2.1 Counselling and voluntary testing

For women to take advantage of measures to reduce MTCT, they will need to know and accept their HIV status. Voluntary counselling and testing services therefore need to be widely available and acceptable. Ideally, everyone should have access to such services since there are clear advantages to knowing one’s serological status.

People who know they are HIV-infected are likely to be motivated to look after their health, perhaps with behaviour and lifestyle changes, and to seek early medical attention for problems. They can make informed decisions about sexual practices, childbearing, and infant feeding, and take steps to protect partners who may still be uninfected. Those whose test results are negative can be counselled about how to protect themselves and their children from infection.

Furthermore, voluntary counselling and testing has an important role to play in challenging denial of the epidemic: it helps societies which are currently only aware of people who are ill with AIDS to recognize that there are many more people living with HIV and who show no outward signs. However, it must be emphasized that, unless people have real choices for action once they have their test results, there is no good reason to take a test.

However, providing voluntary counselling and testing for the whole population will not necessarily be justified in low HIV prevalence areas where resources are scarce. And even where justified on the basis of prevalence, it will not be a realistic option in some places because the health infrastructure is not sufficiently strong to support the service. For, besides the cost and practical requirements of providing counselling and testing itself, there must be an efficient referral system to a range of other basic services that people need once they have received their test results. These include family planning, prevention and treatment of sexually transmitted diseases (STDs), mother-and-child health services, and health care for infected people including prevention and treatment of opportunistic infections, counselling, and psychological support.

Taking local conditions into account, therefore, policy-makers need to decide what kind of counselling and testing services are most appropriate and feasible, and what action, if any, is required to strengthen the health system that supports them. In particular, decisions need to be made about whether to make counselling and testing available to the whole population (comprehensive VCT); or to target the service at women or couples making use of reproductive health services in areas where the HIV prevalence is especially high (targeted antenatal VCT); or to offer counselling and testing to all women attending antenatal services as part of a programme to reduce MTCT of HIV (routine antenatal VCT).