MINISTRY OF HEALTH / BRAZIL SECRETARIAT FOR HEALTH SURVEILLANCE NATIONAL STD/AIDS PROGRAMME (NSAP)

1. MINISTRY OF HEALTH / BRAZILSECRETARIAT FOR HEALTH SURVEILLANCENATIONAL STD/AIDS PROGRAMME (NSAP) COUNSELING IN THE USE OF ANTI-HIV RAPID TEST: THE EXPERIENCE OF THE BRAZILIAN AIDS PROGRAMME Serafim, Denise Ferraz, Dulce Chequer, Pedro Toronto, August 2006

2. CONTEXT HIV Diagnosis • Low rates of HIV testing: 2005 - 32,9%* • Late diagnosis - 5 years • Evaluation of RT algorithm for HIV diagnosis - MH/Brazil e CDC/USA** • Improvement of access to HIV diagnosis is a priority to the Brazilian National STD/AIDS Program **Berquó e Koyama, 2005 **Ferreira et al, 2005

3. CONTEXT Counseling • Highly valorized in the diagnosis of HIV and other STD • Still concentrated in specialized health facilitites (VCT centers, HIV treatment centers) • Risk evaluation and anti-HIV test offer are done in all ordinary health consultations • Adaptation to primary care facilities: possibilities and limits

4. ANTI-HIV RAPID TEST Relevance • Increase in the offer of HIV diagnosis, especially in regions of restrict access, precarious laboratory and health service networks and insuficient human resources • Improvement in the rates of people who don’t return to pick up the tests’ results • Research showing high acceptability for the RT • Recurring question – Rapid test: should counseling also be rapid?

5. IMPLEMENTATION State of Amazonas: • Biggest state in Brazil: 1.558.987 Km2 • Access: mainly by water (rivers) and air; one single road links it to the rest of the country • Diagnosis concentrated in the state’s capital • Selection: 12 municipalities and 14 health facilities

6. Brazil

7. BrazilState of Amazonas

8. STAGES • Development of specific training on counseling for rapid test - 16 hours • Elaboration of counseling protocol, considering RT specificities; • Guiding questions: - Would there be differences in performing counseling when using RT for diagnosis? - What would the main challenges be?

9. STAGES • Training for two groups of 19 and 20 people • Professional Profile - multidisciplinary team: biochemistries; social workers; psychologists; doctors; laboratory technicians; nurses • Most of the health professionals didn’t have any experience with counseling or HIV/AIDS related issues

10. STAGES Contents of training • Health professional’s perception of the new technology: reliability, availability • Concepts: counseling, vulnerability, risk • Objectives and contents of the counseling process • Particularities of the RT: what are the changes? • Dramatization of pre and post-test couseling sessions • Readings of the counseling protocol

11. STAGES • Development of instruments for monitoring and evaluating the implementation in the health facilities’ routine • - Script for counseling observation - Interviews with health professionals, facilities’ managers and patients • Monitoring visits in 12 health facilitites 4 months after implementation

12. CONSIDERATIONS FROM TRAINING The health team’s perceptions • About the health facilities: confidentiality, high demand, priority given to pregnant women • About counseling: - same as the ability to deliver a positive test result - “vulnerability” frequently interpreted as “risk” - fast delivery of test results seems to be more difficult • About training: expectations of practical contents; requests of observing a counseling session in the health facility

13. CONSIDERATIONS FROM MONITORING • Challenges of RT • “Immediate” delivery of test’s results • - health professionals feel more anxious and insecure compared to the traditional methods • - some facilities postponed the delivery to the next day • Counseling protocol: little use in the routine, besides reading and practice activities during training

14. CONSIDERATIONS FROM MONITORING Difficulties non-specific from RT: • Professionals with little or no counseling experience: - dealing with subjectivity; counseling limited to information - risk evaluation done without considering specific vulnerabilities nor the individual needs for testing - negative results permanently devaluated as opportunities for preventive approaches • Cultural and language barriers: the approach of indigenous and Spanish speaking people becomes limited

15. SOME RECOMMENDATIONS • About training • Counseling training when using RT is necessary • Technical contents: remains basically the same • Special attention for handling the anxiety associated to the delivery of the test’s results • Cases’ discussion and dramatizations should use real examples from the health professional’s daily practice

16. SOME RECOMMENDATIONS • About monitoring- is essential to: • identify the particularities of each local, facility and techinical skills • Reinforce some of the information and discuss the barriers that have been found

17. PERSPECTIVES • Process of implementation in other states - priority given to VCT centers and maternity clinics • Development of distance learning course on STD/AIDS counseling

18. LESSONS LEARNED • The use of RT technology has contributed to the debate on counseling contents, types and paradigms • The test methodology does not change the need of understanding the subjective aspects of each patient

19. LESSONS LEARNED STD/AIDS counseling remains as an important practice for prevention in health facilities and for the promotion of comprehensive health care

20. MINISTRY OF HEALTH / BRAZILSECRETARIAT FOR HEALTH SURVEILLANCENATIONAL STD/AIDS PROGRAMME (NSAP) Thank you very much! Contact: denises@aids.gov.br