Malawi PMTCT Participant Manual
Module 6 Testing and Counselling
After completing the module, the participant will be able to:
· Define HIV testing and counselling (TC) correctly.
· Discuss the three guiding principles of HIV testing and counselling.
· Discuss the opt-out and opt-in HIV testing strategies.
· Describe the counselling skills that are important when working in PMTCT settings.
· Describe the three stages of the counselling process.
· Describe the basic steps to HIV testing.
· Discuss the tests used for diagnosing HIV infection.
· Discuss parallel and serial HIV testing procedures.
· Discuss information covered during the HIV pre-test education session.
· List the important components of the post-test session.
Unit 1 Basic Principles of HIV Testing and Counselling (TC) for Prevention of Mother-to-Child Transmission of HIV (PMTCT)
After completing the unit, the participant will be able to:
· Define HIV testing and counselling (TC) correctly.
· Discuss the three guiding principles of HIV testing and counselling.
· Discuss the opt-out and opt-in HIV testing strategies.
HIV testing and counselling
HIV testing
HIV testing is a process that determines whether a person is infected with HIV.
Definition of HIV counselling
HIV counselling is a confidential dialogue between a HCW and a client to enable the client to make an informed decision on HIV testing (pre-test session) or providing information on the HIV test result (post-test session). Testing and counselling can enhance a person’s understanding of HIV/AIDS and help the person make informed choices for the future. The counselling process includes an evaluation of personal risk of HIV transmission and facilitation of preventive behaviour. A trained counsellor (health or non-healthcare worker) can conduct HIV testing and counselling.
Definition of PMTCT counselling
It is a two way communication whereby the counsellor provides information on HIV testing, ARV prophylaxis, infant feeding options, nutrition and follow up care and support.
Who should conduct PMTCT counselling?PMTCT Counsellors may be doctors, clinic officers, medical assistants or nurse/midwives.
· The counsellor must be trained and have knowledge of:
· HIV transmission and prevention strategies
· HIV testing
· Infant feeding
· Clinical staging
· HIV programmes and associated interventions (to facilitate referrals)
· Counsellors should also have a genuine interest in helping people with HIV and AIDS
TC in the context of PMTCT
In the context of PMTCT, HIV TC is a flexible intervention that is integrated into settings where pregnant women and their partners and other women of childbearing age receive reproductive health services such as antenatal, labour, delivery and postpartum care as well as family planning services. TC in the context of PMTCT includes counselling around other PMTCT interventions such as ARV prophylaxis or therapy and infant feeding counselling and support.
Importance of counselling in PMTCT
TC in PMTCT settings requires HCWs to guide clients through a decision-making process to support the client in making the most appropriate choices for her and her infant. Healthcare workers (HCWs) involved in PMTCT services have a vital role to play in:
· Routine testing and counselling for HIV, including information on HIV prevention and PMTCT interventions
· Counselling on nutrition
· Counselling on antiretroviral prophylaxis or therapy (if eligible)
· Couple counselling or partner involvement
· Counselling on infant feeding
· Counselling about positive living
· Counselling on family planning
· Informing the client of opportunities for support in the community e.g., HBC
As helpers and facilitators in the decision-making process, HCWs must work in ways that promote a woman’s control over her own life and respect her ability to make her own choices. Testing and counselling is the foundation of and entry point to HIV prevention and care services.
The content of the pre- and post-test sessions is covered in Unit 4 of this module.
Counselling clients in the PMTCT services
There are three primary counselling scenarios in PMTCT services:
Individual counselling
· Most counselling associated with the PMTCT service will be individual counselling.
· The PMTCT counsellor will help the client make a decision about HIV testing, provide information about HIV, PMTCT and discuss a plan to reduce HIV risk.
Group counselling
If demand for testing is high, pre-test education can be provided in groups. Group pre-test sessions are efficient because they optimize human resources, while allowing for interaction among participants. The groups can be easily integrated into the clinic flow. Where the client-to-provider ratio is high, group information sessions enable HCWs to provide the basic testing and counselling messages to many women at one time.
Couple counselling
HIV counselling in the antenatal setting inevitably targets women. However, many of the issues raised and long-term implications of antenatal testing involve not only the woman, but also her partner, their unborn child and, in some cases, the extended family.
· For this reason, the counsellor should always explore the possibility of couple counselling at the initial visit.
· Pregnant women should be encouraged to come together with their partners for pre-test counselling, testing and post-test counselling.
· If a woman feels unable or unwilling to involve her partner, this must be respected.
· If the partner has not been tested, it may be advisable to again suggest couple counselling during subsequent visits, since HCWs commonly have contact with a woman at least a couple of times during the antenatal period.
Working with couplesWomen coming for HIV or PMTCT counselling should be encouraged (but not forced) to come with their partners as a couple. It is critical that counsellors have some knowledge of couple counselling.
Discordance in couples
Discordance means that one partner is HIV-positive and the other partner is HIV-negative. The reasons for discordance in couples are not fully understood at present, but are believed to be linked to a combination of factors that may include genetics, HIV type, the extent to which the infection has progressed in the HIV-positive partner, and other sexually transmitted diseases. Studies are underway to confirm reasons for discordance. It is important to inform clients that their HIV status does not always reflect their partner’s status. There are many variables involved in the transmission of HIV. HCWs need to be particularly careful if the client is pregnant and HIV-negative and any potential sex partners are positive. If a mother is infected during her pregnancy, the chances of MTCT are much higher due to the high amount of HIV in the blood with a new infection. For that reasons it is always advisable to encourage HIV testing for both partners.
Why encourage couple counselling?
· A change in one of the partner’s sexual behaviour is bound to affect the other partner.
· When couples work together in partnership they are more likely to be successful in what they want to do.
· The issue of disclosure of HIV test results to the partner, which is not easy for most couples, is better handled if they agree to be seen as a couple.
· Couples are better able to cope with the difficult decisions that must be made in light of a positive HIV test result.
· If they are counselled together, they can support each other when making decisions, such as whether to take ARVs and infant feeding.
· Some people seek counselling as a couple because they recognize that their problems are rooted in their relationship rather than being attributable to individual issues.
Guidelines for working with couples· Create a trusting relationship with the couple.
· Contract with both of them.
· Let them know that there will be equal time for both of them.
· Let them know each of their opinions is important.
· Mention the possibility of discordant results (if one partner is infected while the other is not) and prepare them for this possibility.
· Pay attention to both their verbal and non-verbal communication.
· Try and draw out (politely), the silent partner of the couple, if there is one, to share their feelings and opinions.
· Do not judge or take sides.
· Leave your values, prejudices and beliefs aside and work with those of the couple.
Family counselling
· Encourage women to involve a partner or family member in HIV counselling, this person can provide support following the testing.
· The counsellor should encourage adolescents to involve a supportive “significant other”. Younger women (particularly those under 16 years) may not have a permanent partner and may prefer to be supported by a sister or mother.
Guiding principles for testing and counselling in PMTCT settings
The guiding principles for testing and counselling in PMTCT settings are:
· Confidentiality
· Informed consent
· Post-test support and services
Confidentiality
· Confidentiality is one of the most important issues in a counselling situation. When a HCW is clear about the parameters of confidentiality, clients can trust that what they disclose about themselves will remain confidential within the treatment team.
· When clients know and trust that what they disclose will remain confidential, they are more likely to share important information about themselves.
Maintaining confidentiality is an important responsibility of all HCWs and is essential to establishing and maintaining client trust. Information that is shared between HCWs and clients must be kept private. Clients should be informed that personal and medical information, including HIV test results, may be disclosed to other healthcare providers for the purpose of ensuring that the client receives the appropriate medical care.
HCWs should emphasize, however, that only those HCWs who are directly involved in the client's care will have access to the client’s records—and only on a “need-to-know” basis.
All medical records and registers, whether or not they include HIV-related information, should be kept confidential and stored in a safe, secure place. When possible, the same counsellor should provide pre-test, post-test and support counselling.
Informed consent
Informed consent is the second guiding principle of testing and counselling; it is the process during which each client receives clear and accurate information about HIV testing to ensure that the client understands she has the right and the opportunity to decline testing.
One of the important objectives of PMTCT is to make HIV testing a routine or normal part of ANC. Consequently, in the context of PMTCT, written informed consent is not required. However, it is the responsibility of the HCW to address the following elements of informed consent:
· Ensure the client has an understanding of the purpose and benefits of testing, counselling and PMTCT services.
· Ensure the client has an understanding of the testing and counselling process.
· Respect the client’s testing decision.
Post-test support and services
Post-test support and services is the third guiding principle: the HIV test result should always be offered in person. Along with the result, appropriate post-test information, counselling and referral should also be offered.
Guiding principles for PMTCT counsellors1. View each client and her situation as unique, and make every effort to perceive the situation from the perspective of the client.
2. Create a non-judgemental atmosphere in which the counsellor encourages the client to express herself openly and freely.
3. Direct efforts towards helping clients identify and fulfil their goals as well as their needs, within the limitations of their ability, potential, and circumstances.
4. Proceed as if the best solutions to a client’s problems are to be found within the client herself.
5. Continually communicate an attitude of high regard for the client as a worthy person.
6. Demonstrate a belief in the client’s ability to take responsibility for her choices, decisions and actions.
7. Structure each counselling session in a way that enables the client to develop and improve the life skills needed to cope with their problem and situation.
8. Emphasize that counselling is a sharing relationship and that all decisions will be mutually agreed between client and counsellor.
Exercise 6.1 Confidentiality role play
Purpose / To review and apply the principle of confidentiality in a post-test situation where the client tests positive for HIV.
Duration / 25 minutes
Instructions / · Two participant volunteers will take part in a role play in front of the room: one as HCW (Nurse Banda) and the other as the client (Chimwemwe).
· After the role-play, the volunteers will return to the group and the group will be asked the following questions:
· Why is Nurse Banda, the HCW, concerned about not having a separate space to meet with Chimwemwe, the client?
· How do you think Chimwemwe feels about this space and the privacy of this space?
· Is the space appropriate for this interaction?
· What can be done to improve privacy?
· What can HCWs and clinics do to keep a patient’s HIV status confidential?
· What other breaches of confidentiality occurred during this role play? How should this be addressed in the clinic?
Exercise 6.1 Confidentiality role-play script /
Introduction: Chimwemwe is returning to the ANC clinic for a follow-up visit after receiving a positive HIV test result. Today, she is 4 months pregnant. The healthcare worker, Nurse Banda, is very busy this morning and is expecting the rest of the day to be just as busy. She has asked the receptionist to organise the HIV reports. While organising the reports, the receptionist recognizes Chimwemwe’s name and notices that Chimwemwe is HIV-infected.
When Chimwemwe arrives for her appointment, she notices that some of the healthcare workers are looking at her and whispering. When Nurse Banda calls Chimwemwe for her appointment, they are forced to sit in a corner of the waiting room because all of the client rooms are occupied.
Exercise 6.1 Confidentiality role-play script
Nurse Banda / Hello, Chimwemwe. I am glad to see you here on time for your follow-up appointment. Have a seat.
Chimwemwe / Hello, Nurse Banda. I have been so sad and nervous about my recent positive HIV test. What does this mean for me and my family?
Chimwemwe looks around and is very uncomfortable because she thinks other clients can hear her.
Nurse Banda / I wish we had a private office to sit in Chimwemwe, but space is so limited here. I am certain that no one will hear us talking back here.
Chimwemwe / I just want you to know, Nurse Banda, that if my husband finds out, he will be extremely angry. Please tell me what to do.
Nurse Banda / I’m sorry, Chimwemwe I hear you saying that telling your husband your HIV status will be a very difficult thing to do.
She pauses, giving Chimwemwe a chance to hear what she has just said.
I know this is very difficult for you, but I am here to help you through this. Let us talk about your concerns around telling your husband.
Chimwemwe / Oh, Nurse Banda, what will I do? My husband and I were so excited about this pregnancy. Before we were married, I had another boyfriend, and I didn’t always use protection.
Chimwemwe starts to cry. All of the clinic staff is now watching Chimwemwe.
Nurse Banda / You must be feeling very overwhelmed right now, Chimwemwe. Please know that everything you tell me will be held in strict confidence, including your test results. Let’s now discuss some of the concerns you have about disclosing to your husband. Will that be ok?
“Opt-out” (routine) and “Opt-in” (optional) approaches to HIV testing in PMTCT settings
There are two approaches to HIV testing in the ANC and the labour and delivery settings. Each provides easily understood information to the client about HIV and the risks and benefits of testing. The approaches differ in how clients agree to test for HIV. The differences are summarized as follows: