Approaches to HIV Counselling and Testing: Strengths and Weaknesses, and Challenges for the Way Forward

Heidi van Rooyen, Linda Richter, Thomas J. Coates, and Merridy Boettiger

12.1 Introduction

South Africa has the highest rates of HIV infection of any country in the world. The two main goals of the National Strategic Plan on HIV & AIDS and STIs, 2007–

2011 (NSP) are to reduce the incidence of new HIV infections in South Africa by half by 2011 and to ensure that at least 80% of those who are already HIV-positive have access to treatment (National Department of Health, 2007). Knowledge of HIV status is considered critical for both these prevention and treatment goals. Once an individual has been tested for HIV, prevention can be reinforced and referral made to available treatment, care and support services. A potential added benefit is that increasing the number of people who know their HIV status through expanded access to HIV counselling and testing may also result in a decrease in HIV-related stigma, leading to a “normalisation” of the HIV epidemic (Anderson, 2006; De Cock et al., 2002).

12.1.1 Current Availability and Use of CT Services in South Africa

HIV counselling and testing has become increasingly available in South Africa in recent years, with 2,369 facilities providing CT in 2004 (UNAIDS, 2006). While CT has been shown to be an effective method of HIV prevention and is a critical point of entry into HIV treatment, care and support services among persons who are HIV- positive, and despite increasing availability at public health and non-governmental sites in South Africa, uptake of CT remains low (Metcalf and van Rooyen, 2008). Recent studies have estimated that fewer than 20% of South Africans have been tested for HIV and are aware of their HIV serostatus (Pettifor et al., 2004; Shisana and Simbayi, 2002). Moreover, only one in five South Africans who are aware of CT have actually used the services that are available to them (Kalichman and Simbayi,

2003).

P. Rohleder et al. (eds.), HIV/AIDS in South Africa 25 Years On,

DOI 10.1007/978-1-4419-0306-8_12, ∗C  Springer Science+Business Media, LLC 2009

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12.1.2 Reasons for and Barriers to CT Uptake

Reasons for the low uptake of CT services exist at the individual level, as well as at the broader institutional and structural levels that influence individual behaviour. Personal factors include fear of testing positive for HIV and the ramifications of a positive test, as well as fears of stigmatisation, disease and death (Day et al., 2003; Kalichman and Simbayi, 2003; UNAIDS, 2001). HIV prevalence surveys also indi- cate that self-perception of risk of HIV infection is low (Shisana et al., 2005) and that this could contribute to the poor uptake of CT services.

In South Africa, system factors that limit CT uptake include a general lack of trust in the health-care system (van Dyk and van Dyk, 2003); perceptions of lack of confidentiality of CT services (Coovadia, 2000); fear of being discriminated against by health-care workers; and fear of disclosure of one’s HIV-positive status to sex partners (van Dyk and van Dyk, 2003).

Real and perceived stigma and discrimination remains the biggest barrier to widespread implementation of CT in many high-prevalence developing contexts. In particular, there is evidence that for many women, fear of violence is a major barrier to testing and to disclosure of HIV status to sexual partners (Maman et al.,

2001; Taegtmeyer et al., 2005).

The low uptake of CT in South Africa suggests weak or absent social norms pro- moting the knowledge of one’s status. Norms supporting knowledge of status appear to be undermined by beliefs about the negative consequences of knowing one’s HIV status, as well as the conviction that there is nothing to be done if infected by the virus – a form of “HIV/AIDS-related fatalism” – noted by Leclerc-Madlala (1997).

12.1.3 The Need to Scale up CT

A growing awareness of the importance of knowledge of HIV status and increased access to treatment has sparked debate about how to scale up CT in high-prevalence, resource-constrained countries with generalised epidemics, such as South Africa. The gap between those who should know their HIV status and those who do know their status has consequences for public health efforts to redress the HIV epidemic. All individuals, and in particular high-risk individuals, who are not aware of their HIV status but continue unsafe sex practices are major drivers of new infections. In addition, those who are infected with HIV but do not know their status, are not linked to the necessary prevention, treatment and support available to them (Swanepoel, 2004); these services can prolong health and help prevent the spread of infection to others.

12.2 Client-Initiated Counselling and Testing or VCT

The current standard of client-initiated counselling and testing – a voluntary, rights- based encounter – is typically an individual intervention consisting of two coun-

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selling sessions performed before and after a (usually) rapid HIV test. The approach referred to as client-initiated counselling and testing (CICT) is also known as vol- untary counselling and testing (VCT). By combining personalised counselling with knowledge of one’s status, VCT is an opportunity to motivate people to change their behaviours and prevent transmission of the virus (Denison et al., 2008; Swanepoel,

2004).

12.2.1 Evidence Supporting VCT

A two-session HIV-prevention counselling model with a strong risk-reduction focus (the risk reduction model) has been evaluated extensively in several international and developing contexts and found to be acceptable to clients and counsellors and feasible for use in busy public clinic settings (Kamb et al., 1998; Metcalf et al.,

2005; Voluntary HIV-1 Counselling and Testing Efficacy Study Group, 2000). Pre- dominant counselling models in Africa (such as the Egan model in South Africa and The AIDS Support Organization [TASO] model from Uganda) are less struc- tured to achieve behaviour change than the risk reduction model. There have been some efforts to train national, provincial, district and local service providers in South Africa in the risk reduction model, including in research trials (such as Project Accept, also known as HPTN 043, discussed later in this chapter), but there is as yet no widespread implementation.

Several reviews and meta-analyses of VCT studies in international and devel- oping contexts suggest that the evidence for behaviour change following VCT is strongest among sero-discordant couples tested together and among HIV-positive individuals, particularly with their non-primary partners (Denison et al., 2008; Hig- gins et al., 1991; Kamb et al., 1998; Metcalf et al., 2005; UNAIDS, 2001; Volun- tary HIV-1 Counselling and Testing Efficacy Study Group, 2000; Weinhardt et al.,

1999; Wolitski et al., 1997). The effectiveness of VCT as a prevention strategy for HIV-negative people, as well as the long-term preventive effects of VCT for all testers, remain unclear (Higgins et al., 1991; UNAIDS, 2001; Weinhardt et al., 1999; Wolitski et al., 1997).

Counselling of couples and/or partner testing appears to be effective in altering risk behaviour, and more effective than individual counselling when the two are compared (Allen et al., 1992; Kamenga et al., 1991; The Voluntary HIV -1 Coun- selling and Testing Efficacy Study Group, 2000; van der Straten et al., 1995). While efficacy studies have shown that counselling couples together results in significant behaviour change, less than 1% of couples in Africa have been tested together (Kamenga and Sangiwa in the International Counselling and Testing Workshop Report, 2008). The reason for this low uptake is that individuals appear reluctant to disclose their status to their partners. This represents a dilemma since disclosure of their results to each other is one of the key prevention benefits of couples coun- selling over individual testing approaches.

Reviewers have identified various ways in which people come to CT: i.e. self- referred, provider or researcher referred. Weinhardt et al. (1999) showed that greater

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behaviour change occurred among participants who actively sought counselling and testing compared to those who were approached by researchers. Denison et al. (2008), in a recent review of VCT studies in developing countries, point out that given the current debates regarding scaling up CT services, we need to better under- stand how these variations in the implementation of VCT impacts behavioural out- comes.

The supportive goals of VCT – more associated with counselling than the other CT approaches that follow – are to help reduce the psychological and social mor- bidity associated with HIV disease (Allen et al., 1999). Research shows that VCT assists people to cope with a range of psychosocial sequelae associated with an HIV-positive diagnosis (Baggeley, 1997; Krabbendam et al., 1998; Lie and Biswalo,

1994; 1996). Findings from a prevention of mother-to-child-transmission study in South Africa highlight the role that VCT played in helping women manage poten- tially negative reactions of spouses or family members, and also in encouraging partner support, co-counselling and HIV testing (Chopra et al., 2004).

While VCT is an effective prevention strategy for HIV-positive clients and couples, it is but one component of HIV prevention interventions. Its effectiveness is likely to be increased when it is integrated and combined with other prevention services. VCT should be viewed in the context of “Highly Active HIV Prevention” that acts as a “gateway to biomedical prevention strategies, can diagnose and link people to treatment, and is also necessary to fulfil the human right of access to life saving information” (Coates in International Counselling and Testing Workshop,

2008, p. 6).

12.2.2 Criticism of VCT

In recent years, VCT in its current two-session format has come under strong criti- cism. The argument is that in the busy health-care settings where most counselling and testing takes place, the informed consent and counselling components typically accompanying HIV testing create a service delivery “bottleneck” (De Cock et al.,

2002). Consequently, this limits the number of people who are tested, and poten- tially restricts the number of people who could be accessing treatment.

There have been some adaptations of the standard two-session individual VCT model in South Africa. For example, in antenatal clinics, the individual pre-test ses- sion has been converted into a group information session with a shorter individual session used to obtain individual consent for testing. It is clear that consideration needs to be given to the utility of different modalities for providing VCT in medi- cal settings in order to ease the time and resource burden of providing VCT in its current format.

12.2.3 Innovative Approaches to VCT Are Required

To reach the goals of the NSP requires approaches to counselling and testing that are radically different in orientation than VCT as practiced in health-care settings. VCT

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as a health-service-based approach requires users to come to the service and involves significant investment of time, effort and resources – all of which may act as disin- centives and barriers to HIV testing. Novel and innovative approaches to CT, which take services to people (in either their homes or via mobile facilities), have been developed in response to the aforementioned weaknesses of service-based models of VCT. These approaches are offered in locations easily accessible to people and have the potential to reach a range of target groups – men, all women, young people, and possibly couples – not easily accessed by the service-based VCT model.

Some of the different types of CT approaches being used in South Africa, and in other African countries with generalised HIV epidemics, are summarised in Table 12.1.

12.2.3.1 Home-Based VCT

The Rakai research project in Uganda has offered home-based VCT as part of its sentinel surveys in that country since 1990 (Matovu et al., 2002). The approach of offering CT in the homes of participants, whether as part of sentinel surveys or as part of general CT services, is gaining in popularity. Home-based VCT involves taking both counselling and phlebotomy staff to participants’ homes, where the CT service is offered.

12.2.3.2 Evidence that Home-Based VCT Is Effective

Matovu et al. (2002) show that home-based testing in Uganda has contributed to doubling the number of people accepting and receiving VCT in the 6 years prior to 2002. In another study in rural Uganda, Wolff et al. (2005) demonstrate that home-based testing increased uptake from 10% to 36.7% in all age groups 15 years and older. While the total uptake increased from 13.1% to 46.3% in adults aged

25–54 years, there was a marginally significant difference between uptake in men and women in this age group. Women in this age group showed an uptake from

10.5% to 44.4% and men in this age group showed an uptake from 17.6% to 49%.

Both Ugandan studies found that home-based testing was generally acceptable to adults in the household. Focus group discussions in the Wolff et al. (2005) study revealed that participants preferred home-based testing because it was more conve- nient; the tester was not at risk of being seen waiting for his results at high-visibility public facilities (which could lead to stigmatisation); and the vulnerability a per- son felt in receiving results in more public spaces, such as clinics, was reduced. Fylkesnes and Siziya (2004) found that ease of access may have been a contributory factor to the marked difference they found in acceptability between clinic-based and home-based VCT in Zambia.

12.2.3.3 Criticism/Concerns About Home-Based VCT

Home-based testing was found to be less effective amongst adolescents. Young peo- ple appeared reluctant to access CT services in the home because of concerns that

Table 12.1  Summary of different counselling and testing approaches

Model/approach                   Key features                              Advantages/benefits                  Disadvantages/concerns            Additional considerations

Client-Initiated Counselling and Testing

(also known as Voluntary Counselling and Testing [VCT])

Provider-Initiated

Counselling and Testing

• HIV testing requested

(initiated) by the client.

• Provided in a variety of fixed health facilities (including primary health-care clinics) as well as at stand-alone counselling and testing facilities.

• HIV testing recommended

(initiated) by a

• Evidence of behaviour change among HIV-positive individuals, particularly with their non-primary partners

• Evidence of reducing risk

behaviour among serodiscordant couples

• Couples-based counselling is

more effective than individual counselling

• Can help tester manage

psychosocial consequences associated with an

HIV-positive result

• Improves uptake of testing services

• Time devoted to informed consent and counselling services can create a service delivery “bottleneck,” limiting the number of people testing

• Limited data about behavioural outcomes

• Has been adapted in some settings to convert individual pre-test counselling component into a group information session (in conjunction with a shorter individual informed-consent session)

• In South Africa, widely used as part of prevention of

(PICT)

health-service provider.

• Facilitates earlier referral and  • Concerns around

mother-to-child transmission

(also known as “Routine Counselling and Testing”)

PICT “opt-in”: clients actively choose to be tested

PICT “opt-out”: onus is on the client to refuse testing

access to care

• May be more acceptable to women in antenatal settings because it focuses on the benefit to the child

• Evidence of acceptability and feasibility in a range of African settings

psychosocial impact given limited counselling in some contexts

• May act as a barrier to

accessing health-care services if individuals fear pressure to test

(PMTCT) programmes.

• Careful measures need to be taken to ensure that the principle of informed and voluntary consent is not violated.

Table 12.1   (continued)

Model/approach                   Key features                              Advantages/benefits                  Disadvantages/concerns            Additional considerations

Home-based CT                   • HIV counselling and testing is conducted in people’s homes

• Convenient for the tester

• Eliminates the visibility and potential stigma associated with clinic-based testing, where the tester risks being seen waiting for his/her results

• Adolescents express concern that the arrival of the service provider in the home will generate speculation and questions from family members regarding their status

• Working with young people requires careful consideration of factors like age-of-consent, parental involvement in the decision to test, and confidentiality and coercion

• Provides access to individuals • May be unacceptable for

Mobile VCT                         • Provides counselling and testing services in tents and

in rural areas lacking VCT

services

• Reduces opportunity costs associated with

couples with conflicting attitudes about testing or concerns about disclosure

• Lack of privacy in urban

settings

• High operational costs

• Concerns about privacy and anonymity

• Issues of stigma need to be addressed

caravans situated at

facility-based VCT – ease of  • Fear of being labelled HIV

convenient locations in the community

access, convenient locations and operating times

• More acceptable to youth,

men and women not reached by standard VCT services

positive

• High operational costs

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the arrival of the service provider would generate speculation and questions from other family members who might demand to know their status (Matovu et al., 2005; Wolff et al., 2005). In order to address these service barriers identified by young peo- ple, the Rakai group was considering implementing a community-based adolescent health and CT promotion programme as well as youth counselling centres placed in convenient locations in the community. In scaling up CT for young people in devel- oping countries, issues such as age of consent, parental involvement in decisions to test, confidentiality and coercion to testing will vary and merit careful consideration (Family Health International, 2002; Family Health International/YouthNet, 2002).

Wolff et al. (2005) found that home-based testing was less acceptable for couples who may have conflicting attitudes about testing or those who were afraid that dis- closure may result in abandonment and/or marital problems. Other implementation issues relate to the potential lack of privacy of the model in busy urban settings as well as the high operational costs involved in taking services to people, i.e. travel costs, and the establishment of counselling offices in the field (Matovu et al., 2005). However, researchers conclude that providing results in people’s homes, if resources allow, remains one of the best ways of bringing services nearer to the people, par- ticularly those in the rural communities with no easy access to VCT (Wolff et al.,

2005).

12.2.3.4 Mobile VCT

As mentioned above, young people cite concerns about privacy and confidential- ity, cost and access to services as a barrier to CT service usage (Family Health International, 2002; Matovu et al., 2002). Mobile CT involves the provision of CT services through tents or caravans or other temporary accommodation at convenient locations in the community and may address some of the identified barriers to HIV testing for various hard-to-reach groups. In South Africa, Society for Family Health has increased CT uptake amongst young men by offering mobile services in busy urban areas, such as train and bus stations, shopping malls, churches and workplaces (International Counselling and Testing Workshop Report, 2008).

12.2.3.5 Evidence that Mobile VCT Is Effective

Two feasibility studies in Zimbabwe (Morin et al., 2006) and Thailand (Kawichai et al., 2007) evaluated the feasibility and acceptability of a mobile VCT interven- tion. The services provided at study sites included mobile VCT and same-day results, along with HIV/AIDS education. Both studies reported high uptake rates of testing. Morin et al. (2006) showed that mobile VCT seemed to attract a range of target groups to the service: women at high risk of contracting HIV from their partners; men who abused alcohol and used the services of commercial sex work- ers; and people who had identified symptoms of HIV such as illness and weight loss. In Thailand, more than 50% of the participants came for testing because they felt that they needed to know their status; whilst just under half of these felt they needed to test as they had recently engaged in risky behaviours. More than half of

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the participants also reported that the reason for accessing the mobile VCT service was because it was free and convenient (Kawichai et al., 2007).

The results from the feasibility and acceptability studies conducted in Zim- babwe and Thailand are borne out in the larger intervention trial – Project Accept HPTN 043 – that is currently underway. Project Accept, a large-scale and poten- tially groundbreaking HIV/AIDS prevention trial, is a multi-country community randomised controlled trial in 34 communities in Africa (in South Africa, Tanzania, and Zimbabwe) and 14 communities in Thailand (Genberg et al., 2008; Khumalo- Sakutukwa et al., 2008). The study aims to test, with recent HIV incidence as the endpoint (together with reports about behaviour and attitudes), the comparative advantage, including cost-efficacy, of two approaches to HIV prevention using VCT.

Project Accept suggests an exciting alternative model to the standard facility- based VCT services – i.e. community mobilisation for testing, testing made avail- able by mobile services in communities, rapid testing and immediate results and linking testing to post-test support services for both HIV-positive and HIV-negative individuals and their social networks. Data from the rural South African site shows that mobile VCT is effective in recruiting relatively equal number of males (47%) and females (53%) to testing. In addition, across both genders, approximately 75% of testers are in the 16–32-year age group, with a median testing age of 24 years (Fig. 12.1).

Mobile VCT services have several benefits. Firstly, the opportunity costs asso- ciated with health-based VCT – inconvenient locations, transport costs and incon-

Fig. 12.1  Community-Based VCT in KZN, South Africa: Gender By Age

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venient hours required to attend VCT – are reduced (Kawichai et al., 2007; Morin et al., 2006). Secondly, mobile CT is able to reach men, women and young people not typically serviced by health facilities.

12.2.3.6 Concerns About Mobile VCT

Project Accept qualitative cohort interviews with selected community participants reveal a primary concern about the mobile VCT model. Some participants expressed a concern about being visible at mobile testing venues in the community – and not having the privacy and anonymity that comes with testing in busy hospital settings that offer integrated services. In particular, there was a concern that community members might infer that participating in mobile VCT must mean that you are HIV positive. Ellen et al. (2004) argue that whilst mobile testing is effective, the cost effectiveness of this approach might undermine its utility.

12.3 Provider Initiated Counselling and Testing (PICT)

To promote greater access to HIV testing, UNAIDS and WHO (2004)1  are encour- aging expansion of CT models to include provider initiated counselling and testing (PICT). The policy suggests that providers routinely offer HIV testing to clients at increased risk of HIV infection in health care settings, such as STI and TB clin- ics, antenatal care services, and in clinical and community-based health services in places where HIV prevalence is high. PICT is also recommended for those who are asymptomatic, but who fall into the at-risk age categories.

According to this model, all patients who enter the health care system will be routinely asked if they would like to be tested (often referred to as “opt-in testing”); alternatively they will be informed that they will be tested for HIV as part of routine testing procedures in the facility, unless they refuse (opt-out testing). The central difference between PICT and VCT is that the health care provider offers testing, rather than testing being initiated by the client seeking out the service. The policy recommends that PICT adhere to the core principles of HIV testing and counselling, namely that the services must be implemented with the informed and voluntary consent of clients, and testing must be confidential and accompanied by counselling (UNAIDS/WHO, 2004).

Increasingly, the international policy position on CT is to promote provider initi- ated CT in addition to client-initiated models such as VCT as a means of rapidly increasing the numbers of people who know their HIV status. In South Africa, provider initiated counselling and testing has not yet been widely adopted by poli- cymakers other than as part of PMTCT programmes. Proponents of PICT argue that

1 The UNAIDS/WHO policy refers to Provider Initiated Testing and Counselling (PITC), but the acronym Provider Initiated Counselling and Testing is preferred in South Africa. Both terms refer to the same thing, i.e. counselling and testing initiated by the provider.

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instituting PICT would reduce the exceptionalism associated with HIV, in that by approaching the diagnosis of HIV infection like other diseases, more people would be tested, and the stigma associated with HIV testing and HIV infection would be reduced (Metcalf and van Rooyen, 2008).

12.3.1 Evidence that PICT Is Effective

Research shows that PICT is effective in improving testing uptake, identifying previ- ously undiagnosed HIV infections, and facilitating earlier referral and access to care in a range of settings where it has been implemented (Bassett, 2002; Delva et al.,

2006; Perez et al., 2006; Rennie and Behets, 2006). For example, Botswana, the first country to implement the approach in 2004, showed a 19% increase in HIV testing from 2004 to 2005 using the opt-out model (Rennie and Behets, 2006). Studies show that the introduction of PICT in Botswana has had no negative effects on the pro- portion of people receiving test results in Botswana (Steen et al., 2007) nor on post test counselling rates in Zimbabwe (Miller cited in Obermeyer and Osborn, 2007).

There were some initial concerns that the PICT model might create an additional burden on women and girls – already marginalised, disempowered and vulnerable – by routinely testing them in health care settings (WHO, 2006). A few studies indi- cate that rather than creating a burden on women, women are more inclined to be tested if they think that it can benefit their baby (Etiebet et al., 2004; Perez et al.,

2006; Simpson et al., 1998). Obermeyer and Osborn (2007) suggest that routine testing, presumably done for the benefit of the baby, does not make assumptions about women’s sense of moral worth, and thus may be more acceptable to women for these reasons.

12.3.2 Concerns About PICT

Studies are increasingly showing that PICT in a range of African settings is accept- able and feasible, and is likely to play a key role in scaling up CT in this context. However, apart from the acceptability and feasibility studies, little data about the behavioural outcomes and psychosocial impact of PICT approaches has been accu- mulated. This evidence is important for supporting the positive claims that provider initiated approaches to CT could have an impact on prevention, behaviour change, treatment, stigma reduction and normalization of the epidemic.

12.3.3 Expanding Paediatric Testing

As discussed, in South Africa PICT is not widely implemented, other than as part of prevention of mother-to-child transmission services. Rollins et al. (2007) argue that despite the extensive investments in PMTCT programmes many of these programmes function poorly. In addition, antenatal programmes are poorly inte- grated with care and treatment for mothers and children in the post-natal period.

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Consequently, many children fail to be identified as HIV infected until they become ill and require hospitalisation.

Simple methods for definitive, early infant diagnosis remain a challenge in the expansion of paediatric testing and treatment services (International HIV Coun- selling and Testing Workshop, 2008). Barriers to paediatric testing and treatment include inadequate or non-existent policies on age of consent and disclosure, a reluc- tance of health care providers to test children, inadequate trained staff to counsel children, lack of testing technology and a concern about sustainability of supplies (ibid).

12.3.4 Preliminary Evidence in Support of Paediatric Testing

Preliminary findings from routine, unlinked HIV testing at 6-week immunization visits in KwaZulu Natal, South Africa2  revealed that while many women said they were negative, 31% of their infants were detected to be HIV infected at their 6- week immunisation visits. Rollins et al. (2005) suggest that it is likely that many of HIV positive babies were (a) born to mothers who reported testing negative during pregnancy or (b) born to mothers who did not report their HIV status and therefore would not have been identified by current testing algorithms. These authors argue that routinely testing children at 6-week immunisation visits, with their mothers’ consent, could achieve two important goals in paediatric testing. First, it will help to identify HIV infection in children known to be HIV-infected at an earlier age and second, it will help to identify HIV infection in children born to infected moth- ers whose serostatus is either negative or unknown during pregnancy. Significantly, early identification of infection could help to prevent much of the early morbidity and mortality experienced by HIV-infected children in many resource-limited set- tings (Rollins et al., 2005).

12.3.5 Concerns

This is a relatively new approach to testing. More feasibility and acceptability stud- ies in high-prevalence developing countries are required to determine the acceptabil- ity and feasibility of this type of testing (where testing the baby reveals the baby and the mothers HIV status) for service users and service providers. In addition, more studies are required that assess whether testing at 6-weeks leads to better uptake of testing and thus earlier referral of children to treatment and care than traditional ANC testing methods allow.

2 Rollins, N., et al. (2005). Assessing the impact of the PMTCT programme on vital child health indicators in KwaZulu Natal. Unpublished proposal.

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12.4 Challenges for the Way Forward

The poor coverage and the predominantly health-based location of both CICT and PICT models are limiting factors that discourage, rather than facilitate, testing uptake. The capacity of African health systems is severely hampered by a number of factors – limited access, an acute shortage of health personnel, poor management and inefficient resource allocation and utilization (Asante, 2007). Given the weak- ness of these health systems it seems unlikely that the addition of PICT on its own (without simultaneously addressing some of these systemic factors) would lead to any drastic improvement in HIV/AIDS treatment or care.

Key populations to reach in the health facility setting include pregnant women and HIV-exposed children, as well as TB and STI patients. South Africa may wish to expand PICT to include all patients who come into contact with the health system. Many environments do not yet have the means to effectively apply new strategies, including PICT, in which health care workers purposely offer (and pro- vide) more testing (UNAIDS/WHO, 2004). Policy and programme planners need to consider the consequences of widespread PICT implementation for health system provisions.

Optimistic claims of the benefits of provider initiated CT need to be substantiated with evidence. A focus on the number of people tested, without attention to the short- and long-term effects of behaviour change among these individuals, would not be to the benefit of our prevention efforts, and is not likely to encourage positive health-seeking behaviours over time (Gruskin, 2006). Furthermore, as PICT models are implemented, consideration needs to be given to the three C’s (informed consent, confidentiality and counselling) in the model.

In order to expand CT in medical settings, consideration needs to be given to how best to attract men – who don’t typically access public health facilities – to these services. Bond et al. (2005) point out that on the whole, men are less likely to be exposed to services offered in health care facilities because they are less likely than women to have healthcare insurance, to access usual sources of care or to go to the doctor on a regular basis. The lack of male partner involvement in PMTCT settings is a missed prevention opportunity (Bassett, 2002; Delva et al., 2006). Consideration needs to be given to how best to get men to test in these contexts and how to make services more appropriate for male testing.

Health facility-based testing alone will not be enough to achieve the preven- tion and treatment goals of the NSP. To achieve CT scale-up, massive expansion of VCT services through home-based testing and mobile CT models needs to be implemented. Strong evidence exists that these models are capable of reaching tar- get groups thus far missed through the predominant health facility-based CT that currently pertains in South Africa. These groups include: youth at risk and men and women who don’t typically access reproductive health services.

The VCT efficacy literature shows the strongest benefits to couples who test together. Thus far, in South Africa, couples-based VCT has not been widely imple- mented. Consideration needs to be given as to which settings would be best suited and appealing to couples. Mobile VCT facilities may be ideal for couples-based test-

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ing, given their convenience and ability to successfully attract men to services. In addition, counsellors need to be equipped with specialised skills to deal with issues of concurrent partnerships, as this can be a particularly complex matter to navigate within the couples counselling context (Kamenga and Sangiwe in the International Counselling and Testing Workshop, 2008).

12.5 Policy and Research Gaps

Several policy gaps impact CT scale-up in South Africa and need to be urgently addressed. In particular, as outlined by the Joint Civil Society Forum Monitor- ing Group in 2006, the following issues pertaining to lay counsellors need to be addressed: (1) recognised positions for lay counsellors within the health care sys- tem, as well as professional counsellor associations are important for ensuring the sustainability of CT programmes; (2) the issue of remuneration for lay counsellors needs to be resolved, and (3) the scope of practice needs to be revised so that nurse assistants and lay counsellors are permitted to conduct a finger prick or oral saliva test. The last point, is particularly important, to facilitate the kind of scale-up of CT required in both medical and non-medical sites necessary to reach the testing and treatment goals of the NSP.

While the NSP has set clear targets in terms of numbers of people tested, a par- allel goal should be to ensure the delivery of the highest quality and standard of counselling to VCT clients. The risk-reduction model of counselling, with theoret- ically sound and evidence-based behaviour-change outcomes, needs to be widely implemented across the country. Quality issues that impact the delivery of VCT – such as the lack of minimum standards guiding counsellor training, practice, super- vision and support – need to be addressed.

Promotional campaigns have proven to be effective in encouraging counselling and testing. More social marketing “know your status” campaigns that attempt to make HIV testing normative are required. Dixon-Meuller and Germain (2007) sug- gest that normative messages about CT should encompass a sense of responsibility that testing is the right thing to do for oneself and one’s sexual partner: “that being regularly counselled and tested for HIV and other STIs – individually and with one’s partner – and keeping one’s partner informed, is not only a right, but also the right thing to do” (p.287).

As we consider implementation of these various approaches we need to simulta- neously encourage evidence-based decision-making on CT strategies. In particular we need to:

1.  Explore the relationship between HIV testing and prevention, treatment, and stigma-reduction outcomes. We also need to consider how the prevention out- comes of CT can be improved.

2.  Compare uptake for the different HIV testing approaches and understand the decision-making process for each approach, considering the role of different lev-

12    Approaches to HIV Counselling and Testing                                                                     179

els of coercion or voluntariness on decisions to test and their associated conse- quences (Strode et al., 2005).

3.  Explore the role of fear of stigmatization, and self-stigmatization in the context of VCT and how they impact on VCT uptake and how they can be addressed.

4.  Understand perceived advantages and disadvantages of not going for VCT, par- ticularly among asymptomatic individuals. (Swanepoel, 2004).

12.6 Conclusions

South Africa has articulated ambitious HIV testing and treatment goals in the National Strategic Plan on HIV & AIDS and STIs, 2007 – 2011. Achieving the counselling and testing goals outlined in the NSP requires a similar boldness in implementation. The evidence is clear – we need to embrace and promote more than one CT model. Each of the models has strengths and limitations, and works better for some target groups, and in certain settings and contexts. Implementing a combination of models allows for a comprehensive and expanded CT approach – a necessity given the extent of the epidemic in South Africa.

Acknowledgments  The authors thank Lauren Kleutsch for her contributions  in  editing this chapter.

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