6 курс / Кардиология / Kartikeyan_HIV and AIDS-Basic Elements and Properties
.pdfCounselling |
309 |
Victims of Rape: Counselling helps to prepare victims of rape for a positive result of HIV test. The client should be informed about use of ARV drugs for PEP. The client may be referred to a counsellor who has experience of counselling rape victims on issues such as safe abortion and STI testing and treatment (CDC, 1995).
Occupational Exposure: Health care providers who have been exposed to HIV should be advised to
(a)Abstain from unprotected sex and to avoid pregnancy until a HIV seronegativity is confirmed
(b)Avail of ARV therapy for PEP
(c)Periodically undergo repeat HIV test as advised (NACO, Training Manual for Doctors)
Young People: Counselling services must cater to the specific needs of young people, and take into account the social context of their lives, since they comprise more than 50 per cent of newly infected persons worldwide. The counselling needs to be age-appropriate, using familiar language, and examples (CDC, 1995).
IDUs: Personalised interactive models of counselling that set goals for the client may be successfully use these models for bringing about behaviour changes and thereby reducing the risk of contracting HIV infection. IDUs ought to be referred to deaddiction and rehabilitation services (CDC, 1995).
Terminally Ill Patients and their Families: Many terminally ill patients may opt for home care. Counselling can help in providing emotional support to the terminally ill patient, his or her family members, relatives and friends and mentally prime them to deal with impending death. The counsellor should impart information on
(a)Home care of the patients, precautions while handling patient’s body fluids and handling the patient’s body after death
(b)Legal issues (Will, pensions, and power of attorney)
(c)Occupational issues (sick leave and loss of capacity to work)
Psychiatric interventions including specific counselling may be necessary.
20.8 – REFERRALS
20.8.1 – Types of Referrals
Source Referral: In this type of referral, HIV-positive clients are encouraged to counsel their partners about the possibility of their exposure to HIV. Health care providers are not directly involved, but they advise the affected person about the nature of information to be passed on to their partners, and the ways of doing it.
Provider Referral: The source client is encouraged to reveal the names of partners. The counsellor confidentially counsels the partner directly, without revealing the name of the source client to the partners.
medwedi.ru
310 |
HIV and AIDS |
Conditional Referral: The health care providers obtain the names of partners from the source client, who is then allowed a reasonable time period to counsel his or her partners. Failing this, the health care provider or counsellor directly counsels the partners, without naming the concerned client (UNAIDS/WHO, 2000).
20.8.2 – Procedure for Referrals
A client availing of counselling services may require referral to treatment, care, and support services. The counsellor should discuss client’s stated needs and willingness to receive referral services, explain what the client should expect from the referral, ask the client if there are places he or she would prefer. If more than one facility provides the same service, a written referral note is given to the client, recording the services that the client has availed of. If any service has not been used, the reasons for not utilising services are listed. This will reveal how responsive specific services are to the needs of the clients (CDC, 1995).
20.9 – EVALUATION OF COUNSELLING
20.9.1 – Keeping Records of Counselling Sessions
Recording the client’s consent and his or her HIV test results, securely storing confidential information in filing cabinets, keeping records of the counselling sessions, and jotting down the salient points or words are important aspects of record keeping. The salient points or words may be used to complete the records after the session. Writing during the counselling sessions may distract the client. Record keeping will permit continuity, even if there are different counsellors for subsequent sessions and prevent the client from having to repeat the same information from the previous session (CDC, 1995).
20.9.2 – Methods for Evaluation
Since direct observation of a counselling session is difficult due to the confidential nature of HIV counselling, following methods may be used for evaluation: taping the session with the client’s consent, using “dummy” clients, role play, and using feedback from clients through “client satisfaction surveys” (CDC, 1995; UNAIDS, 2000).
20.9.3 – Areas for Evaluation
The quality of counselling is evaluated in the following areas:
(a)Interpersonal relationship
(b)Gathering information
(c)Giving correct and comprehensible information, and handling special situations (CDC, 1995; UNAIDS, 2000)
Counselling |
311 |
Where named-based or coded reporting is used, it is necessary to periodically assess the degree of incomplete reporting, incomplete diagnosis, and duplication (multiple reporting) of cases (UNAIDS/WHO, 2000).
20.10 – IMPROVING COUNSELLING SERVICES
20.10.1 – Strategies for Supporting Counsellors
1.Regular supervision of counselling sessions
2.Periodic training sessions and seminars for acquiring new skills
3.Conducting case conferences to address issues and difficulties that arise during counselling sessions
4.Providing opportunities for peer support/sharing of skills and experiences
5.Arranging for regular support from mentors (professionals carrying out similar work who provide support to staff) who can help in the professional growth of the counsellors
6.Preventing “burnout” of counsellors by limiting the number of clients a counsellor can see in a day or a week (CDC, 1995)
20.10.2 – Confidentiality and Security of Information
It is essential to develop infrastructure such as data storage and transmission systems that ensure the physical security of data and electronic security of computer files. Legislation to protect against breaches of confidentiality and prevent non-public health use of data will increase public confidence in surveillance (UNAIDS/WHO, 2000; CDC, 1995).
REFERENCES
Centers for Disease Control and Prevention (CDC), 1995, US Public Health Service Recommendations for HIV Counselling and voluntary testing for HIV of pregnant women. Morb Mort Wkly Rep 44: 1–15.
Gielen A.C., O’Campo P., et al., 1997, A woman’s disclosure of HIV status – experiences of mistreatment and violence in an urban slum setting. Women’s Health 25(3): 19–31.
Gottlieb M.S., 2001, AIDS – past and future. N Engl J Med 344: 1788–1790.
National AIDS Control Organisation (NACO), 2001–2002. HIV/AIDS handbook for counsellors (2001–2002). New Delhi: Government of India.
National AIDS Control Organisation (NACO). Training manual for doctors. New Delhi: Government of India.
New Mexico AIDS Education and Training Center, 2006, Fact Sheet 151. Safer sex guidelines. University of New Mexico Health Sciences Center. www.aidsinfonet.org. Revised 18 July.
New Mexico AIDS Education and Training Center, 2006, Fact Sheet 207. Vaccinations and HIV. University of New Mexico Health Sciences Center. www.aidsinfonet.org. Revised 15 March.
New Mexico AIDS Education and Training Center, 2006, Fact Sheet 800. Nutrition. University of New Mexico Health Sciences Center. www.aidsinfonet.org. Revised 1 May.
New Mexico AIDS Education and Training Center, 2006, Fact Sheet 801. Vitamins and minerals. University of New Mexico Health Sciences Center. www.aidsinfonet.org. Revised 18 April.
medwedi.ru
312 |
HIV and AIDS |
New Mexico AIDS Education and Training Center, 2006, Fact Sheet 802. Exercise and HIV. University of New Mexico Health Sciences Center. www.aidsinfonet.org. Revised 14 February.
Semba R.D., et al., 1994, Maternal vitamin A deficiency and mother to child transmission of HIV- 1. Lancet 343: 1593–1597.
UNAIDS/WHO, 1999, HIV in pregnancy – a review. Occasional Paper No. 2. Joint United Nations Programme on HIV/AIDS 1999, pp 6–37.
UNAIDS/WHO, 2000, Opening up the HIV/AIDS epidemic. www.unaids.org. August.
UNAIDS, 1999, Counselling and voluntary HIV testing for pregnant women in high HIV prevalence countries – elements and issues. UNAIDS Best Practice Collection, 99.44E. www.undaids.org UNAIDS, 2000, Tools for evaluating HIV voluntary counselling and testing. UNAIDS Best
Practice Collection, 00.09E. www.unaids.org
United Nations, 1998, HIV/AIDS and human rights – international guidelines. New York: United Nations. HR/PUB/98/1:13.
WHO/UNAIDS, 1999. Questions and answers on reporting, partner notification, and disclosure of HIV and/or AIDS sero-status – Public Health and Human Rights implications. www.who.int
CHAPTER 21
VOLUNTARY COUNSELLING AND TESTING SERVICES
Abstract
VCT is a process by which an individual undergoes counselling, enabling him or her to make an informed choice about being tested for HIV. VCT strategy promotes knowledge and awareness about HIV infection and safer sexual practices, encourages community response in developing support systems for HIV-affected individuals, allows potential clients to decide whether to take the HIV test and promotes behaviour change to prevent the transmission of HIV. This can be an entry point for provision of various HIV-related services. In functionally integrated VCT models, most key services, including HIV testing are outsourced while structurally integrated VCT models provide key services, including in-house HIV testing. Programme managers need to know the potential challenges associated with integration of VCT in family planning settings, so that they can take these into account during the planning stages. For successful integration, both qualitative and quantitative methods should be used to assess the organisational objectives, internal capacity of the organisation, resources needed to integrate the services, community needs, and cultural, social, and economic barriers to accessibility of services.
It is essential to increase the access to VCT services through a variety of settings. Among other suggested models for VCT are provision of HIV counselling along with family planning counselling in antenatal and postnatal care settings, free-standing services, private sector models, home-testing, outreach programmes, and social marketing. Youth seem to prefer VCT along with other youth-friendly services such as skill building courses, and sports activities. Innovative approaches are necessary to reach groups such as pregnant women, out-of-school youth, and IDUs.
Key Words
Assessment of Community, Confidentiality, Counselling, Family planning, Models for VCT, Operational assessment, Organisational assessment, Shared confidentiality, Voluntary counselling and testing
21.1 – INTRODUCTION
VCT is a process by which an individual undergoes counselling, enabling him or her to make an informed choice about being tested for HIV (UNAIDS, 2000). Counselling is a confidential dialogue between the client and the health care provider, which enables the client to take realistic personal decisions. Any person (professionally trained counsellor, doctor, nurse, paramedical worker or
313
medwedi.ru
314 |
HIV and AIDS |
volunteer) with necessary patience, dedication, commitment, aptitude, knowledge, and skills can undertake counselling. Preand post-test and follow-up counselling is offered to any client who is contemplating about taking the HIV test. The strategy of combining counselling services with voluntary testing gives prospective clients the informed choice to know their HIV status and to decide whether or not to take the HIV test.
21.1.1 – Issues in VCT
Ideally, each country should determine the procedures for informed consent for using VCT services. Involvement of parents or guardians while testing and reporting results of adolescents is a key issue. According to the Kenyan National VCT Guidelines issued in 2001, “mature minors” do not need parental consent. Mature minors include those individuals younger than 18 years who are “married, pregnant, parents, engaged in behaviour that puts them at risk, or are child sex workers”. Though the HIV test results are to be disclosed only to the client, the guidelines say that counsellors should encourage those younger than 18 years to inform their parents about the results (NASCOP, 2001). Among 240 young people tested in Kenya and Uganda, fewer than one-fourth told their parents about their test results (Horizons Program, 2001). Another issue is that clients report to VCT centres after onset of non-herpes skin eruptions or herpes zoster. There were no significant gender differences in the distribution of these conditions in a study conducted in western India (Maredia et al., 2004).
21.2 – UTILITY OF VCT SERVICES
Utility for the Community: VCT strategy promotes knowledge and awareness about HIV infection and safer sexual practices. It also encourages community response in developing support systems for HIV-affected individuals. It allows potential clients to decide whether to take the HIV test (UNAIDS, 2000; UNAIDS, 2001). It is an effective strategy for promoting behaviour change to prevent the transmission of HIV (UNAIDS, 2001). This can be an entry point for provision of various HIV-related services, such as prevention of MTCT (PMTCT), clinical management of HIV-related illnesses, and provision of support services (psychological, social, and legal).
Utility for HIV-Infected Clients: This strategy enables early initiation of desirable behaviour changes to prevent transmission of infection and reinfection. It empowers the individual to cope with the diagnosis, take informed decisions about informing sexual partners, sexual relationships, safe sex, pregnancy and breastfeeding, and plan his or her future. VCT strategy improves compliance to various interventions and provides information on the available care and support services.
Utility for HIV-Negative Clients: It enables early initiation of behaviour changes to prevent infection, helps in informing partners about the benefits of getting tested, and improves the adoption of family planning services.
Voluntary Counselling and Testing Services |
315 |
21.3 – ESSENTIAL ELEMENTS OF VCT PROGRAMME
Client-centred counselling must be offered to any client who is contemplating about taking the HIV test. This comprises preand post-test counselling and fol- low-up sessions. After counselling, the client should be able to take an informed decision, whether to take the HIV test or not. Oral or written informed consent is to be obtained, without any duress. HIV testing is preferably done at the same site. Alternatively, the client may be referred elsewhere. The result of the HIV test is revealed only to the client. If the client reveals a desire for shared confidentiality (i.e. sharing the result with spouse, partner, a family member, or a close friend), the counsellor should offer guidance. Seropositive status is not to be used as a parameter for differentiation or discrimination between groups of clients/patients. The physical environment at the VCT centre ought to be conducive to confidential discussions between the client and the counsellor. Clients ought to have access to prevention, care and support services, with maintenance of the client’s confidentiality and privacy when referral services are utilised. The VCT services should comply with the protocols and national laws related to the provision of HIV-related services (UNAIDS, 1999; Baggaley et al., 2001).
21.4 – METHODS FOR ASSESSMENT
Factors to be Assessed: The following factors should be assessed by both qualitative and quantitative methods during the planning process itself.
(a)Organisational objectives
(b)Internal capacity of the organisation
(c)Resources needed to integrate the services
(d)Community needs
(e)Cultural, social, and economic barriers to accessibility of services
(f)Review of socio-demographic indicators and data on characteristics of the local population
(g)KAP of the potential clients regarding sexual and reproductive health (SRH)
(h)In-depth interviews, meetings or focus group discussions (FGD) with key informants, family planning staff, clients, community members, and other organisations providing HIV-related services (UNFPA, 2002)
Duration of Assessment: The time period for assessment would depend on size of the community, complexity of factors affecting the HIV prevalence rates, and number of other services available. Adequate time period for most organisations to compile data and assess the situation is 2–6 weeks (UNFPA, 2002). The IPPF/WHR self-assessment module can complete the assessment in approximately 1 week (IPPF/WHR, 2000).
21.5 – ASSESSMENT OF THE COMMUNITY
Community assessment is useful for building on existing services, rather than duplicating them; knowing the responses of local organisations to the idea of introducing VCT services; and compiling a list of referral centres for care
medwedi.ru
316 |
HIV and AIDS |
and support services (UNFPA, 2002). Community assessment comprises the following:
Epidemiological Assessment: To decide the target groups for VCT services (high-risk groups and general population) and to calculate prevalence rates of HIV infection to prioritise allocation of resources for activities.
Knowledge and Attitude to HIV/STIs: To study the knowledge and attitudes of the community by listening surveys, observation of education sessions, and field-based research.
Estimating Level of Risk Among Potential Clients: These include gender-related power relations that affect negotiation of safer sexual relations, economic pressure resulting in commercial sexual activity, relations between young women and older men, and cultural practices contributing to high HIV prevalence rates (UNFPA, 2002; NACO, Training Manual for Doctors). If the risk factors are high in the general population, routine risk assessment is necessary. If the risks are high in certain subgroups in the population, specialised outreach services may be suitable.
Charting the Existing HIV/STI-Related Services: The following information should be collected by interviewing staff of local organisations and used for charting (or “mapping”): existing HIV/STI-related services, community needs, and gaps in services.
21.6ORGANISATIONAL ASSESSMENT
Self-assessment module (IPPF/WHR, 2000) can be used to conduct an organisational assessment. The criteria for assessment include:
(a)Compatibility with the organisation’s goals
(b)Criteria used by the organisation for deciding the services to be offered (expressed community needs, epidemiological data, opinions of staff, resource and cost–benefit analyses, and funding/income generation)
(c)Knowledge, attitudes, level of training, and skills of the staff for delivering VCT services
(d)Existing resources and infrastructure
(e)Compatibility of monitoring and evaluation plan with that for family planning services
(f)Review of relevant legislation, regulations, and national policies (UNFPA, 2002).
21.7 – OPERATIONAL ASSESSMENT
Clients, community members, and staff members from other organisations and family planning personnel are to be involved in operational assessment. Activities for integration are to be identified and operational issues discussed with these stakeholders. The issues for operational assessment are
Voluntary Counselling and Testing Services |
317 |
21.7.1 – Operational Similarities and Differences
Greater degree of similarity between the existing services and VCT indicates that the required financial investment would be less, and that it would be easier to integrate. Provider skills required by both family planning and VCT services are clinical knowledge and skills related to reproductive health, communication skills related to influencing behaviour, and managerial skills for tasks such as condom distribution. If provider skills are similar, providers may be given limited training related to counselling tasks. Integration is facilitated if the setting already provides privacy and permits confidentiality. The existing educational materials can be adapted to suit VCT services. Similarly, the existing logistics system and MIS may be modified to suit the needs of integrated VCT services.
21.7.2 – Selecting Target Groups
In all areas, VCT services are offered to persons with signs and symptoms of HIV/AIDS; preand post-test counselling to those who are concerned about their HIV status. In resource-poor areas, VCT services may be targeted at selected clients. In areas with high HIV prevalence, prevention counselling should be given to all those who use family planning services, and then pre-test counselling may be offered to high risk groups or those interested in VCT. In low-prevalence areas, an initial risk assessment is carried out and VCT should be offered to those considered to be at “high risk”.
21.7.3 – Identifying Additional Resource Needs
Budgeting (for capital and recurring costs) will depend on:
(a)Type of VCT model adopted (structural or functional integration)
(b)Prevalence of HIV infection in the area (large number of clients will lead to higher costs)
(c)Higher degree of similarity of existing services to VCT (fewer additional resources will be required)
Resources for Infrastructure: This includes space for HIV testing and storage space for equipment, kits, and other commodities; cost of renovation of existing site, with cost of disruption to existing sites during renovation; and counselling room that is well-ventilated, provides privacy, and has adequate space for two chairs, a table, and a filing cabinet for securing confidential client information.
Resources for Materials: For community mobilisation, additional resources may be required for preparing leaflets, posters, and audio-visual aids. If the VCT service adopts a structurally integrated model (that provides for on-site HIV testing), purchase of test kits would involve recurring costs. The requirement of HIV test kits would depend upon the number of clients.
medwedi.ru
318 |
HIV and AIDS |
Resources for Hiring Staff and Training: More staff members should be hired to avoid increasing the workload of the existing staff and to maintain the quality of existing services. Additional staff will be needed for HIV testing if the structural model (on-site HIV testing) is adopted and if the number of clients is high. Both new and existing staff will need basic training in counselling skills (for counsellors), skills for effective outreach education, skills in testing technology (for laboratory staff), and supervisory and managerial skills (for managers).
Resources for Referral Networks: Recurring costs in terms of travel costs and staff time for visits, joint training, networking, and attending meetings with other organisations providing HIV-related services.
Resources for Monitoring and Evaluation: Monitoring and evaluation requires additional staff time costs for developing tools for monitoring and evaluation, interviewing users and non-users of VCT services, attending regular meetings, and compiling and analysing data on monitoring and evaluation.
21.8 – MODELS FOR VCT SERVICE DELIVERY
In functionally integrated models, most key services, including HIV testing, are outsourced (provided through a referral service), and they require well-developed referral systems. Structurally integrated models provide key services, including in-house HIV testing (on the premises).
Choice of VCT Model:
Each model has its merits and demerits. There being no ideal model for provision of VCT services, the choice of model will depend on:
(a)Community needs and attitudes to HIV epidemic, political attitudes, and commitment
(b)Prevalence of HIV seropositivity and stage of the epidemic in the area
(c)Availability of financial and other resources
(d)Setting in which VCT services are offered (WHO/UNAIDS, 2001).
Classical Model for VCT:
This model offers the client preand post-test counselling along with HIV testing. Several variations within the classical model, which may be appropriate in different settings, include: group information sessions followed by brief individual pre-test counselling; preand post-test counselling for the couple, or family; and restricting post-test counselling, only to those who test HIV positive. Clients who test HIV negative are merely informed of their test result, without post-test counselling. This is done in some countries with low HIV prevalence.
21.8.1 – Integrated Model
The integration of SRH services was advocated by the International Conference on Population and Development (ICPD) held in Cairo (Egypt), in 1994. Integration envisages the provision of a constellation of services such as family planning,