Botswana: We Need Privacy in HIV Tests - the Disabled

By, Thato Chwaane, Mmegi/The Reporter (Gaborone), December 20, 2006

The president of Botswana Association of the Deaf, Maggie Mapharing and an intern at BONELA, Shirley Keoagile, have cried foul at being left behind in the intervention strategies in the fight against HIV.

"It is difficult for us to go for HIV tests due to lack of confidentiality. This is because we have to go with sign language interpreters, which compromises our right to confidentiality," Keoagile said. She said confidentiality is important in HIV testing, and lack of it or the absence of a guarantee it becomes a hindrance.

Both Mapharing and Keoagile have a hearing impairment and are advocates for people with disability.

Keoagile said there are many who are HIV positive but cannot come out in the open for fear of further discrimination and stigma.

"Very few of us are aware about HIV and have less confusing information. However, illiteracy is the barrier we are facing because most of us do not know how to read sign languages or can lip-read," she said.

Keoagile said at the recent workshop on HIV/AIDS and the deaf, where they were taught on different issues such as ARV, PMTCT, CD4 count among others, it was evident that people were still behind in their awareness. She said although three quarters of the participants tested for HIV, she wondered who would assist them once they got home. She said that communication with people with hearing impairment was a big challenge even to family members.

She said interpretation conducted at the workshop was made in American Sign Language used in textbooks in schools, however it is different from Botswana sign language. She said the message should be clear and that they are people in need of special attention. "Is it not a violation of human rights, if one is tested when they are not ready?" she asked.

Keoagile works on a project of HIV/AIDS, human rights and people with disabilities at BONELA.

Mapharing noted that she had a sick client whom she took to the hospital. "I had to be by her side when waiting for the results, and when they came out, she broke down," she said.

She said that she had to continue to assist her, even going with her for regular check-ups until she was able to accept her situation. "Imagine it was only one client, and it was so burdensome. But where is the privacy and confidentiality?" she asked.

They noted that there was no single board member with a disability championing the cause for the disabled at Botswana Society for Disabled.

Mapharing said one "needs to understand why they should go for an HIV test or how HIV infection is transmitted". She said through Botswana sign language, more people could hear and understand why they needed to test. Mapharing said there is a need of strong campaign and community outreach, education on pregnancy, sexual reproductive health including targeting of parents. She said there was need for people to learn the deaf culture in order to communicate. "Otherwise they (the deaf) will be lost and remain in the dark," she said.

The two called for sufficient interpreters who are able to interpret in Botswana sign language, not volunteers who abandon their duties. "Botswana needs to promote its own sign language through research and consultation," she said.

Mapharing said by next year, she is hopeful of Sign Language Council or even an introduction of the course at the University of Botswana and eventually a dictionary.


Source: http://allafrica.com/stories/200612200892.html

WHO: Provider-initiated HIV testing and counselling in health facilities

WHO/UNAIDS Guidance on Provider-initiated HIV Testing and Counselling in Health Facilities, November 27, 2006

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.
• 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.

• 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.

• 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:

• STI services
• Health services for most-at-risk populations
• 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:

• The reasons why HIV testing and counselling is being recommended
• The clinical and prevention benefits of testing, as well as the potential adverse outcomes
• The fact that the patient has the right to decline the test and that testing will be performed unless the patient exercises that right
• The fact that declining the test will not affect the patient's access to services that do not depend upon knowledge of HIV status
• The follow-up services that are available in the case of either an HIV-negative or an HIV-positive test result
• In the event of an HIV-positive test result, encouragement of disclosure to other persons unknowingly at risk of exposure to HIV
• An opportunity to ask the health care provider questions.

Additional pre-test information for women who are or may become pregnant should include:

• The risks of HIV transmission to infants
• Measures that can be taken to reduce mother-to-child transmission, including antiretroviral prophylaxis and infant feeding counselling
• 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:
• An explanation of the test result
• 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:

• Explain the result simply and clearly, and give the patient time to consider it
• Ensure that the patient understands the result
• Allow the patient to ask questions
• Help the patient cope with emotions arising from the test result
• 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
• Describe follow-up support available in the health facility and in the community
• 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

• Provide information on how to prevent transmission of HIV, including provision of condoms
• 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
• Discuss possible disclosure of the result, when and how this may happen and to whom
• Encourage and offer support for testing and counselling of partners and children
• 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:

• Use of antiretroviral drugs to prevent MTCT, and for her own health, when indicated and available
• Childbirth plans
• Adequate maternal nutrition, including iron and folic acid
• Infant feeding options and support to carry out the mother’s infant feeding choice
• 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 blog or write to tina@aidscarewatch.org

KENYA: Muslim women in the north defy custom to fight AIDS

By, IRIN PlusNews, November 9, 2006

LODWAR - A group of Muslim women in the dusty town of Lodwar, northern Kenya, are breaking with tradition to speak openly about HIV/AIDS and other sexually transmitted diseases.

As in many Muslim societies, the people of Lodwar, in the district of Turkana, have a deep-seated aversion to discussing sexual matters, but the reality of the epidemic has forced them to educate themselves about it.

Many of the female members of Lodwar's mosque attend a weekly meeting where they give each other support and advice. Each of the 51 members is asked to donate 50 shillings (US$0.70) every week, which is then given to a member in need or on a rotational basis. The small sums raised come in very handy for some of the elderly women in the group who are looking after children orphaned by AIDS and women who are already infected and need additional care.

Merlin, a UK-based medical NGO, has visited the women's group to provide voluntary counselling and testing services and HIV/AIDS education.

"At first it was very difficult, as many Muslims refuse testing; many believe that you are working as a commercial sex worker [if you go for testing]," said Amina Bashair, the group's chairwoman. "Once we had received some education, we realised that it was not true and would not bring shame on our religion, so some of our group volunteered for testing."

The meetings encourage the women to be more open with their questions about HIV/AIDS. "It was the first time I had heard of such a thing; it was very informative," said Alima Nakwa, an elderly member of the group after the Merlin visit.

"Before, people from the mosque were dying but we didn't know how," said Rukia Imoni, another member. "Now we know that it was AIDS and [will] not be scared."

The use of condoms is rare in Turkana, and some of the women said they would have no idea where to get them. During Merlin's educational session they were shown how to use a condom, a first for most of them. "It was something so strange to me; what it is and what it can do," said Imoni.

The risks to the women in Turkana, where the HIV prevalence is 11.4 percent - twice the national average - are many: "The men are polygamous and this increases the risk; some men are also unfaithful," said Bashair. The continued use of traditional birth attendants was also "a problem ... as they [birth attendants] do not have access to gloves while birthing", raising the risk of contracting HIV during childbirth if either the woman or the birth attendant is HIV positive.

Men have not been targeted; although they are keen to learn, they feel they need a male educator to teach them. "If a woman was to teach HIV then there should be a curtain [separating her from the men in the Mosque]," said Yahya Asuman, administrator of the Lodwar Islamic Centre, adding that most men wanted to be educated according to Islamic rules. "Only when we get letters from the Ministry of Health do we announce such things."

The Mosque's Imam [senior Muslim scholar] rarely talks about HIV/AIDS or related issues.

Teaching such a conservative society about HIV/AIDS is proving no easy task for the women's group. Turkana has one of Kenya's lowest literacy rates, and the women complained that besides being unable to read the existing literature on the disease, the messages themselves were not aimed at Muslims, who needed to be educated in line with their religious beliefs.

sm/kr/he/kn


Source: http://www.plusnews.org/AIDSReport.ASP?ReportID=6531&SelectRegion=East_Africa&SelectCountry=KENYA

HIV Test, Not a Condition for Employment --Workpolicy

By, Funmi Komolafe, Vanguard (Lagos), December 7, 2006

Nigeria - World Aids Day was marked , Dec. 1st, in the spirit of the day, Labour Vanguard continues its enlightment on the "National Workplace Policy On HIV/AIDS".

This second part of our report, highlights the responsibilities of the employer and the employee in the work place.

Special attention was given to "Protection from Stigma, Discrimination and Exclusion" in Section 8.2.

To protect PLWA, the policy states, "there shall be no obligation placed on employee to reveal his or her HIV/AIDS status to the employer". In order to ensure that they are not discriminated against on account of medical expenses, the policy recommends that "employees living with HIV/AIDS shall not be denied access to statutory benefits and occupationally related welfare schemes". Such persons shall have access to health insurance coverage and " no HIV test shall be imposed as a condition to access any health insurance scheme" and this includes their participation in the National Health Insurance Scheme.

For assurance companies, the policy states "No assurance company shall deny workers access to any insurance coverage on the basis of his or her status".

In order to ensure continuation of employment relationship, the policy states, "HIV infection or AIDS shall not provide a basis for termination of employment. Where fitness to work is compromised by HIV/AIDS and related illness, the employer shall make efforts and arrangements aimed at providing reasonable accomodation for the individual affected".

In order to have access to medicare and counselling, it is recommended that employers should provide flexible hours of work so that PLWA can access counselling, treatment and care during working hours. However, this is expected to be handled on a case by case basis by individual establishments.

Protection of the rights of job seekers.

With the new policy, no employer in Nigeria is expected to subject prospective employees to HIV screening. It is clearly stated that "the only medical criterion for entry to employment is fitness to work and nothing in the pre-employment examination shall oblige or require any candidate to declare his or her HIV status.

For job placements outside the shores of Nigeria, which requires HIV test for placement and residence, the policy states, "the requirement must appear in the vacancy announcement or advertisement for appropriate action by the Federal Ministry of Labour and Productivity and the ministry of foreign affairs.

Consideration was given to PLWA when due for retirement as it is recommended that "a proper retirement strategy will be worked with adequate support being provided for workers living with HIV and AIDS in and out of work in a non discriminatory and non-judgmental manner".

Information and Education - The policy is however not about dos and donts alone.

It provides for information and education as a basis for prevention and control of HIV.

Employers are requested to put in place "effective workplace HIV/AIDS prevention education" for all persons in the workplace in order to protect themselves and their families from HIV infection.

Such an education policy may be developed in collaboration with agencies of government, workers representatives and other concerned groups.

It must also be participatory by enlisting the full support of persons in and around the workplace.

In addition these, workplaces are to encourage social dialogue based using joint consultation which may culminate in consensus/ agreement.

The role of the ministry of labour and productivity.

The Ministry of Labour is expected to provide technical support for HIV/AIDS policy formulation and implementation in each workplace with the establishment of workplace HIV/ AIDS response technical task teams.

It is the duty of the technical team to "provide technical support and guidance for program formulation and implementation including training, HIV and AIDS education and service provision in the work place".

Grievance Procedure

The policy acknowledges that conflits/disagreements may arise in the handling of HIV/AIDS in the workplace. Therefore, it is recommended that "employers shall ensure that the rights of employees with HIV and AIDS, and remedies available to them in the event of breach of such rights become integrated into grievance procedures".

Employers are also obliged to ensure the confidentiality of the complainant during such proceeedings including ensuring that such proceedings are held in private.

To ensure the success of grievance procedure, employers are expected to create an awareness and understanding of the procedure and how employees can ultilize them.

Legal instrument - The policy which is still awaiting legal backing shall be reviewed every three years and "whenever scientific and developmental concerns so dictate. Enterprises are also expected to encourage a review within the same period.

For now, the legal instrument to back up the policy is contained in the bill on Labour Standards now before the national assembly.


Source: http://allafrica.com/stories/200612070887.html

China's worst hit AIDS province plans HIV tests before marriage

By, Muzi.com, December 3, 2006

Officials in China's worst hit AIDS province plan compulsory pre-marital HIV tests as part of a series of tough measures to stem the spread of the fatal virus, state media has said.

Yunnan province, in the nation's southwestern border region with the opium-producing Golden Triangle, will start implementing the measures from January 1, 2007, the Xinhua news agency reported.

"The year 2007 is crucial in our effort to contain AIDS," Zhang Chang'an, director of the provincial AIDS control office, told Xinhua.

"The province will do anything in its power to live up to its promise of containing the spread of AIDS."

Yunnan, a major transit point for drug trade in the region, is now home to one quarter of China's officially reported HIV cases.

The province had 40,157 HIV sufferers at the end of last year, up sharply from 14,905 two years earlier, according to official statistics.

The new rules also oblige people diagnosed with HIV to immediately tell their spouses or partners.

"If they don't, the local disease control department has the authority to do it for them," Xinhua said, citing the rules.

Hu Jia, a Beijing-based AIDS activist, said he was concerned about the rights implications of the new rules.

"The Yunnan pronvicial government is simply motivated by what makes life easier for itself but it violates people's right of privacy," he said.

"It's hard to tell whether someone has informed his spouse or partner, and using a law to ensure it happens is definitely not the way to go."

He said the Yunnan rules did not appear to conform with national policy.

China's cabinet in February issues its first detailed national policy guidelines on dealing with the AIDS epidemic.

The rules said that those who seek information and testing should be given the services for free and no department must reveal the identities of carriers of the virus nor personal information about them without their permission.

While in some parts of China, authorities seek to rein in AIDS with free clinics and needle exchange centers, in other parts officials' first reaction often seems to be an urge to seal off sufferers from the rest of society.

State press reported late last year that the southern province of Guangdong plans to build at least two special prisons for HIV/AIDS inmates to cope with an increasing number of carriers who are serving jail terms.

The report was widely repeated in foreign media, and the foreign ministry eventually issued a denial, saying it merely hoped to improve facilities for HIV sufferers in existing jails.

No one has a precise idea of the extent of the AIDS threat in China, but it is widely assumed that the official statistics severely underestimate the true size of the disaster.

The recent drastic hikes in HIV cases in Yunnan, and in China as a whole, may partly reflect the fact that official data are now gradually catching up with reality.

China's health ministry has said 183,733 people were confirmed with HIV/AIDS at the end of October, a 27.5 percent rise from the end of last year.

The number of confirmed cases is significantly lower than the estimate of 650,000 put forward jointly by the government and United Nations health agencies in January.

But Wan Yanhai, a prominent AIDS activist, has estimated the true number could even be 10 times higher than 650,000, based on research by an awareness group he heads, the Beijing Aizhixing Institute.


Source: http://dailynews.muzi.com/news/ll/english/10027907.shtml?cc=13013&ccr=&a=&ccp=1