HIV Counseling and Testing (HCT)

1. HIV Counseling and Testing (HCT) Unit 2 HIV Care and ART: A Course for Healthcare Providers

2. Learning Objectives • Define HCT, VCT, and PIHCT • Explain the purpose and benefits of HCT as the entry point to HIV prevention, care, and treatment • List the basic components of a HCT program and pre- and post-test counseling • Identify the skills and characteristics of an effective HCT counselor

3. Values Clarification Exercise

4. HIV Counseling and Testing • HIV Counseling and Testing (HCT) is composed of two types of testing: • VCT – Voluntary Counseling and Testing • PIHCT – Provider Initiated HIV Counseling and Testing

5. Providing HCT In High & Low Prevalence Areas • High HIV prevalence in general population, >8% • Universal access for HCT services recommended • Low HIV prevalence in general population, <1% • HCT should target high-risk groups

6. Sample Screening Test (Determine®) Neg Pos Confirmatory Test (Capillus™) Neg Pos Tie Breaker (Uni-Gold™or SeroCard™) Neg Pos HIV Testing Algorithm Source: WHO 2004

7. Parallel Test Sample Test 1 (Determine®) Test 2 (Capillus™) Neg Neg Pos Pos Tie Breaker (Uni-Gold™ or SeroCard™) Source: WHO 2004 Neg Pos

8. Knowing your HIV Status • HCT is a cornerstone for early access to prevention, as well as care and support Why? • “Think About It” exercise

9. Objectives of HCT • HCT assists individuals and couples to: • Assess their HIV risk behaviors • Develop a risk reduction plan • Discuss testing of children • Access HIV testing • Adopt risk reduction behavior • Access medical and psychosocial referral services

10. HCT: Foundation of HIV Prevention and Care ACCEPTING AND COPING WITH HIV STATUS • SUPPORT • FAMILY • FELLOWSHIP • HIV POSITIVE PEERS • LIVING POSITIVELY • NUTRITION • CLEAN WATER • REDUCED STRESS • WELLBEING • MEDICAL CARE • STI & TB TREATMENT • TB & OI PROPHYLAXSIS • PEDIATRICS HIV • DIAGNOSIS, CARE AND • TREATMENT • RISK REDUCTION • BEHAVIOR CHANGE • DISCLOSURE OF STATUS • PARTNER REFERRAL TO VCT • CONDOM ACCESS HCT • PLANNING FOR FUTURE • FAMILY PLANNING • ORPHAN CARE • FINANCIAL PLANNING • COMMUNITY INTERVENTIONS • SENSITIZATION • MOBILIZATION • DESTIGMATIZATION PREVENTION OF MOTHER TO CHILD TRANSMISSION

11. VCT Overview • Voluntary Counseling & Testing (VCT) is an HIV-prevention intervention initiated by the client at his or her free will • VCT provides the opportunity for the client to confidentially explore and understand his/her HIV risks and to learn his/her HIV infection status with the support of a counselor • VCT is composed of: • Counseling • Testing • Referral

12. VCT Models • Integrated within existing health services, i.e., general clinical care settings and specialized clinics, such as ANC, TB, STI • Free-standing VCT sites • Mobile (outreach) VCT services • Private VCT services • Youth-friendly VCT services • Workplaces

13. Seeking VCT: Logic Model Community Education Individuals/Couples/Family Want to Have HIV Test Decision to Seek Testing VCT/Pre- and Post-Test Counseling Risk Reduction Ongoing Counseling (Preventive & Supportive)

14. VCT Program Components • Type of counseling session • Individual • Couple • Family • Pre-test counseling • Introduction and orientation • Risk assessment • Discussion of testing children, if applicable • Options for risk reduction • Preparation for the test result

15. VCT Program Components (2) • HIV Test • Post-test counseling • HIV negative test result • Negotiate risk reduction plan • Support for risk reduction plan • Negotiate disclosure & partner referral • HIV positive test result • Identify source of support • Negotiate disclosure and partner referral • Risk reduction issues • Referral

16. What are the Concerns and Benefits of VCT? • To the individual • To the couple, children, and family • To the community

17. Provider Initiated HIV Counseling and Testing • PIHCT is routine, confidential, HIV testing offered to patients visiting health institutions • Routine HIV testing (opt-out) at health institutions increases access to HIV testing • Many people prefer to be tested by a medical provider within the context of a regular health care visit • PIHCT takes less time as the focus is more on post-test counseling and referral

18. Indications for Offering PIHCT • Patient reporting high risk behavior • Patient with tuberculosis • Patient presenting with STI • Symptom complex suggestive of HIV/AIDS • Pregnant women attending antenatal clinic • Patients receiving in-patient care

19. Difference between VCT and PIHCT

20. Counseling Skills for HCT

21. Counseling is a Relationship • Client and counselor both bring: • Hope • Knowledge • Questions and answers • Personal experiences

22. Seven Qualities of a Good Counselor • Self-confidence • Empathy • Acceptance • Genuineness • Trustworthiness • Confidentiality • Competence

23. Skills and Characteristics of Effective HCT Counselors • Believes that HIV prevention counseling can make a difference in preventing and controlling HIV for the individual, the family, and the community • Balances well-selected, open-ended questions with statements, summaries, and reflections that guide the session and maintain the focus on risk issues

24. Skills and Characteristics of Effective HCT Counselors (2) • Uses active listening skills • Feels and behaves comfortably when discussing specific HIV risk activities • Able to help a client develop a realistic and relevant risk reduction plan

25. Counseling Essentials • Remember to always: • Demonstrate professionalism and maintain rapport throughout the session • Convey to the client that his or her confidentiality will be strictly protected • Speak with the client at his or her level of understanding • Conduct an interactive session focused on risk reduction

26. Counseling Essentials (2) • Clarify important misconceptions, but avoid extended talk on issues not related to risk • Stay organized, and avoid counseling outside the protocol’s structure • Know that it is all right to tell the client that you will be covering something later • Avoid collecting data about the client during the counseling session

27. Questioning Skills • Acknowledge that you have heard and understood the client • Blend reflective, guiding, and directive statements with well chosen open-ended questions • Ask questions that guide the client to consider their HIV risk, risk reduction, coping, and support • Ask appropriate follow-up questions • Ask client to elaborate on unclear issues • Ask client to clarify confusing or contradictory information

28. Closing a Counseling Session • Remind client of pre-test information • Assess client’s emotional state • Give client space to ask questions • Schedule client for further sessions • Refer to appropriate services

29. Referrals • Developing linkages with other services • Referral directory of services • Referring clients • Developing a system for tracking referrals

30. VCT Client Referral VCT Client Pre and Post Test Counseling Referral NO Medical Examination (Clinical and Lab) YES ART counseling ART administration and follow up

31. Working With Couples • Make sure both partners have an understanding of HIV/AIDS • Review willingness to have HIV test • Explain the process of testing and receiving results • Discuss advantages and disadvantages of knowing results as a couple

32. Working With Couples: Making a Plan • Review options for positive, negative, and discordant results • Explore the possibility of discordant results • Identify others who may be affected by the outcome • Discuss testing their children

33. Ethical Principles • Counselors must be respectful toward the patient’s/client’s dignity and rights • Dignity • Acceptance • Non-judgment • Rights • Confidentiality • Privacy • Autonomy • Self-determination

34. Ethical and Legal Issues: Disclosure • Counselors cannot force disclosure of HIV status • To whom and when is always the choice of the patient • Can encourage the partner to have an HIV test • Can prevent the spread of HIV to the partner

35. Ethical and Legal Issues: Children • Persons 15 years-old and above can give informed consent for testing • Children under 15 years-old may only be tested with consent of their parents or guardians • “Mature minors” between 13-15 years of age are allowed to consent for HIV testing

36. Ethical and Legal Issues: Children (2) • Mature minors should be informed of their results like adults • Children 12 years-old and above should be informed after appropriate counseling, and with the involvement of their parents or guardians • Children under 12 should not be informed of results until they reach an age when they can understand and parents/guardians give consent • Counselors should carefully consider to whom they disclose results, with the child’s best interests in mind

37. Pre/Post-Test Counseling Trainer Role Plays

38. Pre-Test Counseling • What does the client understand about HIV? • What does the client understand about HIV testing? • How does this information apply to the client?

39. Pre-Test Counseling in the PIHCT Setting Trainer Role Play

40. HIV-Negative Results • Give time and space for the client to express emotions • Explore the client’s reaction • Review the meaning of the test result (revisit the window period) • Discuss prevention/risk reduction • Refer for ongoing support/counseling at appropriate site

41. Giving HIV-Negative Results Trainer Role Play

42. Giving HIV-Positive Results • Allow some time • Discuss what this means • Identify a coping strategy • Emphasize risk reduction • Link with support services

43. Giving HIV-Positive Results Trainer Role Play

44. Key Points • HCT is a cornerstone of early access to prevention, care and support • HCT is composed of Voluntary Counseling and Testing (VCT) and Provider Initiated Counseling and Testing (PIHCT)

45. Key Points (2) • VCT is a HIV-prevention intervention initiated by the client at his or her free will. • VCT provides an opportunity to individuals and couples to work confidentially with a counselor to: • Assess their HIV risk behaviors • Develop a risk reduction plan • Adopt risk reduction behavior • Access medical and psychosocial referral services

46. Key Points (3) • PIHCT is routine confidential testing of HIV offered to patients visiting health institutions by their providers • Effective counseling requires a number of qualities, characteristics and skills that can be developed and improved with practice.