCT During Pregnancy: Special Counseling Issues • Impact of HIV on pregnancy • Risk of mother-to-child transmission (MTCT) • Interventions to decrease MTCT • Information on antiretrovirals, if available • Infant feeding options • Screening and treatment of STIs • Disclosure issues • Use of condoms • Infant care issues • Pregnancy termination option, if legal and safe

16. Prevention Counseling • Helping the individual identify and acknowledge her personal risks for HIV • Help individual set and reach a specific behavior change goal that will prevent acquisition or transmission of HIV • Barriers to change • Skill-building exercises

17. Age < 25 yrs Single Sexual behavior: woman or partner More than one partner in last 3 months Multiple partners New or casual partner Mobile population Refugee Husband in military or long distance truck driver STIs: woman or partner History Signs or symptoms History of substance abuse Pregnant History of TB Sex worker Signs or symptoms suggesting HIV Risk Assessment

18. Signs and Symptoms That May Suggest HIV • Oral thrush • Fevers of unknown cause • Chronic diarrhea • Significant weight loss • Generalized enlarged lymph nodes

19. Other Conditions That May Suggest HIV • Tuberculosis • Cervical cancer • Cytomegalovirus infection • Cryptococcosis • Kaposi Sarcoma • Genital herpes simplex virus infection – especially if chronic, severe and/or frequently recurring

20. Personalized HIV Risk Assessment • Condom use • High-risk sexual partners • High-risk sexual situations • Drug use • Alcohol use • Sexual coercion or assault • Injection drug use practices including sharing of drug equipment

21. HIV Testing: Antibody Detection • Serum or plasma • Screening EIA • Confirmatory Western Blot • Sensitivity/specificity > 99.9% • Rapid tests • Results generally available in 10-15 minutes • Sensitivity 99.9%, specificity 99.6% • Simple, inexpensive • Positive results need confirmation • Alternative specimens – saliva, urine • Positive results need confirmation

22. HIV Testing: Viral Detection • Culture • DNA-PCR – HIV detection in newborns, acute retroviral syndrome • RNA-PCR – prediction of progression, therapeutic monitoring • Expensive and labor intensive

23. HIV Testing: Special Issues • “Window period” • HIV-2 • Rapid test • Consent issues • Special counseling needs

24. Meaning of HIV Test Results • Positive • Should be considered positive only after both screening and confirmatory tests are positive • Indicates that a person is infected with HIV • Negative • Indicates absence of HIV infection • Special considerations • Window period • HIV-2

25. Meaning of HIV Test Results continued • Indeterminate • Reactive EIA and indeterminate Western Blot • May represent: • Evolving HIV antibody response in infected person • Nonspecific reactions in serum from uninfected person • Infection with HIV-2 or different HIV-1 strain • Repeated indeterminate test results at least 1 month apart do not represent HIV infection (in absence of recent and ongoing risk behavior)

26. VCT and its links with other services VCT as an Entry Point for Prevention and Care Prevention Acceptance ofserostatus Provision ofmaternity services Reproductivehealthcare Planning for the future Peer, social, &community support Access to early medical care Source: UNAIDS Technical Update 2000.

27. Important Points to Consider • In higher HIV prevalence settings and in clinics serving clients at increased behavioral risk for HIV, offering testing based on reported risk factors will miss many individuals with HIV • In lower HIV prevalence settings, targeting services to higher risk groups should be a priority • A negative HIV test result does not mean the individual is not at risk for HIV or cannot become HIV-infected

28. Important Points to Consider continued • Drug (injection and noninjection) and alcohol abuse increase the risk of sexual transmission of HIV • Positive prevention messages are important because the majority of individuals, even in areas with high prevalence, are not infected

29. Barriers to VCT • Concerns about confidentiality • Stigma • Abandonment • Abuse • Discrimination • Fear of positive results • Lack of perceived benefit in knowing HIV status

30. Barriers to VCT continued • Lack of perceived risk for HIV • Inability to change sexual behavior • Communication difficulties • Lack of power in decision-making • Desire to have children • Economic dependence on money or goods obtained in exchange for sex

31. Summary • VCT shown to reduce risky behaviors • Knowledge of HIV status benefits both HIV-infected and uninfected persons • VCT should be voluntary and confidential • VCT should include information about HIV and personalized prevention counseling • Barriers to VCT must be acknowledged and confronted