HIV Testing and counselling: the gateway to treatment, care and support

HIV testing and counselling form the gateway to care, treatment and support for persons in need. To ensure that people can exercise their right to know their HIV status, and that people with HIV can benefit from increased access to antiretroviral (ARV) treatment provided in the 3 by 5 Initiative, HIV testing and counselling must be radically scaled up, using innovative, ethical and practical approaches to delivery. Testing and counselling services must become commonplace in settings where those most likely to benefit from knowledge of their HIV status can be reached, such as services for tuberculosis, sexually transmitted infections and acute medical care as well as antenatal care services. At the same time, people who want to learn their HIV status should have better access to voluntary counselling and testing in a variety of venues.

The World Health Organization (WHO) recommends that, in the context of community mobilization around the importance of learning one’s HIV status, HIV testing and counselling should be offered whenever a patient shows signs or symptoms of HIV infection or AIDS. It should also be offered whenever this will aid their clinical diagnosis and management. Under these circumstances, the offer of testing and counselling should be considered the standard of care.

After having been provided with sufficient information to enable informed consent, all patients can "opt out" of being tested if they do not want the test performed. All testing and counselling should be accompanied by information on prevention of future transmission of HIV, whether the patient is infected or not.

Milestone: By end 2004, 2000 public and nongovernmental (NGO) service outlets will provide testing and counselling services, increasing to 20 000 by the end of 2005.

All services offering HIV testing and counselling should conform to WHO’s guiding principles for expanded testing and counselling:

HIV testing should be voluntary

Mandatory HIV testing is not effective for public health purposes, nor is it ethical. Everyone being tested should give informed consent. This involves:

  • providing pre-test information on the purpose of testing and on the treatment;
  • and support available once the result is known;
  • ensuring understanding; and
  • respecting the individual’s autonomy.

Confidentiality must be protected

  • Only health-care staff with a direct role in management should have access to medical information, on a “need to know” basis.

Post-test support services should be offered

  • People who receive positive test results should receive counselling and referral to care, support and treatment.

1. The importance of simple/rapid tests

Wherever possible, simple/rapid tests – which require only a drop of blood from a finger-prick and which give a reliable result in about 20 minutes – should be used in the expansion of testing and counselling services, particularly in clinical settings and those reaching mobile, vulnerable and marginalized populations. Non-laboratory staff who have been appropriately trained and supervised can administer these tests so more people can be reached. The importance of having strict procedures for quality assurance in testing and in counselling cannot be overstated. Systems to ensure quality of testing and counselling services include the following:

  • validation (to WHO standards) of all training processes, counselling and diagnostic procedures, and HIV testing equipment;
  • regular assessment of test kits by central referral laboratories and employment of national standards to assess procedures for record-keeping and information management;
  • linkages to high-quality reference laboratory facilities for confirmatory testing and quality assurance, especially when rapid/ simple tests are used; and
  • supervision, support and regular review of testing and counselling services.

  • WHO/CDC will issue guidance on the use of rapid/simple HIV tests in early 2004.

2. The importance of adequate human resources

Finding the human resources to support scaled-up testing and counselling is a major challenge, and creative solutions are needed:

  • 3 by 5 will require training of staff in testing and counselling in up to 20 000 service-delivery points.
  • In many settings, the use of lay counsellors, including people living with HIV/AIDS makes it possible for high standards to be maintained and eases the burden on formal health staff.
  • Where possible, pre-test counselling may be replaced with group education that ensures those being offered testing can give informed consent to being tested. This may be done by lay counsellors.
  • Strong links with community-based services has been important to ensure that those needing additional help get appropriate support.
  • Working with affected communities and engaging the support of people living with HIV/AIDS is crucial to improving the quality and expanding the range of services, to normalizing the knowledge of one’s HIV status, and to reducing stigma and discrimination.

The more HIV testing is available, the more counsellor training is required. Training issues include:

  • HIV/AIDS awareness and how to encourage HIV prevention;
  • the process of pre- and post-test counselling;
  • interpretation of test results (positive, negative and indeterminate);
  • giving results and approaches to dealing with difficult issues (such as disclosure, prevention negotiation), and mechanisms for onward referral.

All staff members administering and interpreting rapid tests require training in the following:

  • simple/rapid test protocols and algorithms for confirmatory testing;
  • test-tracking and record-keeping;
  • giving test results, and in counselling seropositive clients; and
  • managing referral processes.

  • WHO will, by mid-2004, issue a training package identifying core competencies for testing and counselling for all health staff who will be administering rapid tests and providing counselling.

3. Infrastructure needs

HIV testing and counselling services require:

  • a private space to provide counselling;
  • the capability to undertake testing, and mechanisms for easy sample referral for regular quality assurance testing (10% of samples to be confirmed centrally);
  • mechanisms for referral to post-test diagnostic and care services;
  • accurate documentation and information management procedures to ensure accuracy and confidentiality of all patient test and diagnostic information; and
  • an adequate supply of simple/rapid tests, condoms and client information materials.

Requirements for quality testing and counselling

It is the responsibility of governments to ensure that testing and counselling services are available for all who might wish to know their status, and all who might benefit from learning their status as a part of their health management. Operational responsibility may be shared with NGOs and other partners that have established facilities and expertise in delivery of testing and counselling services. The establishment of a quality system of testing and counselling requires:

  • government commitment and support;
  • national policies for testing and counselling-service delivery, training and assessment;
  • a coordinated plan for testing and counselling roll-out involving all key partners, including professional bodies, training institutions, referral laboratories, NGOs and community-based organizations (CBOs);
  • a human capacity building plan;
  • a national system to ensure quality assurance of counselling and of testing services;
  • aggressive advocacy and activities to combat stigma and to promote the "right to know" one's HIV status;
  • development and enforcement of anti-discrimination laws.