Provider-Initiated Hiv Testing and Counselling

NURSING MATTERS

Nursing Matters fact sheets provide quick reference information and international perspectives from the nursing profession on current health and social issues.

Provider-initiated HIV Testing and Counselling (PITC) in Health Care Facilities

Introduction

Health facilities provide an opportunity for early diagnosis of HIV and access to services. The traditional approach has reliedon client-initiated testing and counselling often with low uptake and late diagnosis of HIV. The low uptake of HIV testing and counselling is a major challenge in the response to the HIV epidemic. Surveys in sub-Saharan Africa have shown that a median of 12% of men and 10% of women had been tested for HIV.[1] Recent recommendations have shifted to a proactive approach where the health care provider initiates the HIV testing and counselling. While nurses should strongly support the continued scale up of client-initiated HIV testing andcounselling, they must also recognize the need for additional approaches to ensure opportunities to diagnose and counsel individuals at health facilities through PITC.

What is PITC?

In contrast to client-initiated HIV testing and counselling(also called Voluntary Counselling and Testing, orVCT), PITC is initiated byhealth care providers as part of the patient’s routine clinical management. Provider-initiated HIV testing and counselling presents an opportunity for early diagnosis of HIV in health care facilities and facilitates access to prevention, treatment, care and support services. For example a study in Uganda showed that among adults who were offered HIV testing at a hospital (abouthalf of whom were subsequently found to be HIV-positive), 83% were unaware of their HIV status,even though 88% had been to a health unit in the previous six months.[2]

With this approach, an HIV test is recommended:[3]

• for all patients, irrespective ofepidemic setting, whose clinical presentation might result from underlying HIV infection;
• as astandard part of health care for all patients attending health facilities in generalized HIVepidemics; and
• more selectively in concentrated and low-level epidemics.

In the developed world, a number of European countries have introduced provider-initiatedHIV testing and counselling in the context of prenatal care. Provider-initiated HIV testing andcounselling appears to have resulted in considerable increases in testing uptake in the UnitedStates, United Kingdom, Hong Kong, Singapore, Norway and Canada, where the majority of clients agreed to be tested.[4] Inlight of the evidence that people who are aware of their HIV status reduce risk behaviours, the United States’ Center for Disease Control and Prevention (CDC)

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issued revisedguidelines recommending “HIV screening” for all persons aged 13-64 yearsattending health facilities in the United States.[5] Similarly, several low and middle-income countriesincluding Botswana, Kenya, Malawi, South Africa andUganda have introduced provider-initiated HIV testing andcounselling in a variety of settings.[6],[7],[8]

When recommending HIVtesting and counselling, the health care provider should supply thepatient with the following information:[9]

• Reasonsfor recommending HIV testing and counselling.
• Benefits of HIV testing and the potential risks, such asdiscrimination, abandonment or violence.
• Which services are available in the health facility or through referrals.
• Assurance thatthe test result will be treated confidentially.
• Thepatient’s right to decline the test.
• Assurance that declining an HIV test will not affect the patient's access to services.
• The patient has the opportunity to ask the health care provider questions.

Individuals mustspecifically decline or “opt out” from HIV testing if they do not want it to be performed. Additional discussion ofthe right to decline HIV testing, of the risks and benefits of HIV testing and disclosure, and aboutsocial support available may be required for groups especially vulnerable to adverseconsequences upon disclosure of an HIV test result.

What are the benefits of PITC?

Universal access to testing and counselling is essential to universal access to HIV prevention, treatment, care and support. Where antiretroviral therapy (ARVs) is available, maximum benefit in terms of reduced morbidity andmortality is obtained when HIV is diagnosed at an early stage. Even insettings where antiretroviral therapy is not available, interventions such as co-trimoxazoleprophylaxis and ARV prophylaxis for the prevention of mother-to-child transmission offerhealth benefits to individuals and their children.[10] Early diagnosis alsopresents an opportunity to provide people with HIV with information and tools to prevent HIVtransmission to others.

What are the concerns with PITC?

PITC is based on the principle of the “opt-out” approach including simplified pre-test information. However, there are some concerns about the potential coercion of patients for mandatory HIV testingand adverseoutcomes of disclosure which are clear violations of human rights of patients. There is also concern that provider-initiated HIV testing and counselling could deter clients fromaccessing health services, but there is no evidence to support this. For example, the introduction of PITC in antenatal care clinicsin Botswana appears to have caused no reduction in the use of prenatal care.[11] In general, the available evidence suggests that PITCcan be an important addition to the range of approaches available for scaling up HIV testing andcounselling and facilitates access to HIV treatment, prevention, care and support services.[12]

How are the concerns with PITC addressed?

The concerns related to human rights violations can be addressed through adequate safeguards such as training and supervision of health care providers, and close monitoring and evaluation of provider-initiated HIVtesting and counselling programmes. Training and supervision of health care providers andadministrators is a critical component of PITC. Training should include the following key areas:[13]

• Ensuring an ethical process for obtaining informed consent.
• Protecting confidentiality and privacy.
• Avoiding stigma and discrimination in the health facility.
• Patient referral.

It is important that regular HIV testing does not become a substitution for prevention behaviours. Nurses and other health care providers should emphasize the importance of responsible relationships and safesexbehaviours.

For further information, please contact:

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References

[1]WHO/UNAIDS/UNICEF. Towards universal access: scaling up priority HIV/AIDS

interventions in the health sector. Progress Report. Geneva: World Health Organization, UNAIDS and United Nations Children’s Fund; April 2007.

[2]Nakanjako D et al. Acceptance of Routine Testing for HIV among Adult Patients at the Medical Emergency Unit at a NationalReferralHospital in Kampala, Uganda. AIDS and behaviour. 2006

[3]. WHO and UNAIDS (2007), Guidance on Provider-initiated HIV Testing and Counselling in Health Facilities. Geneva: WHO

[4]Nakanjako D et al. Acceptance of Routine Testing for HIV among Adult Patients at the Medical Emergency Unit at a NationalReferralHospital in Kampala, Uganda. AIDS and behaviour. 2006.

[5]Branson B et al. Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health-Care Settings. Morbidity and Mortality Weekly Report (CDC). 2006, 55(RR14):1-17

[6]National AIDS and STD Control Programme: Guidelines for HIV testing in clinical settings.Nairobi, Ministry of Health, Republic of Kenya, 2004.

[7]Weiser SD et al. Routine HIV Testing in Botswana: A Population-Based Study on Attitudes, Practices, and Human Rights Concerns. PLoS medicine. 2006, 3(7):e261

[8]Nuwaha F et al. Factors influencing acceptability of voluntary counselling and testing for HIV in Bushenyi district of Uganda. East African medical journal. 2002, 79(12):626-32.

[9]Guidance on Provider-initiated HIV Testing and Counselling in Health Facilities, WHO and UNAIDS, Geneva, 2007.

[10]Guidance on Provider-initiated HIV Testing and Counselling in Health Facilities, WHO and UNAIDS, Geneva, 2007.

[11]Steen TW et al. Two and a Half Years of Routine HIV Testing in Botswana. Journal of acquired immune deficiency syndromes. 2007, 44(4):484-8.

[12]National AIDS and STD Control Programme: Guidelines for HIV testing in clinical settings.Nairobi, Ministry of Health, Republic of Kenya, 2004.

[13]GUIDANCE ON PROVIDER-INITIATED HIV TESTING AND COUNSELLING IN HEALTH FACILITIES, WHO.