Provider-Initiated HIV Provider-Initiated HIV Testing and Counseling: Testing and Counseling:

An IntroductionAn Introduction

Dr Esther Tan, MSDDr Esther Tan, MSD

Background & Objective of PptBackground & Objective of Ppt

Ppt purpose is to Ppt purpose is to introduce UN health care introduce UN health care providersproviders to the PITC concept to the PITC concept

PITC, while encouraged by the UN Medical PITC, while encouraged by the UN Medical Directors, have Directors, have yet to be formally yet to be formally implementedimplemented by many UN health services by many UN health services

Hopeful that the information presented here will Hopeful that the information presented here will inform future task of launching PITC in the inform future task of launching PITC in the UNUN

Presentation OutlinePresentation Outline

1.1. Evolution of HIV PoliciesEvolution of HIV Policies

2.2. WHO Guidelines on PITCWHO Guidelines on PITC

3.3. Discussion QuestionsDiscussion Questions

4.4. UN PEP Starter KitsUN PEP Starter Kits

HIV Testing Policies – HIV Testing Policies – EvolutionEvolution

Highlights of 1980sHighlights of 1980s HIV testsHIV tests become available become available

Govts focus testing on blood, Govts focus testing on blood, immigrants, immigrants, specific pop sub-gpsspecific pop sub-gps (SW, IVDU, MSM)(SW, IVDU, MSM)

Evidence emerges that mandatory HIV Evidence emerges that mandatory HIV testing testing drives people undergrounddrives people underground

Three Cs – Three Cs – Confidentiality, Confidentiality, Counseling, ConsentCounseling, Consent seen as seen as integral part of testingintegral part of testing

Highlights in 1990sHighlights in 1990s WHO issues guidelines on need for WHO issues guidelines on need for

testing to be voluntary: testing to be voluntary: Birth of VCTBirth of VCT

Respect for human rights in HIV Respect for human rights in HIV testingtesting seen as legal obligation and seen as legal obligation and good public healthgood public health

Changes to the Changes to the HIV testing HIV testing environmentenvironment:: Low uptake of VCTLow uptake of VCT Increased availability of Increased availability of

antiretroviral therapy (ART)antiretroviral therapy (ART)

Highlights in 2000sHighlights in 2000s Availability of Availability of HIV rapid tests with HIV rapid tests with

high sensitivity and specificityhigh sensitivity and specificity

Emergence of targets for number of Emergence of targets for number of people on ART – leading to people on ART – leading to high high targets for HIV testingtargets for HIV testing

WHO/UNAIDS issues new Guidance WHO/UNAIDS issues new Guidance on HIV testingon HIV testing: Distinguishes between : Distinguishes between VCT and PITCVCT and PITC

Emerging testing strategiesEmerging testing strategies: PITC, : PITC, household testing, mobile household testing, mobile testing..etc..increasingly commontesting..etc..increasingly common

Universal Access by 2010?Universal Access by 2010?2005 G8 Summit at Gleneagles, Final Communiqué:“…working with WHO, UNAIDS and other international bodies to develop and implement a package of HIV prevention, treatment and care, with the aim of as close as possible to universal access to treatment for all those who need it by 2010.”

HIV Testing – Then and NowHIV Testing – Then and Now

UN Medical Directors UN Medical Directors Position Statement (Oct 2008)Position Statement (Oct 2008)

““Voluntary, confidential HIV/AIDS Voluntary, confidential HIV/AIDS counselling and testing and counselling and testing and provider provider initiated counselling and testinginitiated counselling and testing in UN in UN staff members should be staff members should be encouraged by encouraged by medical staff during all contacts with medical staff during all contacts with staff membersstaff members, particularly , particularly in duty in duty stations where HIV is prevalentstations where HIV is prevalent, and , and ARV treatment is available.”ARV treatment is available.”

WHO / UNAIDS:WHO / UNAIDS:Guidance on Provider-Initiated HIV Guidance on Provider-Initiated HIV Testing and Counseling in Health Testing and Counseling in Health

Facilities (May 2007)Facilities (May 2007)

Background and Background and RationaleRationale

Sub-Saharan Africa: Sub-Saharan Africa: Only 12% Only 12%

men, 10% womanmen, 10% woman had been had been tested for HIV and receive tested for HIV and receive resultsresults

““WHO/UNAIDS strongly support continued scale up of WHO/UNAIDS strongly support continued scale up of VTC, but VTC, but recognize need for additional, innovative recognize need for additional, innovative and varied approachesand varied approaches (including PITC)….” (including PITC)….”

““Evidence…suggests that Evidence…suggests that many opportunitiesmany opportunities to to diagnose and counsel individuals at health facilities diagnose and counsel individuals at health facilities are are being missed and that PITC facilitates diagnosis and being missed and that PITC facilitates diagnosis and access to HIV-related services.”access to HIV-related services.”

% of 15-49 yr old Africans ever % of 15-49 yr old Africans ever tested and received test resulttested and received test result

0102030405060708090

100

Women

Men

Demographic and Health Surveys, MEASURE DHS, 2003-2005

Average: 10%

% of 15-49 yr old Africans who % of 15-49 yr old Africans who know their test resultknow their test result

0102030405060708090

100

Women

Men

Demographic and Health Surveys, MEASURE DHS, 2003-2005

Average: 15%

Pregnant women who received an HIV test: Pregnant women who received an HIV test: data from the 10 countries with the highest estimated number data from the 10 countries with the highest estimated number

of HIV-infected pregnant women, 2005of HIV-infected pregnant women, 2005

Average: 15-20%

HIV-positive tuberculosis cases identified HIV-positive tuberculosis cases identified

through testing for HIV in 2005, Globalthrough testing for HIV in 2005, Global

TOWARDS UNIVERSAL ACCESS. Scaling up priority HIV/AIDS interventions in the health sector . Progress Report, WHO, Geneva, April 2007

Globally, only 14% of the HIV-positive TB patients identified through for HIV during their treatment

TB patients should be offered HIV test

Unmet need for ARV in low- and middle-Unmet need for ARV in low- and middle-income countries, December 2006income countries, December 2006

0

500 000

1 000 000

1 500 000

2 000 000

2 500 000

3 000 000

3 500 000

4 000 000

4 500 000

5 000 000

Sub-SaharanAfrica

Latin Americaand the

Caribbean

East, South andSouth-East Asia

Europe andCentral Asia

North Africa andthe Middle East

Nu

mb

er o

f p

eop

le

Unmet need ARVtherapyReceiving ARVtreatment in Dec 2006

68% of the total unmet need

No. of pp who need ARV and are not getting it

Lancet paper: Mortality in the months after Lancet paper: Mortality in the months after starting ART in low- and high-income settingsstarting ART in low- and high-income settings

High mortality rate in first months of starting ARV

Mortality in patients on ART in Mortality in patients on ART in low-income settingslow-income settings

73% deaths occurred in persons starting 73% deaths occurred in persons starting therapy at CD4+ <100 per cu mmtherapy at CD4+ <100 per cu mm

38% deaths occurred in first month, 80% in 38% deaths occurred in first month, 80% in first 4 monthsfirst 4 months

Above points to Above points to late diagnosislate diagnosis, identification , identification of HIV only at of HIV only at later stages of infection / AIDSlater stages of infection / AIDS

Source: ART-LINC and ART-CC Groups, Lancet, 2006

UK: Late diagnosis in high-risk groupsUK: Late diagnosis in high-risk groups

A Complex Picture. HIV and other Sexually Transmitted Infections in the United Kingdom: 2006 Health Protection Agency, London, 2007.

British Medical Journal Articles, British Medical Journal Articles, June 30, 2000June 30, 2000

Time to move towards opt-out testing for Time to move towards opt-out testing for HIV in the HIV in the UKUK, , Hamill M et al.Hamill M et al.

Routine testing to reduce late HIV Routine testing to reduce late HIV diagnosis in diagnosis in FranceFrance, , Delpierre C et al.Delpierre C et al.

Reducing the length of time between HIV Reducing the length of time between HIV infection and diagnosis, infection and diagnosis, EditorialEditorial

Importance of Encouraging TestingImportance of Encouraging Testing

Knowledge of HIV status is essential for:Knowledge of HIV status is essential for:

Expanding accessExpanding access to HIV treatment, care, and to HIV treatment, care, and supportsupport

Improving HIV/AIDS Improving HIV/AIDS treatment treatment outcomesoutcomes

Enhancing HIV Enhancing HIV preventionprevention, , including PMTCTincluding PMTCT

Definition of PITCDefinition of PITC

Refers to HIV testing and counselling which is recommended by health care providers to persons attending health care facilities as a standard component of medical care.

While this type of testing can be routine under certain conditions, it should never be mandatory or compulsory.

WHO: Importance of ContextWHO: Importance of Context

PITC should be PITC should be accompanied by accompanied by Recommended package of HIV-related Recommended package of HIV-related

prevention, treatment, care and support prevention, treatment, care and support services and services and

Implemented within framework of national Implemented within framework of national plan to achieve universal access to ARV plan to achieve universal access to ARV therapy for all who need it (therapy for all who need it (access to ARV access to ARV therapy is not absolute prerequisitetherapy is not absolute prerequisite))

WHO RecommendationsWHO Recommendations Recommend HIV test to:Recommend HIV test to:

All patients, All patients, irrespective of epidemic settingirrespective of epidemic setting, , where there is clinical suspicion of underlying where there is clinical suspicion of underlying HIV infectionHIV infection

In In generalized HIV epidemicsgeneralized HIV epidemics, as , as standard part standard part of medical careof medical care for all patients attending health for all patients attending health facilitiesfacilities

In In concentrated and low-level epidemicsconcentrated and low-level epidemics, , more more selectivelyselectively

““Opt-out” approach to PITCOpt-out” approach to PITC

Giving simplified pre-test infoGiving simplified pre-test info

In All Epidemic TypesIn All Epidemic Types HIV testing and counselling should be recommended to:HIV testing and counselling should be recommended to:

Symptomatic patientsSymptomatic patients: (all adults, adolescents or children with signs, : (all adults, adolescents or children with signs, symptoms or conditions that could indicate HIV infection, including symptoms or conditions that could indicate HIV infection, including tuberculosis) (i.e. tuberculosis) (i.e. Diagnostic TestingDiagnostic Testing))

HIV-exposed children or children born to HIV+ womenHIV-exposed children or children born to HIV+ women

Men seeking male circumcision for HIV preventionMen seeking male circumcision for HIV prevention

This recommendation This recommendation should should ordinarily lead to the test being ordinarily lead to the test being performed performed unless the patient unless the patient declines declines

In Generalized HIV EpidemicsIn Generalized HIV Epidemics

HIV testing and counselling should be HIV testing and counselling should be recommended to ALL patients regardless of the recommended to ALL patients regardless of the reason for presenting to the health facility (i.e. reason for presenting to the health facility (i.e. ScreeningScreening))

Implementation can be prioritizedImplementation can be prioritized according according to type of facility and HIV prevalence, eg:to type of facility and HIV prevalence, eg: Medical wards and outpatient Medical wards and outpatient

facilities facilities Antenatal, childbirth and Antenatal, childbirth and

postpartum health services postpartum health services STI services..etcSTI services..etc

In Concentrated and Low Level In Concentrated and Low Level HIV EpidemicsHIV Epidemics

HIV testing and counselling should not be HIV testing and counselling should not be recommended to all patients attending recommended to all patients attending health facilities, only to health facilities, only to symptomatic and symptomatic and perinatally exposed individualsperinatally exposed individuals

Consider PITC forConsider PITC for STI servicesSTI services Services for most-at-risk populationsServices for most-at-risk populations Maternal health servicesMaternal health services

DEFINING OPT-IN AND OPT-OUTDEFINING OPT-IN AND OPT-OUT

1.1. Opt-in HIV testingOpt-in HIV testing.. Requires health provider Requires health provider to provide counseling and a separate written to provide counseling and a separate written informed consent, which patients must sign informed consent, which patients must sign before being permitted to have an HIV test.before being permitted to have an HIV test.

2.2. Opt-out HIV testingOpt-out HIV testing.. Patients are informed Patients are informed either orally or via general medical consent either orally or via general medical consent that HIV testing will be included as part of the that HIV testing will be included as part of the routine blood tests. Patients can decline the routine blood tests. Patients can decline the HIV test (opt-out). Assent is inferred unless the HIV test (opt-out). Assent is inferred unless the patient declines testingpatient declines testing

UptakeUptake of PMCT Testing by Testing of PMCT Testing by Testing Strategy, Kisumu, Kenya, 2003-04Strategy, Kisumu, Kenya, 2003-04

0

10

20

30

40

50

60

70

80

90

100

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

%

'Opt in' 'Opt out'

Opt-In

Opt-Out

Pre-Test Information and Informed Pre-Test Information and Informed Consent – What’s New?Consent – What’s New?

Pre-Test InformationPre-Test Information Can be Can be individual or group info sessionsindividual or group info sessions Minimum set of infoMinimum set of info should be provided should be provided

Informed ConsentInformed Consent Verbal communication adequateVerbal communication adequate

for obtaining informed consent for obtaining informed consent (i.e. no need for written consent) (i.e. no need for written consent)

Consent always given individually, Consent always given individually, in private, in presence of health in private, in presence of health care provider care provider

Minimum Pre-test informationMinimum Pre-test information Why HTC is recommendedWhy HTC is recommended Clinical and prevention benefits; risks: discrimination, Clinical and prevention benefits; risks: discrimination,

abandonment, violenceabandonment, violence Services available for + and -, including ARTServices available for + and -, including ART That results will be confidential That results will be confidential The right to decline, but that test will be done unless The right to decline, but that test will be done unless

declineddeclined That, if testing is declined, access to services that do not That, if testing is declined, access to services that do not

require knowing one's serostatus will not be affectedrequire knowing one's serostatus will not be affected That, in case of positive test, disclosure is encouragedThat, in case of positive test, disclosure is encouraged Opportunity to ask questionsOpportunity to ask questions

Post-Test CounselingPost-Test Counseling

All patients must be counseledAll patients must be counseled when when test results are giventest results are given

Minimum set of infoMinimum set of info for those with for those with HIV-negative resultsHIV-negative results HIV-positive resultsHIV-positive results pregnant women who is HIV-positivepregnant women who is HIV-positive

Post test counsellingPost test counselling

If HIV negative:If HIV negative: Explain test result – incl. window period, and Explain test result – incl. window period, and

recommend to be re-tested if recent exposure recommend to be re-tested if recent exposure Give basic advice on how to prevent getting Give basic advice on how to prevent getting

HIV HIV Provide condoms Provide condoms

Post test counsellingPost test counselling If HIV positive:If HIV positive:

Explain test result/give time to consider Explain test result/give time to consider Ensure understands result; Allow questions; Help Ensure understands result; Allow questions; Help

cope with emotionscope with emotions Discuss immediate concerns – map support networkDiscuss immediate concerns – map support network Describe health and social services available and Describe health and social services available and

refer/providerefer/provide Give information on how to prevent HIV, safer sex, Give information on how to prevent HIV, safer sex,

condomscondoms Advice on nutrition, cotrimoxazole, ITNAdvice on nutrition, cotrimoxazole, ITN Encourage HTC for partners and childrenEncourage HTC for partners and children Assess risk of suicide and violence and discuss steps Assess risk of suicide and violence and discuss steps

to ensure safetyto ensure safety Arrange time and date for follow upArrange time and date for follow up

Post test counsellingPost test counselling

In Pregnant Woman who is HIV-In Pregnant Woman who is HIV-positive:positive: Childbirth plansChildbirth plans ARV for preventing mother-to-child ARV for preventing mother-to-child

transmission and own healthtransmission and own health Nutrition, iron and folic acidNutrition, iron and folic acid Infant feeding and supportInfant feeding and support Infant testing and follow upInfant testing and follow up Partner testing Partner testing

Frequency of TestingFrequency of Testing

DependsDepends on continued risks taken by on continued risks taken by patient, availability of human/financial patient, availability of human/financial resources and HIV incidence in settingresources and HIV incidence in setting

Re-testing every Re-testing every 6-12 months 6-12 months may may be beneficial for be beneficial for those at those at higher risk of HIV higher risk of HIV exposureexposure

US Testing PolicyUS Testing Policy

For patients in ALL health-care settings:For patients in ALL health-care settings: HIV screening recommended for all HIV screening recommended for all

patientspatients using “opt-out” screening using “opt-out” screening Persons at Persons at high-riskhigh-risk should be screened at should be screened at

least annuallyleast annually Separate Separate written consent not requiredwritten consent not required: :

general consent for medical care sufficientgeneral consent for medical care sufficient Prevention counseling not Prevention counseling not

required required for diagnostic / for diagnostic / screening test screening test

US Testing PolicyUS Testing Policy

For pregnant women:For pregnant women: HIV screening included in routine panel of HIV screening included in routine panel of

prenatal screening tests prenatal screening tests for all using opt-out for all using opt-out approachapproach

Separate Separate written consent not requiredwritten consent not required: : general consent for medical care sufficientgeneral consent for medical care sufficient

Repeat screening in 3Repeat screening in 3rdrd trimester trimester recommended in locations with recommended in locations with elevated rates of HIV infection elevated rates of HIV infection among pregnant women among pregnant women

Discussion Discussion QuestionsQuestions

For DiscussionFor Discussion

What is What is level of HIV infectionlevel of HIV infection in local in local population in your mission?population in your mission?

What is What is level of HIV infectionlevel of HIV infection among staff among staff population in your mission?population in your mission?

In your mission, In your mission, who oversees and who oversees and manages issuesmanages issues of HIVof HIV testing and testing and counseling of staff?counseling of staff?

For DiscussionFor Discussion

Do you think the following are Do you think the following are difficult to difficult to implement? What are the barriers?implement? What are the barriers?

1.1. HIV testing of all staff with HIV testing of all staff with clinical suspicionclinical suspicion (e.g. (e.g. TB positive)TB positive)

2.2. ““Opt-out”Opt-out” approach approach

3.3. Verbal consent onlyVerbal consent only without written consent without written consent

4.4. Providing Providing minimum pre-test infominimum pre-test info (eg with no pre- (eg with no pre-test counselling) in eg group sessions or through test counselling) in eg group sessions or through provision of a leafletprovision of a leaflet

For DiscussionFor Discussion

What do you think is the What do you think is the main barrier to main barrier to HIV testingHIV testing among staff in your mission? among staff in your mission?

What do you think is What do you think is the the level of stigma and level of stigma and discrimination discrimination in the in the UN staff population? UN staff population?

UN PEP Starter KitsUN PEP Starter Kits

General PrinciplesGeneral Principles PEP = PEP = Post Exposure ProphylaxisPost Exposure Prophylaxis, ,

Full PEP involves set of services provided to manage the Full PEP involves set of services provided to manage the specific aspects of HIV exposure and to help prevent HIV specific aspects of HIV exposure and to help prevent HIV infection in exposed personsinfection in exposed persons

Includes first aid, counseling Includes first aid, counseling (assessment of risk of exposure, (assessment of risk of exposure, HIV testing, course of anti-HIV medication, follow up)HIV testing, course of anti-HIV medication, follow up)

Must Must initiate ASAPinitiate ASAP after exposure, after exposure, ideally within 2 hours or less, not ideally within 2 hours or less, not >72 hours post-exposure >72 hours post-exposure

Adherence to a Adherence to a full 28 days full 28 days coursecourse of ARV critical of ARV critical

UN PEP Starter Kits ContentsUN PEP Starter Kits Contents ARVs:ARVs: 5 days of a two-drug treatment (Zidolam 5 days of a two-drug treatment (Zidolam

1 tab bd)1 tab bd) Full course is 28 days – must ensure continuityFull course is 28 days – must ensure continuity

Pregnancy test kitPregnancy test kit Emergency oral contraceptionEmergency oral contraception (“morning-after” (“morning-after”

pill): pill): 1st tablet to take ASAP and no later than 5 days after 1st tablet to take ASAP and no later than 5 days after

exposure, 2exposure, 2ndnd tablet 12 hours later tablet 12 hours later Patient Registry FormPatient Registry Form: filled and : filled and

signed by treating physician who signed by treating physician who will monitor care will monitor care

EligibilityEligibility PEP Starter Kits (not full!) available to PEP Starter Kits (not full!) available to all staff all staff

with a UN agency contract, and their spouses with a UN agency contract, and their spouses and dependent childrenand dependent children who are exposed to who are exposed to HIV because of:HIV because of:

Sexual assaultSexual assault Occupational exposureOccupational exposure An accident, criminal assault An accident, criminal assault

or security incident or security incident

Not meant for exposure through voluntary Not meant for exposure through voluntary activities outside workactivities outside work

5 Patient Information Sheets5 Patient Information Sheets

5 Patient Information Sheets5 Patient Information Sheets

Specific Info for ProvidersSpecific Info for Providers

Specific Info for CustodiansSpecific Info for Custodians

Report Use of Kits to UNMSReport Use of Kits to UNMS

Notify UN Medical Services via email (Notify UN Medical Services via email (tan2@un.orgtan2@un.org))

Accompanying information required:Accompanying information required: OrganizationOrganization of person of person Duty stationDuty station of person of person GenderGender of person of person ReasonReason for use of kit for use of kit

e.g. occupational exposure, e.g. occupational exposure, sexual assault, criminal assault…etc sexual assault, criminal assault…etc

Thank youThank you