Voluntary Counseling and Testing (VCT) for HIV

Presentation Objectives By the end of this session, you should be able to: Describe the basic facts about voluntary counseling and testing (VCT). Explain the importance of VCT. Describe the goals and outcomes of VCT. Describe the link from VCT to HIV prevention, care and treatment.

HIV Counseling and Testing Confidential dialogue between a client and a care provider aimed at enabling the client to cope with stress and make personal decisions related to HIV and AIDS. Voluntary Counseling and Testing (VCT) A combination of two activities– counseling and testing –into a service that amplifies the benefits of both.

VCT is an entry point and not the end point. Why is VCT So Important? 90% of those infected in Eastern and Southern Africa do not know that they are infected. Knowing one’s serostatus allows people to alter their behavior. VCT provides an opportunity for prevention counseling and referral to care and support services. VCT is an entry point and not the end point. Many approaches to HIV prevention and care require people to know their HIV status. The importance of voluntary counseling and testing (VCT) has brought about the wider promotion and development of VCT services. However, since the majority of countries where HIV has a major impact are also the poorest, the lack of resources has meant that VCT is often still not widely available in the highest-prevalence countries. For VCT services to be prioritised and for resources to be provided for their development, demonstrating the effectiveness of VCT is essential.

Why is VCT So Important? Effective prevention and care activities require people to know their HIV status. VCT promotes and sustains behavior change (prevention). VCT facilitates early referral to care and support services- including access to antiretroviral therapy. VCT links with PMTCT, STI, and OI services. VCT assists in stigma reduction.

Early management of OIs and STDs Acceptance of Serostatus and coping Early management of OIs and STDs Planning for future orphan care; Will preparation Voluntary Counseling Testing Reduces mother-to-child transmission Referral to social and peer support Normalizes HIV/AIDS VCT as an entry point for the following: Planning for future orphan care Will preparation Normalizes HIV/AIDS Referral to social and peer support Preventive therapy and contraceptive advice Early management of opportunistic infections and STDs Reduces mother-to-child transmission Facilitates behavior change Acceptance of serostatus and coping Facilitates behavioral change Preventive therapy (TB and bacteraemia) and contraceptive advice

Goals of VCT (1) Prevention of HIV transmission From +ve tested people to -ve or untested partner/s From +ve tested mother to child From +ve or untested partner/s to -ve tested people Early uptake of services Counseling for positive living Social support Legal advice Future planning Medical care Family planning Emotional care

Goals of VCT (2) Societal benefits Increase adherence to: Normalisation of HIV Reduction of stigma Promote awareness Support human rights Increase adherence to: ARV therapy Preventive therapies ARV regimens for PMTCT Infant feeding choices

Components of VCT Explaining the test and obtaining informed consent Determining clients knowledge Giving accurate information Conducting personalized risk assessment Developing a personalized risk reduction plan Demonstrating appropriate condom use Explaining the test and obtaining informed consent Discussing implications of HIV result Assessing coping ability Result notification Providing psychological and emotional support and referral as appropriate

Rationale for VCT as an Intervention Strategy Effective in promoting behavioural change and providing psychosocial support. Cost effective especially when it is targeted to couples and “high risk groups”. Feasible as a component of comprehensive HIV prevention and care strategies in developing countries. Facilitates the linkage to other HIV prevention and care activities.

Cost Effectiveness of VCT VCT is cost effective $ 12.77 $ 17.78 Cost /DALY Saved $ 249 $ 346 Cost/HIV Infection Averted 1104 895 HIV Infections Averted Per 10,000 Persons Kenya Tanzania Outcome Cost-effectiveness analysis leaves out many of the hidden benefits of VCT, particularly, in the areas of care and quality of life, which may be cost-saving. Results from the multi-center trial have shown that VCT can be a highly cost-effective intervention (Sweat et al). Using a hypothetical cohort of 10 000 seeking VCT, they estimated that the intervention averted 1 104 HIV infections in Kenya and 985 in the United Republic of Tanzania. The cost per client for VCT was estimated to be US$ 29 in the United Republic of Tanzania, and US$ 27 in Kenya. In both these sites total costs were composed of 74% for labor and infrastructure, 2% for start-up, and 24% for commodity expenses. The single largest cost was for counselor salaries and benefits (36%). The cost per HIV infection averted averaged US$ 346 in the United Republic of Tanzania and US$ 249 in Kenya. The cost per disability-adjusted life-year (DALY) saved was US$ 17.78 and US$ 12.7. VCT was found to be more cost-effective when targeted at seropositive people, couples and women. The most cost-effective intervention was VCT aimed at couples. If they increased the proportion of couples attending VCT to 70% this would reduce the cost per DALY to US$ 13.39 in the United Republic of Tanzania and US$ 10.71 in Kenya. VCT compares favorably to other interventions in cost per HIV infection averted in East Africa (e.g. US$ 251 per case of HIV averted for enhanced STI services in Mwanza. This intervention was estimated to cost US$ 10 per DALY saved (Gilson et al.). It is likely that the costs of VCT will fall as testing methods get cheaper and innovative approaches to counseling may reduce costs. Furthermore, if VCT is targeted at couples and a people of higher risk this will also increase cost-effectiveness. (Sweat et al).

Review of VCT Outcomes Prevention of HIV transmission Prevention of HIV transmission in special populations Care: Improving access to medical, emotional, and social support The most definitive measure of VCT’s effectiveness in reducing HIV transmission is the rate of new HIV infection in people following VCT, compared with a control group who were tested but were unaware of their serostatus. An appropriate proxy-indicator of adoption of safer sex practices (and hence reduction of HIV transmission) is incidence of STIs following VCT. Many studies that try to assess the effectiveness of VCT have looked at changes in reported sexual behaviour following testing. There are, however, methodological problems associated with these types of studies. Attempts at obtaining information on sexual behaviour must rely on self-reporting and there are few opportunities for checking information obtained against that from other sources. Knowledge of HIV status can enable women to make informed decisions about whether or not to have children. Early in the epidemic there were no effective interventions to prevent mother-to-child transmission (MTCT) of HIV and women were sometimes advised by health care workers not to have children. It is difficult to make long-term changes in sexual behaviour without being able to share HIV test results with a sexual partner or partners. Disclosure to a sexual partner or partners can be viewed as an important indicator of understanding and acceptance of HIV status. There are, however, societal factors that have a strong influence on rates of disclosure, particularly for women. The views of counsellors may also influence disclosure rates.

Barriers to VCT (1) Fear No cure or treatment Stigma No need: I’m faithful Partner with a negative HIV result Gender inequalities Lack of perceived benefit Lack of access to care and support services Uptake of VCT services varies greatly between settings and between countries. VCT services have different methods of reporting HIV results, and this may influence uptake of the service, especially where people are worried about confidentiality or belong to groups that are already unsupported or marginalized. Stigma and discrimination may be important factors in the uptake of VCT in different communities. It has been postulated that political commitment to HIV prevention and care have led to less discrimination and, hence, higher demand for VCT in Uganda when compared to neighbouring countries. It has also been argued that, conversely, it is the large number of people who have been tested that is a major factor in promoting normalization and reducing stigma and discrimination associated with HIV. Countries where ARVs and other effective medical interventions are available for people with HIV, there are considerable advantages to people with HIV being diagnosed early. In developing countries, the lack of these interventions for people with HIV is reported as a reason for the poor uptake of VCT. Many studies have shown that if people are able to obtain their HIV test result within a few hours using simple/rapid technologies they are much more likely to receive their test result than if they have to wait one to two weeks. Unless VCT services are promoted as part of comprehensive HIV prevention, care and support uptake is likely to be poor. Provision of adequate IEC and community mobilization is thought to be an important element in ensuring uptake of MTCT services associated with MTCT interventions In some countries VCT services are under-utilized because the services they offer are inadequate and do not meet client needs.

Barriers to VCT (2) Fear “I feel if I tested positive it would just devastate me. You know that, while I know I might be positive - I had herpes zoster - there are times I tell myself that its my father-in-law doing some black magic on me. If I went and had a test and they said ‘you have it’ then I know I would be dead in a week.” Woman 28 years, Kara Counseling and Training Trust, Lusaka, Zambia

Barriers to VCT (3) No cure or effective treatment “I do not even want a test. What are you going to do about it if I come out positive? Are you going to give me medicines? If you tell me that you can give me medicines or that you will cure the disease then I can go for a test tomorrow.” Man 30 years, Kara Counseling and Training Trust, Lusaka, Zambia

Barriers to VCT (4) Stigma “ If you go for a test and the result comes out positive your family will not take care of you because you will be an outcast.” Woman 22 years, Kara Counseling and Training Trust, Lusaka, Zambia

Barriers to VCT (5) No need “Its not necessary since a test is only for those young ones who have not followed their parents’ advice of not indulging in things like careless sex.” Woman 56 years, Kara Counseling and Training Trust, Lusaka, Zambia

Barriers to Changing Sexual Behavior Following VCT Partner communication difficulties Gender imbalances in sexual decision making Difficulties in changing sexual behaviour Desire to have children Stigma Economic deprivation