Institutional context and VCT practitioner narratives: possibilities and limitations for HIV prevention in Rio de Janeiro,Brazil

Background

Voluntary Counseling and Testing (VCT) is an HIV prevention strategy that promotes the principles of confidentiality and informed consent. International research has highlighted VCT counselors’ isolation from service planning and the contradictions they negotiate between local values and global testing recommendations. In Brazil, studies have identified many limitations, including counselors’ difficulties to implement a vulnerability approach to HIV prevention as recommended in the country’s national guidelines. These studies, however, have not considered the particularities of the institutional contexts where counselors work. This research addresses these gaps in the VCT literature by exploring how VCT services are organized and how counselors perceive and perform their practices in the state of Rio de Janeiro, Brazil.

Methods

This is a case study of VCT services in the state of Rio de Janeiro. The research design included individual structured interviews with seven VCT service coordinators and twenty individual semi-structured interviews with VCT counselors. Participants were sampled according to gender, undergraduate degree and work trajectory to capture a diverse range counselor narratives.

Results

The VCT services were relatively homogenous in terms of functioning and had a similar restricted roll of activities including individual counseling and occasional external prevention activities with groups vulnerable to HIV. All VCT services reported reductions in staff size. Some counselors used dialogical practices to build trust, guarantee confidentiality and adjust their practices in accordance with their clients’ values and practices. Others emphasized imperative messages or focused on risk and individual responsibility. Connections between how counselors perceive their practices and the organization of their work environment were observed.

Conclusions

Due to the importance of counseling as a prevention strategy we recommend rethinking the relationship between counselors’ practices and the organization of VCT services. The challenges brought about by the expansion of “test and treat” programs globally and other social and symbolic aspects of the HIV epidemic, such as gender inequalities, must also be taken into account. Further reflection is also needed on the relationship between counseling guidelines and practices within the vulnerability approach to HIV prevention.

     

Integrating family planning into Ethiopian voluntary testing and counselling programmes

Problem

Governments and donors encourage the integration of family planning into voluntary testing and counselling (VCT) services. We aimed to determine if clients of VCT services have a need for and will accept quality family planning services.

Approach

“Voluntary HIV counselling and testing integrated with contraceptive services” is a proof-of-concept study that interviewed 4019 VCT clients before the addition of family planning services and 4027 different clients after family planning services were introduced. Clients attended eight public VCT facilities in the Oromia region, Ethiopia. The intervention had four components: development of family planning counselling messages for VCT clients, VCT provider training, contraceptive supply provision and monitoring.

Local setting

Ethiopia’s population of 80 million is increasing rapidly at an annual rate of 2.5%. Contraceptive prevalence is only 15%. The estimated adult HIV prevalence rate is 2.1%, with more than 1.1 million people infected. The number of VCT facilities increased from 23 in 2001 to more than 1000 in 2007, and the number of HIV tests taken doubled from 1.7 million tests in 2007 to 3.5 million in 2008.

Relevant changes

Clients interviewed after the introduction of family planning services received significantly more family planning counselling and accepted significantly more contraceptives than those clients served before the intervention. However, three-quarters of the clients were not sexually active. Of those clients who were sexually active, 70% were using contraceptives.

Lessons learned

The study demonstrated that family planning can be integrated into VCT clinics. However, policy-makers and programme managers should carefully consider the characteristics and reproductive health needs of target populations when making decisions about service integration.     

The cost-effectiveness of neonatal screening for Cystic Fibrosis: an analysis of alternative scenarios using a decision model

Objectives

From a health care provider prospective, to assess the cost-effectiveness of four Antiretroviral therapy (ART) regimens given in addition to voluntary counselling and testing (VCT) for preventing mother-to-child transmission of HIV: a) Zidovudine (AZT); b) Nevirapine (NVP); c) a combination of AZT for early antenatal attenders and NVP for late arrivals; and d) combined administration of AZT and NVP and to assess the incremental cost-effectiveness of adding a second VCT session in late pregnancy.

Design & Setting

We examine a hypothetical cohort of 100,000 pregnancies as a decision model. Cost and outcome parameters are estimated as they would apply under Thai routine health service conditions. Effectiveness probabilities are based on best available evidence, from systematic reviews where possible. The main outcome is the number of cases of paediatric HIV averted.

Results

The combining administration of AZT and NVP is the most cost-effective drug option. One VCT session with AZT+NVP averts 337 cases of infection at 556 USD per case averted, while two VCT with the same drug regimen averts 16 additional cases at cost of 1,266 USD per infection averted. The incremental cost-effectiveness ratio of moving from 1VCT, AZT+NVP to 2VCT, AZT+NVP is 16,000 USD per additional averted case, which is much lower than the recommended threshold value for HIV infection averted in Thailand. Multivariate uncertainty analysis supports the findings, showing that at a threshold of 35,000 USD, 2VCT, AZT+NVP is preferable to other VCT and drug strategies.

Conclusion

Interventions for preventing mother-to-child transmission of HIV are cost-effective. Further costs and negative effects of drug resistance, are unlikely to outweigh the social benefits of reduce transmission of HIV. This model suggests that the new drug regimen is a cost-effective option in the Thai health system at currently accepted thresholds for adopting health technologies.     

宁波市镇海区艾滋病自愿咨询检测情况分析

目的调查宁波市镇海区艾滋病自愿咨询检测(VCT)人群的社会人口学特征和艾滋病病毒(HIV)感染状况,有针对性的制定镇海区艾滋病健康教育和高危干预措施。方法对2008年1月-2009年12月镇海区VCT门诊求询者的调查结果进行分析。结果 2 111名求询者以15～34岁青壮年为主,占83.94%。男性314名,占14.87%;女性1 797名,占85.13%;男女比例为1:5.72。36.95%未婚,51.63%已婚。初中及以下文化占64.84%。求询原因以非婚异性性行为为主(49.08%)。99.86%接受HIV抗体检测,阳性4例,阳性率为0.19%;以性途径感染为主(75.00%),1人通过同性性行为感染,2人通过异性性行为感染。结论艾滋病自愿咨询检测者主要是青年人,求询原因多样,以非婚异性性行为为主。VCT能有效发现HIV抗体阳性者,应广泛开展VCT工作。     

A survey of risk behaviors for unintended pregnancy and human immunodeficiency virus among youth attending voluntary counseling and testing (VCT) services in nine centers in urban Haiti and Tanzania

Little is known about the behavioral risks for both human immunodeficiency virus (HIV) and unintended pregnancy among sexually active youth attending voluntary counseling and testing (VCT) in developing countries, and whether youth engaging in risky sexual behaviors perceive themselves to be at risk for HIV. Data are from two cross-sectional studies with youth VCT clients in four facilities in Dar es Salaam, Tanzania and five facilities in Port-au-Prince, Haiti. We measured risky behavior for HIV and unintended pregnancy and perceptions of risk among VCT clients who reported ever having had sex. The majority of sexually active clients, 69% of men and 62% of women in Haiti and 65% of men and 60% of women in Tanzania, reported recent risky behaviors for HIV. Clients also reported risk behaviors for unintended pregnancy: 15% of men and 53% of women in Haiti and 21% of men and 29% of women in Tanzania. The majority of clients with risk behaviors in Tanzania, but not in Haiti, perceived themselves at risk. Strategies to meet youth VCT clients' broader reproductive health needs and avoid any missed opportunities should be tested.     

2004～2007年扬州市艾滋病自愿咨询检测资料分析

[目的]了解扬州市艾滋病自愿咨询检测（VCT）门诊求询者有关情况及检测结果,以便提供有针对性的措施。[方法]对20042007年我市VCT门诊求询者信息及检测资料进行分析。[结果]20042007年合计8 438人在门诊接受VCT服务（每年人数分别为461、502、2 943、3 947人）,其中接受检测的6 633人,只咨询未检测的1 805人。在接受检测的6 633人中,HIV抗体阳性的20例,阳性率0.30%（男性17例、阳性率0.41%,女性3例、阳性率0.12%,P〈0.05）;3个月至14岁为0.00%,1524岁为0.05%,2534岁为0.42%,3544岁为0.26%,4584岁为0.63%（P〉0.05）;静脉吸毒者为16.67%,HIV感染者配偶/性伴为11.11%,男男性接触者为5.36%,性病门诊人员为0.10%,其他人员为0%（P〈0.01）。[结论]今后需进一步加强咨询员的培训,重点关注25岁50岁,有静脉吸毒史、HIV感染者配偶/性伴及男男同性性接触者的男性求询者。     

艾滋病项目地区自愿咨询检测服务现况分析

目的 对第三轮中国全球基金艾滋病项目启动以来,项目地区自愿咨询检测(VCT)工作进展状况进行分析。方法 收集项目地区咨询检测点按规范要求完成的所有咨询个案表及其人类免疫缺陷病毒(HIV)抗体检测结果,并进行描述性分析。结果 至2006年底,72个项目县共建立咨询点645个,是项目启动时(149个)的4.33倍,平均为每个咨询检测点培训咨询员5.41人次,每个咨询点月平均提供服务仅7.58人次;项目地区共提供VCT服务134 098人次,接受VCT服务者中以行为状况不详者所占比例最大,占29.46%,其次为孕产妇、性接触者及既往卖血/受血者,所占比例分别为26.4%,20.99%和17.77%。各项目省咨询对象的特征分布也不完全相同;项目地区接受VCT服务的人中HIV抗体的总检出率为2.62%(3516/134098),其中既往卖血/受血或血制品的人群抗体检出率高达10.80%,其次为HIV感染者或患者(PLAHA)配偶/性伴、吸毒人群及性接触,抗体检出率分别为7.45%,2.29%和0.76%;占咨询检测人数的56.06%;其他人群及孕产妇中检出的HIV抗体阳性者仅占总阳性者的7.6%。结论 VCT提高了项目地区VCT服务的能力及可及性;但目前咨询点的利用率较低、VCT服务对高危及重点人群的覆盖不够、部分地区服务目标人群定位仍不清楚等。     

The Use of Adventure Therapy in Community-Based Mental Health: Decreases in Problem Severity Among Youth Clients

Background

There is an increasing need to identify effective mental health treatment practices for children and adolescents in community-based settings, due to current mixed findings of existing interventions. This study looked at adventure therapy (AT) as a viable option to meet this need.

Objective

Using a sample of 1,135 youth from a community-based mental health center, this study addressed the following questions: (1) Is AT an effective treatment modality for youth compared to traditional counseling? (2) How do changes in problem severity associated with participation in AT-based interventions compare with those associated with traditional counseling across gender, age, primary diagnosis, and race? (3) What are the predictors of changes in problem severity in clients?

Methods

In this exploratory non-equivalent groups quasi-experimental design study, pre- and post- mean scores of problem severity as reported by youth’s primary clinician were compared by type of treatment and client characteristics. Treatment and client characteristics were used as predictors of changes in problem severity.

Findings

Participants in AT had significant reported mean decreases in problem severity larger than those of clients not involved in counseling with an adventure component with larger decreases in female and African American clients. AT and psychological counseling were found to be significant predictors of decreases in problem severity; however, length of counseling, not length of AT, was a significant predictor.

Discussion

These findings suggest that community-based AT may be a viable treatment for youth in community settings; yet these findings should be interpreted with caution due to several study limitations.     

Rapid operation assessment of voluntary HIV counselling and testing services in three cities in China, 2009

Objectives

To assess the operation of voluntary counselling and testing (VCT) services for human immunodeficiency virus (HIV) in three cities in China.

Study design

A cross-sectional study using mixed methods, including focus group discussions, in-depth interviews, field assessment, archive checking and structured questionnaire interviews, was conducted to assess different aspects of VCT services.

Methods

Surveys were undertaken in six counties of three China Global Fund AIDS Program (Round Five) cities, including 11 VCT clinics, 38 counsellors, 83 clients and 332 individuals at risk for HIV infection.

Results

All counsellors were trained and approved for providing counselling. As there were adequate numbers of clinics and counsellors, VCT services ran smoothly. Clients were generally satisfied with VCT services and considered service operation to be adequate. Problems with the VCT programme included fewer VCT services in general hospitals, lack of a referral mechanism, and long delays between testing and receipt of results.

Conclusions

The operation of VCT services in the three cities was generally adequate, but referral services were poor. More attention needs to be paid to HIV testing and counselling in general hospitals, and referral networks need to be strengthened.     

湖北省2013年VCT人群HIV抗体筛查阳性率及影响因素

目的 了解湖北省2013年艾滋病自愿咨询检测(VCT)情况,并探讨其影响因素,为调整VCT策略提供依据。方法 对2013年湖北省333个VCT门诊求询者的人口学信息、求询者类型和主要求询原因以及艾滋病病毒(HIV)抗体检测情况进行统计分析。结果 共有57378人接受了自愿咨询检测,其中56654人接受了HIV抗体筛查,筛查率为98.74%(56654/57378),查出HIV抗体阳性442人,阳性率为0.78%(442/56654)。求询者类型以主动求询为主,占91.96%(52099/56654)。求询原因以非商业非固定异性性行为和商业异性性行为为主,分别占34.23%(19390/56654)、30.87%(17489/56654)。HIV抗体阳性率最高的是男男性行为者,达6.88%(145/2109),其次是配偶/固定性伴阳性者,为5.47%(61/1116)。多因素logistic分析显示,年龄、求询者类型、咨询单位以及既往检测情况等4个因素与求询者HIV抗体阳性率有关。结论 将VCT与医疗机构开展医务人员主动提供HIV检测咨询相结合,要加强男男性行为者和老年人检测后咨询及干预力度。     

大理市艾滋病自愿咨询检测结果分析

目的:了解大理市艾滋病自愿咨询检测(VCT)者的社会人口学特征及艾滋病毒(HIV)感染状况,及时发现HIV感染者和艾滋病患者,有针对性地制定大理市艾滋病健康教育和高危行为干预措施。方法:对2007年-2008年,大理市疾病预防控制中心艾滋病VCT门诊求询者的调查结果进行分析。结果:两年来VCT门诊求询者共1361人次,HIV抗体总阳性率13.44%;求询者以20岁～40岁的青壮年为主,占64.95%;男女性别比为1.27∶1;求询原因以发生危险性行为为主,静脉吸毒人群的HIV抗体阳性率最高。结论:VCT门诊是发现HIV感染者/病人及实施行为干预的重要窗口。     

湖南省2006年艾滋病自愿咨询检测工作情况分析

目的分析湖南省艾滋病自愿咨询检测工作的开展情况。方法利用卫生部统一下发的《艾滋病自愿咨询检测统计报表》进行数据收集,对全省艾滋病自愿咨询检测工作开展的相关情况进行分析。结果2006年全省137个自愿咨询检测点共接受咨询67942人,其中59593人接受了HIV初筛检测,检测率为87.71%,初筛阳性681例,确认阳性人数540人。HIV阳性人群中占比例最高的是吸毒人群,占49.8%,最低的是职业暴露人群,为0%。从求询者类型来看,前来接受咨询的人群以男性异性性接触者为主,占43.4%,其次是女性异性性接触和吸毒人群,分别占15.15%和14.4%。结论艾滋病自愿咨询检测工作起到了宣传HIV知识,发现感染者的作用,今后应对HIV感染高危人群进一步加大工作力度,吸引更多的人来接受咨询和检测服务。     

Evaluation of uptake and attitude to voluntary counseling and testing among health care professional students in Kilimanjaro region, Tanzania

Background  

Voluntary counseling and testing (VCT) is a corner stone for successful implementation of prevention, care and support services among HIV negative and positive individuals. VCT is also perceived to be an effective strategy in risk reduction among sexually active young people.. This study aimed to assess the acceptability of VCT and its actual uptake among young health care professional students at KCM College of Tumaini University and Allied health schools.     

Suicidal ideation and HIV risk behaviors among a cohort of injecting drug users in New Delhi, India

Background

Data on mental health among injecting drug users in South Asia is scarce yet poor mental health among users has significant implications for the success of HIV prevention and treatment programmes. A cohort of 449 injecting drug users in Delhi was examined on the following issues (1) examine trends in suicidal ideation, suicide plan and suicidal attempts over a 12-month period, (2) examine association between injecting practices (receive and give used syringes) and suicidal ideation over a 12 month study period.

Methods

An observational study was conducted providing phased interventions with follow up interviews every 3 months to 449 injecting drug users (IDUs), from August 2004 to November 2005. The study was conducted in Yamuna Bazaar, a known hub of drug peddling in Delhi. Interventions included nutrition, basic medical services, needle exchange, health education, HIV voluntary counseling and testing, STI diagnosis and treatment, oral buprenorphine substitution, and detoxification, each introduced sequentially.

Results

Suicidal ideation and suicide attempts, did not significantly change over 12 months of observation, while suicide plans actually increased over the time period. Keeping other factors constant, IDUs with suicidal ideation reported more giving and receiving of used syringes in the recent past. Conclusions: Mental health services are warranted within harm reduction programmes. Special attention must be paid to suicidal IDUs given their higher risk behaviours for acquiring HIV and other blood borne infections. IDU intervention programmes should assess and address suicide risk through brief screening and enhanced counseling.     

Survey of motivation for use of voluntary counseling and testing services for HIV in a high risk area of Shenyang, China

Background  

HIV voluntary counseling and testing (VCT) is considered an effective prevention method of HIV infection. In order to understand the VCT environment and enhance the effective delivery of VCT services in a country, an accurate assessment of the current status of VCT services is very important.     

Association between expatriation and HIV awareness and knowledge among injecting drug users in Kabul, Afghanistan: A cross-sectional comparison of former refugees to those remaining during conflict

Background

Little is known about human immunodeficiency virus (HIV) awareness among Afghan injecting drug users (IDUs), many of whom initiated injecting as refugees. We explored whether differences in HIV awareness and knowledge exist between Afghan IDUs who were refugees compared to those never having left Afghanistan.

Methods

A convenience sample of IDUs in Kabul, Afghanistan was recruited into a cross-sectional study through street outreach over a one year period beginning in 2005. Participants completed an interviewer-administered questionnaire and underwent voluntary counseling and testing for HIV, syphilis, hepatitis B surface antigen, and hepatitis C antibody. Differences in HIV awareness and specific HIV knowledge between IDU who lived outside the country in the last decade versus those who had not were assessed with logistic regression.

Results

Of 464 IDUs, 463 (99%) were male; median age and age at first injection were 29 and 25 years, respectively. Most (86.4%) had lived or worked outside the country in the past ten years. Awareness of HIV was reported by 46.1%; those having been outside the country in the last decade were significantly more likely to have heard of HIV (48.3% vs. 31.7%; OR = 2.00, 95% CI: 1.14 – 3.53). However, of those aware of HIV, only 38.3% could name three correct transmission routes; specific HIV knowledge was not significantly associated with residence outside the country.

Conclusion

Accurate HIV knowledge among Afghan IDUs is low, though former refugees had greater HIV awareness. Reported high-risk injecting behavior was not significantly different between IDU that were refugees and those that did not leave the country, indicating that all Afghan IDU should receive targeted prevention programming.     

Information systems on human resources for health: a global review

Background

Although access to life-saving treatment for patients infected with HIV in South Africa has improved substantially since 2004, treating all eligible patients (universal access) remains elusive. As the prices of antiretroviral drugs have dropped over the past years, availability of human resources may now be the most important barrier to achieving universal access to HIV treatment in Africa. We quantify the number of HIV health workers (HHWs) required to be added to the current HIV workforce to achieve universal access to HIV treatment in South Africa, under different eligibility criteria.

Methods

We performed a time and motion study in three HIV clinics in a rural, primary care-based HIV treatment program in KwaZulu-Natal, South Africa, to estimate the average time per patient visit for doctors, nurses, and counselors. We estimated the additional number of HHWs needed to achieve universal access to HIV treatment within one year.

Results

For universal access to HIV treatment for all patients with a CD4 cell count of ≤350 cells/μl, an additional 2,200 nurses, 3,800 counselors, and 300 doctors would be required, at additional annual salary cost of 929 million South African rand (ZAR), equivalent to US$ 141 million. For universal treatment (‘treatment as prevention’), an additional 6,000 nurses, 11,000 counselors, and 800 doctors would be required, at an additional annual salary cost of ZAR 2.6 billion (US$ 400 million).

Conclusions

Universal access to HIV treatment for patients with a CD4 cell count of ≤350 cells/μl in South Africa may be affordable, but the number of HHWs available for HIV treatment will need to be substantially increased. Treatment as prevention strategies will require considerable additional financial and human resources commitments.