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
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
posted by AIDS-Care-Watch at 10:45 am
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Thanks
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