EXECUTIVE SUMMARY
1. BACKGROUND
Limited knowledge of HIV status in many countries means that large
numbers of people fail to receive HIV treatment, care and support in a
timely manner, and do not take steps to prevent transmission to others
because they do not know they are infected. Efforts are needed to
expand voluntary counselling and testing (VCT) services and to provide
HIV testing in a more diverse range of settings than is currently the
case. Because health facilities represent a key point of contact with
people who are potentially infected with HIV, provider-initiated
testing and counselling in health facilities should be seen as one of
several potential components in an overall strategy to increase uptake
of HIV testing and counselling and knowledge of HIV status.
This document responds to growing demand at country level for basic
operational guidance on provider-initiated testing and counselling in
health facilities. It is based on an assessment of available evidence
and is intended for a wide audience including policy-makers, HIV/AIDS
programme planners and coordinators, health-care providers,
non-governmental organizations providing HIV/AIDS services and civil
society groups.
The document recommends an "opt-out" approach to provider-initiated
HIV testing and counselling in heath facilities, including simplified
pre-test information, consistent with WHO policy options developed in
2003 and with the 2004 joint UNAIDS/WHO policy statement on HIV
testing and counselling. With this approach, an HIV test is
recommended as a standard part of medical care for all patients
attending health facilities in generalized HIV epidemics, and in
certain settings in concentrated and low-level epidemics. Individuals
must specifically decline the HIV test if they do not want it to be
performed.
The process of adapting this guidance at country level will require an
assessment of the local epidemiology as well as the risks and benefits
of provider-initiated testing and counselling, including an appraisal
of available resources, prevailing standards of HIV prevention,
treatment, care and support, and the adequacy of social and legal
protections available to those living with, or at risk of exposure to,
HIV. Implementation of provider-initiated testing and counselling
should be undertaken in consultation with key stakeholders. Phased
implementation in priority settings and careful monitoring will enable
the best use to be made of available resources and help to avoid
negative outcomes, including stigma and discrimination, violence and
unmet demand for treatment and other services.
Provider-initiated testing and counselling in health facilities should
always aim to do what is in the best interests of the patient. This
requires giving individuals sufficient information to make an informed
and voluntary decision to be tested, including an opportunity to
decline the test. Post-test counselling and referrals to
appropriate services are essential for all patients regardless of the
test result, and patient confidentiality must always be maintained.
2. RECOMMENDATIONS
Guidance in the document is categorized according to HIV epidemic type
and refers to two types of provider-initiated testing and counselling:
diagnostic HIV testing and HIV screening. Provider-initiated testing
and counselling is voluntary and the "Three C's" - informed consent,
counselling and confidentiality - must be observed for both these
forms of provider-initiated testing and counselling.
o Diagnostic HIV testing in all epidemic types
Diagnostic HIV testing should be part of the normal standard of care
anywhere, recommended for adults, adolescents or children who present
to clinical settings with signs and symptoms or medical conditions
that could indicate HIV infection, including tuberculosis (TB).
Diagnostic HIV testing for children born to women who have
participated in programmes for the prevention of mother-to-child
transmission (PMTCT) and who were found to be HIV-positive is
considered a routine component of the follow-up care for these
children. Diagnostic HIV testing is also recommended for children with
suboptimal growth and malnutrition in generalized epidemics, and may
be considered for children under certain circumstances in other
settings.
Surgical patients may require diagnostic HIV testing for diagnosis and
management of conditions potentially associated with HIV. However, HIV
testing of surgical patients is not justified simply for knowledge of
HIV status by service providers, and HIV test results must not be used
to deny surgery or clinical services that are otherwise indicated.
o HIV screening in generalized epidemics
WHO and UNAIDS recommend HIV screening for all adults and adolescents
seen in all health facilities in generalized epidemics, regardless of
the individual's reason for presenting to the facility. This
recommendation applies to medical and surgical services, public and
private facilities, and inpatient and outpatient settings.
Resource and capacity constraints will likely require prioritization
of sites for implementation of HIV screening, guided by an assessment
of the local epidemiological and social context. The following health
facilities may be considered for the implementation of HIV screening
(in order of priority):
o Antenatal, childbirth and postpartum health services
o Sexually-transmitted infection (STI) services
o Health services for most-at-risk populations
o Other medical inpatient and outpatient facilities
o Services for children under 10 years of age
o Surgical services
o Reproductive health services, including family planning
o Services for adolescents.
o Options for provider-initiated testing and counselling in
concentrated and low-level HIV epidemics
HIV screening is not recommended for all persons attending all health
facilities in settings with concentrated and low-level epidemics,
since most people will have low risk for exposure to HIV.
In settings with low-level and concentrated epidemics, the first
priority should be to ensure that diagnostic HIV testing is
appropriately and correctly performed for adults, adolescents and
children who present to health facilities with signs and symptoms
suggestive of underlying HIV infection, including underlying
tuberculosis. When data have shown that HIV prevalence in patients
with tuberculosis is very low, diagnostic HIV testing of all such
patients may not remain a priority.
Decisions about whether to implement HIV screening in certain settings
in low-level and concentrated epidemics should be guided by an
assessment of the epidemiological and social context. Consideration
may be given to the implementation of HIV screening in the following
health facilities or services:
o STI services
o Health services for most-at-risk populations
o Antenatal, childbirth and postpartum services.
3. ENABLING ENVIRONMENT
Although access to antiretroviral therapy should not be an absolute
prerequisite for the implementation of provider-initiated testing and
counselling, provider-initiated testing and counselling should be
accompanied by a minimum set of HIV-related prevention, treatment,
care and support services and implemented within the framework of a
national plan to achieve universal access to antiretroviral therapy
for all who need it.
At the same time as provider-initiated testing is implemented, efforts
must be made to put in place a supportive policy and legal framework
to maximize positive outcomes and minimize potential risks to the
patient. This includes an ethical process for obtaining informed
consent, measures to maintain confidentiality and protect privacy and
measures to prevent stigma and discrimination in health care settings.
National plans to achieve universal access to HIV prevention,
treatment, care and support for all who need it should also address
beneficial disclosure and ethical partner notification as well as
broad social measures to protect the human rights of people living
with HIV/AIDS and at risk of exposure to HIV.
4. PRE-TEST INFORMATION AND INFORMED CONSENT
With the "opt-out" approach to provider-initiated testing and
counselling recommended by WHO and UNAIDS, an HIV test is recommended
as a standard part of the patient's medical care. Individuals must
decline the test if they do not want it to be performed.
For both diagnostic HIV testing and HIV screening, the health care
provider should at a minimum provide the patient with the following
information:
o The reasons why HIV testing and counselling is being recommended
o The clinical and prevention benefits of testing, as well as the
potential adverse outcomes
o The fact that the patient has the right to decline the test and that
testing will be performed unless the patient exercises that right
o The fact that declining the test will not affect the patient's
access to services that do not depend upon knowledge of HIV status
o The follow-up services that are available in the case of either an
HIV-negative or an HIV-positive test result
o In the event of an HIV-positive test result, encouragement of
disclosure to other persons unknowingly at risk of exposure to HIV
o An opportunity to ask the health care provider questions.
Additional pre-test information for women who are or may become
pregnant should include:
o The risks of HIV transmission to infants
o Measures that can be taken to reduce mother-to-child transmission,
including antiretroviral prophylaxis and infant feeding counselling
o The benefits to infants of early diagnosis of HIV.
Pre-test information should be tailored to the client's age and
developmental stage; special considerations will apply for obtaining
informed consent from children and adolescents. Verbal communication
is adequate for the purpose of obtaining informed consent to either
diagnostic HIV testing or HIV screening.
Declining an HIV test should not result in any denial of services,
coercive treatment or breach of confidentiality, nor should it affect
a person's access to health services that do not depend on knowledge
of HIV status.
5. POST-TEST COUNSELLING
Post-test counselling is an integral component of the HIV testing
process and all individuals undergoing HIV testing must be counseled
when their test results are given, regardless of the test result.
Counselling for those who test HIV-negative should include the
following minimum information:
o An explanation of the test result
o Advice on methods to prevent the acquisition of HIV and provision of
condoms.
The health worker and the patient should jointly assess whether the
patient needs referral to more extensive post-test counselling or
additional prevention support.
In the case of individuals who test HIV-positive, the health care
provider should:
o Explain the result simply and clearly, and give the patient time to
consider it
o Ensure that the patient understands the result
o Allow the patient to ask questions
o Help the patient cope with emotions arising from the test result
o Discuss any immediate concerns and assist the patient in determining
who in her/his social network may be available and acceptable to offer
immediate support
o Describe follow-up support available in the health facility and in
the community
o Arrange a specific date and time for follow-up visits or referrals
for treatment, care, counselling, support and other services as
appropriate (e.g. tuberculosis treatment, OI prophylaxis, STI clinics,
family planning clinics, antenatal clinics, opioid substitution
therapy, and needle and syringe exchange programmes
o Provide information on how to prevent transmission of HIV, including
provision of condoms
o Provide information on other relevant preventive health measures
such as good nutrition and preventing endemic diseases, such as the
use of anti-malarial prophylaxis and insecticide-treated bed nets
o Discuss possible disclosure of the result, when and how this may
happen and to whom
o Encourage and offer support for testing and counselling of partners
and children
o Discuss possible steps to ensure the physical safety of women who
test positive.
In addition, post-testing counselling for women identified as
HIV-positive should emphasize the following:
o Use of antiretroviral drugs to prevent MTCT, and for her own health,
when indicated and available
o Childbirth plans
o Adequate maternal nutrition, including iron and folic acid
o Infant feeding options and support to carry out the mother's infant
feeding choice
o HIV testing for the infant and the follow-up that will be necessary.
6. FREQUENCY OF TESTING
How often individuals are tested will depend on the continued risks
taken by the individual, the availability of human and financial
resources and HIV incidence in the setting. Re-testing at least once a
year may be beneficial for individuals at high risk of exposure to
HIV, such as persons with a history of a sexually transmitted
infection, sex workers and their clients, men who have sex with men,
injecting drug users, and sex partners of people with HIV.
HIV-negative women should be tested with each new pregnancy,
particularly those in high-prevalence settings or high-risk
populations. Re-testing late in pregnancy may also be advisable.
Individuals who are known to be HIV-positive do not require
re-testing.
7. HIV TESTING TECHNOLOGIES
An important recent advance has been the introduction of highly
sensitive and specific, simple-to-use, rapid antibody tests. Use of
rapid HIV testing for provider-initiated testing and counselling has
many advantages, particularly for health facilities where access to
laboratory services is poor.
Decisions on whether to use rapid tests or ELISA tests for
provider-initiated testing and counselling should take into account
factors such as cost and availability of the test kits, reagents and
equipment; available staff, resources and infrastructure; the number
of samples to be tested; sample collection and transport; the setting
in which testing is proposed; convenience, and the ability of
individuals to return for results.
Virological testing, while more complex, expensive and requiring
highly trained staff, is optimal for diagnosing HIV infection in
children of less than 18 months.
8. MONITORING AND EVALUATION
The implementation and scale up of provider-initiated testing and
counselling needs to be monitored and evaluated for coverage, quality,
adverse outcomes, funding and overall performance of services. Routine
programme monitoring may need to be supplemented with focused
evaluations on specific aspects of implementation, such as health care
worker performance and patient satisfaction.
To read the report, please go to:
http://www.who.int/hiv/topics/vct/publicreview/en/index.html
To participate in the debate on provider-initiated HIV testing and
counselling in health facilities, please submit your comment below the
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