|Counselling and Voluntary HIV Testing for Pregnant Women in High HIV Prevalence Countries - Elements and Issues (UNAIDS, 1999, 24 p.)|
|5. Operational considerations|
Providing counselling and voluntary testing for HIV in pregnancy-related services is easier said than done. While such services are clearly desirable wherever interventions to prevent HIV infection in infants and sex partners of pregnant women can be offered, they will add to the cost of antenatal and reproductive health services.
This section of the document considers what is necessary to provide such services, and makes recommendations about staff training, counselling options and test types. It tries to focus on the feasible, rather than the ideal.
In most developing countries, specialist counsellors are in short supply. And there is unlikely to be enough money available to train and hire as many specialist counsellors as would be needed in the context of routine antenatal care.
It is recommended, rather, that existing reproductive health staff be trained in the basics of counselling and testing for HIV. They are already familiar with many of the issues surrounding reproductive health and infant feeding. Training existing staff to provide additional advice on HIV care and prevention in the context of pregnancy may be easier that training professional counsellors to deal with all the medical questions that may arise around the subject of reproductive health and childbearing. However, extra staff will probably need to be hired to cope with the extra volume of work created by providing counselling and HIV testing services.
The work of providing information and of counselling should be diffused as efficiently as possible though the hierarchy of care, according to the particular needs of each client. Much of the routine provision of basic information about HIV transmission, prevention and testing for example, can be done in groups and carried out by staff with little special training in counselling. For more complex issues - analysis of resources in helping HIV-infected mothers reach feeding decisions, or counselling of discordant couples, for example - specialized counsellors may be needed and discussion with clients on a one-to-one basis will be essential. Regular staff should be able to refer those in need to progressively more specialized levels of counselling. The more specialized counselling may be provided by dedicated voluntary counselling and testing centres outside the reproductive health facility. Facility managers will need to identify services to which they can refer clients, and would be well advised to discuss their clients needs with key staff in those services.
Health workers will need additional training in all the basic areas of pre- and post-test counselling if they are to provide useful HIV-related counselling to women contemplating a test or digesting its results. In addition, they may need extra training to help them deal non-judgmentally with clients in often difficult situations. Perhaps most importantly, health workers need a rigorous understanding of the importance of confidentiality.
Counselling needs vary according to the situation. It is often not necessary (and more often still not affordable) to impart all the necessary information to each woman in individualized in-depth pre- and post-test counselling sessions. The majority of women who test HIV-negative need less individualized post-test counselling than women who test positive, for example.
These varying needs should be taken into account in designing counselling and testing services. The reality is that if counselling and testing for HIV is to become a routine part of already overstretched reproductive health services in low resource, high-fertility countries, the degree of individualized attention provided is likely to fall short of the ideal.
Routine information that is relevant to all women and their partners regardless of HIV status may be imparted in group sessions. This is especially true of information provided before a test. Individualized counselling will be needed to answer specific questions that arise from the information, as well as to help women weigh up their particular situations and arrive at a decision about testing. A client should always be able to communicate their decision about whether to be tested or not in private.
Some post-test information, such as reinforced prevention information relevant to all clients regardless of HIV status, can also be given in groups. However the balance between general information needs and counselling needs is different for clients who have chosen to undergo a test and are receiving their results.
Pregnant women who are HIV-infected may need considerable individualized attention to help them arrive at decisions on information imparted in groups. All women who test HIV-positive should receive individual counselling to help them reach important decisions about therapy, infant feeding, sharing their status and other aspects of living with infection.
Information on video
Obviously, human interaction and especially individualized attention are the ideals in both providing information about HIV as well as in counselling clients. But limitations of time, money, space and personnel are likely to make these the exception rather than the norm in reproductive health settings in developing countries.
Much of the basic information people need when making decisions about sexual behaviour and fertility in the context of HIV does not vary according to context. Basic information about HIV infection, prevention, therapy and infant feeding can be imparted successfully on video, as experience in antenatal clinics in Thailand has shown. These videos have the advantage that their accuracy is assured and they are guaranteed to be informative and non-judgmental - not always the case where individual counsellors are involved.
Where information is imparted by video (or in group counselling sessions), people must always be given the opportunity to ask questions and discuss individual problems and circumstances in private with a trained counsellor.
Obviously, this option is not open to sites that have no electricity or video equipment, and is unlikely to be necessary or desirable in low-volume sites. Service providers will have to weigh up the one-time cost of video-equipment versus the recurrent costs of counsellors salaries and make decisions accordingly.
Ideally, women and their partners would go through the whole pre-test counselling, testing procedure and post-test counselling together. However since men very rarely present together with their wives or partners at reproductive health facilities, this is unlikely to be practical.
It is recommended that counsellors discuss the benefits of couple counselling with women during pre-test counselling sessions. Those women who would like to be counselled and tested together with their partners can be referred to specialized counselling and testing services. In this case, a mechanism must exist for communicating test results to the original service providers with the consent of the couple and without breaching confidentiality.
Visiting a clinic often requires considerable travel time and expense. Adding to this burden by requiring a woman who has chosen to be tested to return for her HIV test results may be unhelpful. It is likely to result in a high proportion of women not returning to collect their results - a waste of time and resources from the point of view of the service provider. In addition, sending specimens to a laboratory for testing can lead to lost samples and uncertain quality control.
Reliable rapid test kits for on-the-spot testing for HIV are now widely available at prices similar to laboratory test kits. These kits do not need highly trained staff or sophisticated laboratory equipment, although most do require refrigeration. Training clinic staff to use these kits can cut down on time and paperwork involved in sending specimens for lab testing, and can avoid doubling travel time for clients. In terms of quality, they have been shown to be as reliable on a national level as laboratory testing services.
There are, however, some difficulties associated with rapid test kits. Firstly, on-the-spot testing may provide more opportunities for breaches of confidentiality than outside laboratory testing. The need to maintain confidentiality should be central to all staff training around testing and counselling for HIV.
Secondly, it is possible that women will feel obliged to undergo a test offered on the spot, without having thoroughly thought through the consequences. They may also want to discuss the implications of testing with their partners, and opt for couple counselling and testing. It is therefore suggested that women are told about rapid testing during the pre-test counselling, and are then given the opportunity to make an appointment to come back at a convenient time if they decide they want to go ahead with the test. More information on rapid tests is available in the WHOs Weekly Epidemiological Record (1998, 73:321-326).