From caution to urgency: the evolution of HIV testing and counselling in Africa

Objective

To describe recent changes in policy on provider-initiated testing and counselling (PITC) for human immunodeficiency virus (HIV) infection in African countries and to investigate patients’ experiences of and views about PITC.

Methods

A review of the published literature and of national HIV testing policies, strategic frameworks, plans and other relevant documents was carried out.

Findings

Of the African countries reviewed, 42 (79.2%) had adopted a PITC policy. Of the 42, all recommended PITC for the prevention of mother-to-child HIV transmission, 66.7% recommended it for tuberculosis clinics and patients, and 45.2% for sexually transmitted infection clinics. Moreover, 43.6% adopted PITC in 2005 or 2006. The literature search identified 11 studies on patients’ experiences of and views about PITC in clinical settings in Africa. The clear majority regarded PITC as acceptable. However, women in antenatal clinics were not always aware that they had the right to decline an HIV test.

Conclusion

Policy and practice on HIV testing and counselling in Africa has shifted from a cautious approach that emphasizes confidentiality to greater acceptance of the routine offer of HIV testing. The introduction of PITC in clinical settings has contributed to increased HIV testing in several of these settings. Most patients regard PITC as acceptable. However, other approaches are needed to reach people who do not consult health-care services.     

Opt-out provider-initiated HIV testing and counselling in primary care outpatient clinics in Zambia

Objective

To increase case-finding of infection with human immunodeficiency virus (HIV) in Zambia and their referral to HIV care and treatment by supplementing existing client-initiated voluntary counselling and testing (VCT), the dominant mode of HIV testing in the country.

Methods

Lay counsellors offered provider-initiated HIV testing and counselling (PITC) to all outpatients who attended primary clinics and did not know their HIV serostatus. Data on counselling and testing were collected in registers. Outcomes of interest included HIV testing coverage, the acceptability of testing, the proportion testing HIV-positive (HIV+), the proportion enrolling in HIV care and treatment and the time between testing and enrolment.

Findings

After the addition of PITC to VCT, the number tested for HIV infection in the nine clinics was twice the number undergoing VCT alone. Over 30 months, 44 420 patients were counselled under PITC and 31 197 patients, 44% of them men, accepted testing. Of those tested, 21% (6572) were HIV+; 38% of these HIV+ patients (2515) enrolled in HIV care and treatment. The median time between testing and enrolment was 6 days. The acceptability of testing rose over time.

Conclusion

The introduction of routine PITC using lay counsellors into health-care clinics in Lusaka, Zambia, dramatically increased the uptake and acceptability of HIV testing. Moreover, PITC was incorporated rapidly into primary care outpatient departments. Maximizing the number of patients who proceed to HIV care and treatment remains a challenge and warrants further research.     

Assessing the accessibility of HIV care packages among tuberculosis patients in the Northwest Region,Cameroon

Background  

Tuberculosis (TB) and human immunodeficiency virus (HIV) co-infection is a major source of morbidity and mortality globally. The World Health Organization (WHO) has recommended that HIV counselling and testing be offered routinely to TB patients in order to increase access to HIV care packages. We assessed the uptake of provider-initiated testing and counselling (PITC), antiretroviral (ART) and co-trimoxazole preventive therapies (CPT) among TB patients in the Northwest Region, Cameroon.     

Mistrust in marriage-Reasons why men do not accept couple HIV testing during antenatal care- a qualitative study in eastern Uganda

Background  

A policy for couple HIV counseling and testing was introduced in 2006 in Uganda, urging pregnant women and their spouses to be HIV tested together during antenatal care (ANC). The policy aims to identify HIV-infected pregnant women to prevent mother-to-child transmission of HIV through prophylactic antiretroviral treatment, to provide counseling, and to link HIV-infected persons to care. However, the uptake of couple testing remains low. This study explores men's views on, and experiences of couple HIV testing during ANC.     

Barriers to gender-equitable HIV testing: going beyond routine screening for pregnant women in Nova Scotia,Canada

Background  

Women and men face different gender-based health inequities in relation to HIV, including HIV testing as well as different challenges in accessing HIV care, treatment and support programs and services when testing HIV-positive. In this article, we discuss the findings of a mixed methods study exploring the various individual and structural barriers and facilitators to HIV counselling and testing experienced among a sample of adult women and men living in Nova Scotia, Canada.     

Low HIV testing rates among tuberculosis patients in Kampala,Uganda

Background  

HIV testing among tuberculosis patients is critical in improving morbidity and mortality as those found to be HIV positive will be offered a continuum of care including ART if indicated. We conducted a cross-sectional study in three Kampala City primary care clinics: to assess the level of HIV test uptake among newly diagnosed pulmonary tuberculosis (PTB) patients; to assess patient and health worker factors associated with HIV test uptake; and to determine factors associated with HIV test uptake at the primary care clinics     

Selling sex in unsafe spaces: sex work risk environments in Phnom Penh, Cambodia

Background

Evidence shows that smokers are generally misinformed about the relative harmfulness of nicotine, and smokeless forms of nicotine delivery in relation to smoked tobacco. This study explores changing trends in the beliefs about the harmfulness and use of stop smoking medications and smokeless tobacco in adult smokers in four countries where public education and access to alternative forms of nicotine is varied (Canada, the US, the UK and Australia).

Methods

Data are from seven waves of the ITC-4 country study conducted between 2002 and 2009 with adult smokers from Canada, the US, the UK and Australia. For the purposes of this study, data were collected from 21,207 current smokers. Using generalised estimating equations to control for multiple response sets, multivariate models were tested to look for main effects of country, and trends across time, controlling for demographic variables.

Results

Knowledge remained low in all countries, although UK smokers tended to be better informed. There was a small but significant improvement across time in the UK, but mixed effects in the other three countries. At the final wave, between 37.5% (US) and 61.4% (UK) reported that NRT is a lot less harmful than cigarettes. In Canada and the US, where smokeless tobacco is marketed, only around one in six believed some smokeless tobacco products could be less harmful than cigarettes.

Conclusions

Many smokers continue to be misinformed about the relative safety of nicotine and alternatives to smoked tobacco, especially in the US and Canada. Concerted efforts to educate UK smokers have probably improved their knowledge. Further research is required to assess whether misinformation deters smokers from appropriate use of alternative forms of nicotine.     

Barriers for introducing HIV testing among tuberculosis patients in Jogjakarta,Indonesia: a qualitative study

Background  

HIV and HIV-TB co-infection are slowly increasing in Indonesia. WHO recommends HIV testing among TB patients as a key response to the dual HIV-TB epidemic. Concerns over potential negative impacts to TB control and lack of operational clarity have hindered progress. We investigated the barriers and opportunities for introducing HIV testing perceived by TB patients and providers in Jogjakarta, Indonesia.     

Factors associated with HIV testing among immigrants in Portugal

Objectives  

This paper describes the uptake of HIV testing and its associated factors among a sample of immigrants in Portugal.     

Premarital HIV testing in Malaysia: a qualitative exploratory study on the views of major stakeholders involved in HIV prevention

Background

HIV screening has existed in numerous methods as an important part of HIV prevention efforts over the years. Premarital HIV testing for couples who wish to marry has been implemented in a number of regions, which often operate in a mandatory rather than voluntary basis and is considered a contentious issue, with viewpoints held in favour and against. One such region is Malaysia which has a policy of mandatory premarital HIV testing of prospective Muslim married couples. The purpose of this study is to understand stakeholders’ views on premarital HIV testing given the Malaysian Islamic context.

Methods

35 in-depth face to face semi-structured interviews were undertaken with key stakeholder groups involved in HIV prevention policy in Malaysia, namely, officials from the Ministry of Health, religious leaders and people living with HIV. Participants were recruited from the Klang Valley area, from July to December 2013, using purposive sampling techniques. Inclusion criteria necessitated that participants were over the age of 18 and provided full consent. Interviews were audiotaped, followed a standardised topic guide, transcribed verbatim and analysed using a framework analysis.

Results

Participants identified pre-marital HIV testing as an effective HIV prevention policy implemented in Malaysia and was viewed, for the most part, as a positive initiative across all stakeholders. Religious leaders were supportive of testing as it provides a protective mechanism, in line with the teachings of the Shariah, while Ministry of Health officials considered it a normal part of their HIV prevention screening initiatives. However, there were concerns surrounding issues such as confidentiality, counselling and discrimination surrounding the test described by the PLHIV group.

Conclusion

The findings of this study show that among the participants interviewed was strong support for mandatory premarital HIV testing, which could possibly expose the vulnerability to HIV, reluctance to test and other areas in the HIV response in Malaysia that need to be addressed. Furthermore, although international health organisations are vehemently against mandatory premarital HIV testing, the strong local support for such measures and the mismatch between these views is worth exploring in more detail, given the cultural, social and religious context.

     

Home-based voluntary HIV counselling and testing found highly acceptable and to reduce inequalities

Background  

Low uptake of voluntary HIV counselling and testing (VCT) in sub-Saharan Africa is raising acceptability concerns which might be associated with ways by which it is offered. We investigated the acceptability of home-based delivery of counselling and HIV testing in urban and rural populations in Zambia where VCT has been offered mostly from local clinics.     

Understanding patient acceptance and refusal of HIV testing in the emergency department

Background  

Despite high rates of patient satisfaction with emergency department (ED) HIV testing, acceptance varies widely. It is thought that patients who decline may be at higher risk for HIV infection, thus we sought to better understand patient acceptance and refusal of ED HIV testing.     

Perception of risk of vertically acquired HIV infection and acceptability of provider-initiated testing and counseling among adolescents in Zimbabwe

Objectives. We investigated attitudes toward provider-initiated HIV testing and counseling (PITC) in the suburbs of Harare, Zimbabwe, where late presentation after mother-to-child HIV transmission (MTCT) is a major cause of adolescent mortality.Methods. Adolescents (10–18 years) attending 2 primary clinics were offered PITC. Participants completed a questionnaire investigating acceptability of PITC, and in-depth interviews with 41 adolescents and 30 guardians explored understanding of long-term survival after MTCT.Results. Of 506 participants, 16 were known to be HIV-positive; of the remaining 490, only 5 (1%) declined HIV testing. Infected adolescents and their guardians often anticipated a positive result and reported being advised by relatives (but not health workers) to be tested because of chronic illness, especially if parents or siblings had died or were HIV-infected. However, HIV-negative participants were not aware that long-term survival following MTCT could occur. All adolescents felt that HIV diagnosed at their age would be assumed to have been sexually acquired regardless of the true mode of transmission.Conclusions. Including late diagnosis of MTCT in pretest counseling and health educational messages may facilitate PITC for older children and adolescents, especially for those who have not had their sexual debut.Almost 3 decades after the emergence of the HIV epidemic, underdiagnosis of HIV infection remains a significant issue globally, with more than 60% of adult HIV infections remaining undiagnosed in sub-Saharan Africa.1 Much attention has been given to facilitating HIV diagnosis in adults through provision of testing services in a variety of settings.1 The most notable change in recent years has been a shift from client-initiated to provider-initiated HIV testing and counseling (PITC) in adults, which has much lower costs per HIV-positive person tested than alternative strategies.2,3 International guidelines recommend routine PITC for all people seen in health facilities during generalized HIV epidemics as part of universal access to HIV testing and care.4 Routine implementation of PITC effectively increases uptake of HIV testing in a variety of health care settings.5–10In recent years, late presentation of vertically acquired HIV infection has become an increasingly important cause of adolescent mortality and serious morbidity in southern Africa. This trend reflects high regional HIV prevalence rates during the 1990s, lack of interventions to prevent mother-to-child transmission (MTCT) at that time, and the passage of enough time for HIV-infected infants who are long-term survivors to reach adolescence.11,12 It is now recognized that the probability of long-term survival following MTCT was greatly underestimated in the early days of the HIV epidemic. Although only about half of infected infants survive their first 2 years without antiretroviral treatment, about a quarter will live 10 years or more.13–15Infants born in southern Africa during the late 1990s were exposed to exceptionally high risks of acquiring HIV infection, with no effective prevention interventions in place and national antenatal surveys of pregnant women showing an HIV prevalence of 30% or higher in several countries, including Zimbabwe.16 Although infant diagnosis is well established, the need to consider HIV in acutely or chronically unwell older children has not been emphasized, leaving guardians and health providers alike potentially unaware of the high risk of HIV as the underlying cause of ill health in older children and adolescents in this region.12,17 Without this awareness, older children may not be offered HIV testing and guardians may feel unable to raise their suspicion of HIV with health providers, resulting in failure to diagnose underlying HIV despite frequent consultations. HIV testing of minors also requires consent from a legal guardian, a potential barrier that may be compounded by changing or informal guardianship due to parental death.18,19 Orphans may be further disadvantaged by poverty and suboptimal parenting.20–22Zimbabwe has experienced a severe HIV epidemic, with antenatal HIV prevalence rates peaking at 30% in 1997 and currently at 15% among adults and 6.8% among 15- to 19-year-old adolescents.23–26 HIV prevalence among 10-year-old children is estimated to be around 3%, with more than 70% of adolescents with HIV infection acquired through MTCT still undiagnosed.15,27,28 Zimbabwe has moved toward provision of PITC for adults in all health facilities, but children are not routinely offered PITC. Oral consent from a legal guardian is required, but not written consent or documentation of legal guardianship.We investigated the perception of risk of HIV infection and acceptability of PITC among adolescents attending primary health care facilities, the predominant source of health care in Zimbabwe.     

Missed opportunities for earlier HIV testing and diagnosis at the health facilities of Dessie town,North East Ethiopia

Background  

For patients in all health-care settings HIV screening is recommended after the patient is notified that testing will be performed unless the patient declines. The nation's physicians and other health care providers should assume a much more active role in promoting HIV testing. The aim of this study was to investigate the extent to which missed opportunities for earlier HIV testing and diagnosis occur in the health facilities of north east Ethiopia.     

Uptake of HIV testing and HIV positivity among presumptive tuberculosis patients at Puducherry,South India

Setting:

Puducherry, a district in South India with a low prevalence of human immunodeficiency virus (HIV) infection (<1% among antenatal women).

Objectives:

1) To estimate the proportion of patients with known HIV status who were HIV-positive, 2) to describe the demographic and clinical characteristics of patients with unknown HIV status among presumptive TB patients, and 3) to assess the additional workload at HIV testing centres.

Design:

In this cross-sectional study, consecutive presumptive TB patients attending microscopy centres for diagnosis during March–May 2013 were asked if they knew their HIV status. Patients with unknown HIV status were offered voluntary counselling and HIV testing.

Results:

Of 1886 presumptive TB patients, HIV status was ascertained for 842 (44.6%); 28 (3.3%) were HIV-positive. The uptake of HIV testing was significantly higher in younger age groups, males, residents of Puducherry and smear-positive TB patients. The median increase in the number of clients tested for HIV per day per testing centre was 1 (range 0–6).

Conclusion:

The uptake of HIV testing was low. HIV prevalence was higher among presumptive TB patients than in antenatal women, and as high as in TB patients. With minimal increase in workload at HIV testing centres, HIV testing could be implemented using existing resources.     

Acceptability of HIV counselling and testing among tuberculosis patients in south Ethiopia

Background  

To benefit from available care and treatment options, patients should first be counselled and tested for HIV. Our aim was to assess the acceptability of HIV testing among tuberculosis patients under routine care conditions in south Ethiopia.     

Geographical information system and access to HIV testing, treatment and prevention of mother-to-child transmission in conflict affected Northern Uganda

Objectives  

Using Geographical Information System (GIS) as a tool to determine access to and gaps in providing HIV counselling and testing (VCT), treatment (ART) and mother-to-child transmission (PMTCT) services in conflict affected northern Uganda.     

The voluntary HIV counselling and testing service in Kenema District, Sierra Leone, 2004-2006: a descriptive study

Background  

Voluntary counselling and testing (VCT) is an important component of national HIV programs, which are necessary to realize the right to health. VCT data also provide valuable information on regional HIV epidemiology.     

Practicing provider-initiated HIV testing in high prevalence settings: consent concerns and missed preventive opportunities

Background  

Counselling is considered a prerequisite for the proper handling of testing and for ensuring effective HIV preventive efforts. HIV testing services have recently been scaled up substantially with a particular focus on provider-initiated models. Increasing HIV test rates have been attributed to the rapid scale-up of the provider-initiated testing model, but there is limited documentation of experiences with this new service model. The aim of this study was to determine the use of different types of HIV testing services and to investigate perceptions and experiences of these services with a particular emphasis on the provider initiated testing in three selected districts in Kenya, Tanzania, and, Zambia.