Scaling Up HIV Testing and Counseling in Africa Successes, by cqd71714


									  Scaling Up HIV Testing and
 Counseling in Africa: Successes,
Challenges, and the Way Forward

              2008 Global Health Mini-University
    George Washington School of Public Health and Health Services
                          September 12, 2008

                         Allison M. Schilsky, MPH
         Global AIDS Program, Centers for Disease Control and Prevention
          HIV Counseling and Testing Technical Working Group, OGAC
      Global View of HIV Infection

33 million people [30-36 million] living with HIV, 2007
Source: UNAIDS 2008 Global Update
 Goal of HIV Testing and Counseling
          (HTC) Programs:
Universal Knowledge of HIV Status

 In the past: “Have you ever been tested for HIV?”
 Moving toward: “When was your last HIV test?”
            Slow Progress…
Most people in Africa do not know their HIV
– WHO estimates that just 10% of adults in low and
  middle income countries have ever been tested
– More may have been tested but not told results
Repeat and regular testing needed in settings or
populations with high incidence
~ 50 to 100 million persons need HTC to meet
international treatment goals
                                 Number of persons trained to conduct HTC in
                                   15 PEPFAR Focus Countries, 2004-2007
Persons Trained (in thousands)








                                                  2004     2005   2006   2007   Total

                                 Source: PEPFAR database
                                      Number of HTC sessions conducted in 15
                                       PEPFAR Focus Countries, 2004-2007
Number of CT Sessions (in millions)


                                      10          ~6.6
                                           2004   2005         2006         2007    Total

                                                         CT    PMTCT-C&T

        Source: PEPFAR database
 Percentage of population (15-49 years) in selected
 countries of Africa who were ever tested for HIV
       and received the results, 2003-2005
                                              Men      Women

       Mozambique (2003)
            Ethiopia (2005)
              Ghana (2003)
           Lesotho (2004)
Republic of Congo (2005)
             Uganda (2004)
           Tanzania (2004)
             Nigeria (2003)
          Cameroon (2004)
              Kenya (2003)
             Malawi (2004)
          Botswana (2005)
       South Africa (2005)

                               0         20        40       60       80   100
                                               Percent Ever Tested

Source: Towards Universal Access, Progress Report, April 2007, WHO
        Presentation Overview
Definitions and key elements of HTC
Barriers to expansion of HTC
Efforts to address barriers
– Policy revisions
– Rapid tests and task shifting
– Innovative models of service delivery
– Promotion of HTC
Debates, questions, challenges
Recent developments
                       HTC Models
Client-initiated HTC
– Voluntary counseling and testing (VCT)
      Social or personal reasons for testing
– “Opt-in” model
– Community settings, mobile

Provider-initiated HTC
–   Integrated into medical care
–   “Opt-out” model
–   Also called “diagnostic CT” or “routine CT”
–   Terminology of “screening” not used much

Mandatory or required testing
– Pre-employment, military recruits and blood donors
– Consent and results counseling recommended but not always done
Essential Elements of Quality HTC
3 “C’s” (WHO guidance)
–   Consent
–   Confidentiality
–   Counseling
       Length and intensity varies widely
– Rapid tests and same hour results preferred
– HIV positive results must be confirmed
2 “R’s”
– Referral
– Record keeping
Quality assurance of both counseling and testing
        Past Barriers to HTC
Sense of hopelessness about AIDS diagnosis
Prohibitive HIV policies and practices
– Lab based testing, long waiting periods for results
– Health workers overburdened with other duties,
  personal fears about testing
– VCT model applied to all settings
     Perception that lengthy counseling session always required
Fear of discrimination, stigma, difficulty of
    Current Barriers to HTC
Opt-out testing policies in health facilities not
yet implemented in many countries
Rigid rules on who can test and counsel
Task shifting to lay counselors not yet the norm
Family testing still very limited
– Testing within couples
– Readiness of parent to disclose versus right of child
  to access treatment
Policy Revisions: Updated Guidance
Guidance on Provider-
Initiated HIV Testing
and Counselling in
Health Facilities, May
New national
guidelines in countries
like Kenya, Tanzania,
Botswana on PITC or
on all models of HTC
        Technological Advances:
          HIV Rapid Testing
Evidence from many countries and many studies show
that rapid tests are as accurate as machine read tests

Use of finger-prick (whole blood):
– Reduces occupational risk
– Reduces waste management problems
– Enables “point of care” testing which reduces recording and
  reporting errors
Array of Personnel Perform Rapid Tests

                      Counselors show clients
                      the test strips, involve
                      clients in test result

                      Many studies have found
                      lay counselor performance
                      to be equal to lab based
Coming Soon to Africa: Oral Testing


               Positive Negative
New Technology Increases Demand
Number of VCT Clients in Malawi 92 - 01

          92     93    94    95     96   97    98    99     2000 2001

                      Waiting period     Same day results

Waiting period versus same day results
   HTC Service Delivery Types
HTC comes in many shapes and sizes!
 Stand alone (freestanding) VCT
 HTC in health facilities
 Community-based or Mobile HTC
 Workplace VCT
 Special HTC events/campaigns
 HTC targeted to special groups
 Home-based or door-to-door HTC
                  Stand-alone VCT

Operated by a women’s group, Nigeria
HTC in Outpatient Departments

   South Africa
HTC in Inpatient Wards

 Community-based/Mobile VCT

Sponsored by a community group, Nigeria
             HTC in a Tent

Mobile testing, Tanzania
             HTC on Wheels!

Mobile testing, Kenya
Fear Appears to be Minimal
            Workplace VCT

All workers in this
factory in Malawi can
receive counseling,
testing and ART at the
       Youth Friendly VCT

Recreational activities and VCT, Kenya
VCT Available for Deaf Persons

  VCT services for the deaf population, Kenya
    VCT for the Military

HTC services for uniformed personnel, Kenya
VCT in Prisons

                 Camel VCT!

Serving nomadic populations in northern Kenya
         Door-to-door VCT

Community members, Uganda
     Home-based HTC

Families of index patients, Uganda
    HIV Prevalence in Uganda
Household Members of ART Patients
   Age Group        Prevalence
   0-5                       7%
   6-14                      2%
   15-24                     3%
   25-44                    37%
   45+                       8%

                      97% uptake
Promotion and Special Campaigns
      to Increase Uptake
 Professionally designed mass media campaigns in
 some countries
  – Nationally recognized HTC logos
 Great interest in special campaigns and national
 testing events
  –   Malawi 2006 and 2007
  –   Ethiopia 2006 - 2007
  –   Tanzania 2007
  –   Kenya 2007
  –   Lesotho “Know Your Status” campaign
Promotion of VCT in Kenya, 2001-2
HTC Week in Malawi
Malawi National Testing Week Results
            HCT Week Output by Year
   80,000                             Tested
             2006           2007
Debates and Questions about HTC
How many additional messages?
Best model for HTC in health facilities?
Who should perform HTC?
How much training is needed?
How much counseling is needed?
Does HCT promote behavior change?
How much repeat testing is needed?
What does HCT cost?
       Recent Developments
Expansion supported by:
– National investments
– Global Fund for AIDS, TB and Malaria
Access to care and treatment encouraging
Effectiveness of referral systems for HIV positive
persons is unclear
Upcoming guidance on retesting HIV negative
persons in light of acute HIV infection
Many unanswered questions
– Testing of pregnant women, infants, children still
– How to increase couples testing, mutual
– Effectiveness of referral systems
– Prevention impact
Technology advances
Health worker crisis in many African
countries impedes delivery of HTC
             Thank you!
Dr. Elizabeth Marum, CDC
Alison Surdo, USAID

Mini – U participants
I just spent 30
minutes talking to
a pregnant young
girl who tested
positive and her     Oh? But did you manage to
partner refuses to   talk about…
get tested.          ..FP….
                     STI s,
                     …Male condoms,
                     ..Female condoms,
                     … malaria
 ?                   … safe water and
                     ..Positive living?
  What is the best model for
  provider-initiated HCT?
All patients or only those with risk
behaviors or symptoms?
At the patient’s bedside or in a more
private location?
A separate rapid test or testing along with
other medical tests?
 Who should perform HCT?
– Health worker: short diagnostic message,
  focusing on a treatment plan for HIV+
– Lay counselor: pre-test and post-test
  prevention and supportive counseling?
– Only lab technicians or technologists?
– Only health workers?
– Lay counselors?
How much training is needed?

Different countries have different lengths
of training ranging from 6 hours to 6
No studies yet done assessing impact of
longer or shorter training
Current draft training curriculum for
health workers (CDC/WHO) is 4 ½ days
and includes training in rapid testing
How much counseling is really
Is risk assessment or “confession” needed
for behavior change?
Does counseling promote behavior change?
  Does HCT promote behavior change?
Yes: evidence from Kenya and Tanzania
– More effective than health education alone
Recent meta-analysis found that:
– VCT recipients less likely to engage in unprotected
  sex compared with prior to VCT or to control
  group not receiving VCT
– Effect strongest on HIV+ recipients and discordant
– No effect on number of partners
Denison et al, AIDS and Behavior, Dec 2007
  HCT alone probably not effective as a
    prevention intervention when:
Couples don’t get tested together or don’t disclose
– Faithfulness to one partner of unknown status risky
  behavior in high prevalence countries
Poverty encourages young women to engage in sex
for money or gifts
– Higher rates of infection in young girls evidence for
  prevention failure in this group
Social norms encourage multiple concurrent partners
and early sexual activity
Post-test messages are inaccurate or confusing
Persons in window period (early infection) engage in
unprotected sex
  How much repeat testing is
High rates of repeat testing (~30% to 40%) of
repeat testing being observed in some countries
Some counselors routinely tell all persons testing
negative to return in 3 months
Better screening tools needed to identify those with
possible acute infection who need re-testing
US guidelines are for annual testing of persons
engaged in risky behavior
– What is risky behavior in high prevalence countries in Africa?
  Anyone sexually active?
     What does HCT cost?
Costs of training, supervision, QA, site
preparation, salaries, promotion, much
greater than cost of the test kits
Traditional VCT studied more
– Costs range from ~ $8 to $30 per person
– Costs include staff salaries, rent, operating
Provider-initiated testing in medical
facilities not yet thoroughly analyzed
– Costs likely to be lower if testing becomes part
  of regular duties
    Average cost per outcome in
     Kenya: mobile VCT versus
        stand-alone (2006)
Outcome                                                  Mobile  Stand-
Cost per client tested                                   $14.40  $23.62
Cost per first time client                               $15.91  $39.21
tested HIV +ve client
Cost per                                                 $151.62 $171.07
Cost per HIV +ve client                                  $177.23 $474.68*
previously undiagnosed
  *Note: high cost for HIV+ previously undiagnosed at stand alone may reflect repeat testing
   HIV Prevalence Among Pediatric
         Patients (Uganda)
Age group     Number Positive         Prevalence (%)
Under 5yrs      9,058       1,145           12.6

 6-10yrs        2,184        232            10.6

 11-18yrs       8,962        788             8.8

   Acceptance to test children: 96%
   Overall HIV seroprevalence among children was 11%

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