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The Role of Voluntary Counselling & Testing in preventing HIV Transmission

Introduction

Voluntary Counselling & Testing (VCT) programmes form an important component of both primary and secondary HIV prevention strategies. Early diagnosis of HIV infection has potentially significant individual and public health benefits. This is especially important for the African community in the UK, where African people are often diagnosed at more advanced HIV disease stages than non-Africans. Along with the 7000 black Africans living with diagnosed HIV infection in the UK, there are likely to be several thousand more living undiagnosed, given that around two thirds of Africans in UK have never had an HIV test.

Benefits of VCT programmes

VCT programmes have both individual and public health benefits. Those who test negative have their minds put at rest, can be encouraged to reduce their risk and can be referred to supplemental prevention services. Individuals who test positive can be referred to appropriate follow-up services and have their health monitored. Treatments, such as HAART, mean that VCT programmes and early diagnosis play an important role in accessing potentially life-saving care. Individuals who learn of their positive status are also likely to reduce risk-taking behaviours; thereby reducing the risk of onward transmission or becoming infected with other sexually transmitted infections (STIs).

Individual prevention strategies to reduce onward transmission of infection have obvious public health benefits. VCT programmes are cost-effective since late identification of infection is often associated with increased treatment costs and hospitalisation. Additionally, effective antiretroviral therapy reduces mother-to-child transmission and HIV viral load (which in turn reduces the risk of heterosexual transmission) . As a primary prevention tool VCT can be effective in helping people reduce their risk behaviours for HIV and other STIs.

Barriers

Stigma and the fear of testing positive are potential barriers to testing. Individuals are more likely to seek HIV testing when it is offered anonymously. Anonymity can be critical component for establishing trust and ensuring client demand for services, as has been shown in Uganda’s VCT programme. Policies that require mandatory testing or name reporting of HIV positive persons may also act as a barrier to test seeking. Clients are more likely to accept testing if the service providers have a “pro testing attitude” and stress the potential benefits for the individual such as peace of mind, treatment access and the welfare of partners and offspring.

Counselling

It has been demonstrated that counselling, as opposed to basic health information in the form of a culturally appropriate video, leads to a lower incidence of STIs and longer periods of HIV/STD risk reduction. There are different counselling strategies available that potentially increase the efficacy of VCT as a prevention intervention. Short-term, client-centred counselling has been shown to be more effective in reducing unsafe behaviours than brief, didactic counselling.

In some instances pre-test counselling may act as a barrier to testing, by making it difficult to access a test. In the UK, the uptake of antenatal HIV testing has been significantly increased by the normalisation of the testing process. In most clinics HIV testing is now a normal part of the antenatal booking procedure, where it is offered with the routine antenatal blood tests. There is a pre-test discussion but no pre-test counselling is provided.

VCT for Couples

The provision of VCT programmes targeted at couples can be a very effective tool in HIV prevention, especially when the client is offered a HIV test whilst seeking care or treatment for other reasons, e.g. Pregnancy. Many clients may be surprised by the offer and refuse on the spot or defer their refusal by asking for time to think. Absent partners can affect the decisions of VCT clients, causing them to refuse the test, or fail to return for the results and post-test counselling. The decision to begin treatment, to prevent mother-to-child transmission, may also be affected by a partner. In the UK universal antenatal testing has reduced the undiagnosed fraction of prevalent HIV infection among African women attending these services. VCT for couples could provide a way to improve the testing opportunities for men.

A VCT client may decide to take effective protective action against HIV, but then find they lack the required communication and negotiation skills to follow through on these intentions. VCT for couples provides a way to combat the obstacles faced by individuals wanting to engage in HIV prevention practice.

Promoting VCT and Early diagnosis in the African Community.

The most effective and cost efficient VCT programmes are those targeted specific groups, using culturally appropriate methods of delivery. Research and development of a VCT promotion campaign is important in ensuring specific individuals within target groups, such as those at high risk and undiagnosed, are reached. Research must also be carried out about the motivators to testing; the placement and locale of VCT programmes; barriers to testing and the potential costs (e.g. stigma, job loss) of testing.

With regard to the African community in Britain, little research exists about the facilitators and barriers to testing. The most common reason given for testing is a preceding event, such as ill-health or the positive diagnosis in a child or partner. Knowledge of where to test, concern of entitlement to care, stigma and confidentiality issues have been identified as barriers to testing. Non-white ethnic groups are less likely to be offered a HIV test than white patients, although they are just as likely to accept once offered. The majority of HIV diagnoses are carried out in antenatal, GUM and hospital setting, most of which occurs in London.

There is little legislation protecting those who test positive from discrimination. For black Africans, accusations in the national press of “treatment tourism” and misinformation about migrants and asylum seekers, increases the potential cost of testing.

Conclusion

Voluntary Counselling & Testing programmes form the cornerstone HIV prevention strategies. They increase awareness of HIV issues and potentially reduce both primary and secondary HIV transmission. Just over a third of Africans in the UK have had a HIV test and increasing the proportion of Africans who seek out VCT, should be a priority. More research is need into the barriers and motivators for testing among this population, with a view to evaluating the effectiveness of VCT for couples.

References

Valdiserri, R. O. et al. (1999). Promoting early HIV diagnosis and entry into care. AIDS, 13, 2317-2330.

Summers, T. et al. (2000). Voluntary counseling, testing, and referral for HIV: new technologies, research findings create dynamic opportunities. J.Acquir.Immune.Defic.Syndr., 25 Suppl 2, S128-S135.

Painter, T. M. (2001). Voluntary counseling and testing for couples: a high-leverage intervention for HIV/AIDS prevention in sub-Saharan Africa. Soc.Sci.Med., 53, 1397-1411.