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					Malawi PMTCT Trainer Manual



Module 6 Testing and Counselling


               Total Time: 395-445 minutes


After completing the module, the participant will be able to:
 Define HIV testing and counselling (TC) correctly.
 Discuss the three guiding principles of HIV testing and counselling.
 Discuss the opt-out and opt-in HIV testing strategies.
 Describe the counselling skills that are important when working in PMTCT settings.
 Describe the three stages of the counselling process.
 Describe the basic steps to HIV testing.
 Discuss the tests used for diagnosing HIV infection.
 Discuss parallel and serial HIV testing procedures.
 Discuss information covered during the HIV pre-test education session.
 List the important components of the post-test session.



Have the following available:
 For Exercise 6.4 have rapid HIV test kits and supplies
 HIV Testing and Counselling, A Training Manual for Site Counsellors and
  Supervisors for Malawi
 HIV/AIDS Counselling and Testing, Guidelines for Malawi. 2 Edition, 2004.
                                                            nd

  Ministry of Health


UNIT 1               Basic Principles of HIV Testing and Counselling (TC) for
                     Prevention of Mother-to-Child Transmission of HIV
                     (PMTCT)
 Activity/Method                                                    Time
 Interactive lecture                                                25 minutes
 Exercise 6.1 Confidentiality role play                             25 minutes
 Exercise 6.2 Implementing routine testing: small group work        25 minutes
 Questions and answers                                              10 minutes
                                             TOTAL UNIT TIME        85 minutes




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UNIT 2             Counselling Skills
 Activity/Method                                                          Time
 Interactive lecture                                                      30 minutes
 Exercise 6.3 Basic counselling skills: demonstration and role play       60 minutes
 Questions and answers                                                    10 minutes
                                                TOTAL UNIT TIME           100 minutes

UNIT 3             HIV Testing
 Activity/Method                                                          Time
 Interactive lecture                                                      30 minutes
 Exercise 6.4 Rapid HIV test demonstration                                50-100 minutes
 Questions and answers                                                    10 minutes
                                              TOTAL UNIT TIME             90-140 minutes

UNIT 4             HIV Pre-Test and Post-Test Counselling
 Activity/Method                                                          Time
 Interactive lecture                                                      20 minutes
 Exercise 6.5 HIV pre-test counselling role play                          30 minutes
 Exercise 6.6 Post-test counselling role play                             60 minutes
 Questions and answers                                                    10 minutes
                                                TOTAL UNIT TIME           120 minutes



               Trainer Instructions
               Slides 1-3
Begin by reviewing the module objectives listed above.

Note: This module is not intended to be a comprehensive course in testing and
counselling in healthcare settings, but rather it complements existing training on this
subject and reinforces principles and protocols of testing and counselling in PMTCT
settings.




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UNIT 1           Basic Principles of HIV Testing and Counselling
                 (TC) for Prevention of Mother-to-Child
                 Transmission of HIV (PMTCT)

               Advance Preparation
               Review Exercise 6.1 Confidentiality role play and the script to be sure both
               reflect local customs, issues and policies. Ask PMTCT healthcare workers
               to help you adapt the script if necessary. Insert names as appropriate to
               reflect common local names.
               Review content from HIV Testing and Counselling, A Training Manual for
               Site Counsellors and Supervisors for Malawi.
               Make two copies (one for each of the volunteers) of Exercise 6.1
               Confidentiality role play script.


               Total Unit Time: 85 minutes


              Trainer Instructions
              Slides 4-5
Introduce the unit and review objectives.


After completing the unit, the participant will be able to:
 Define HIV testing and counselling (TC) correctly.
 Discuss the three guiding principles of HIV testing and counselling.
 Discuss the opt-out and opt-in HIV testing strategies.


                 Trainer Instructions
                 Slides 6-9
Introduce HIV testing and counselling using the content below.


                Make These Points
   Testing and counselling should be accessible to all sexually active young people,
    women and men.
   Testing and counselling may help clients make informed changes in their behaviour to
    reduce the risk of HIV acquisition or transmission.
   Specific PMTCT interventions depend on a woman knowing her HIV status; TC is
    also an entry point to other care and support services.
   Counselling for clients who are HIV-negative is aimed at reducing HIV risk and
    providing guidance for remaining HIV-negative.


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HIV testing and counselling
HIV testing
HIV testing is a process that determines whether a person is infected with HIV.

Definition of HIV counselling
HIV counselling is a confidential dialogue between a HCW and a client to enable the
client to make an informed decision on HIV testing (pre-test session) or providing
information on the HIV test result (post-test session). Testing and counselling can
enhance a person‘s understanding of HIV/AIDS and help the person make informed
choices for the future. The counselling process includes an evaluation of personal risk of
HIV transmission and facilitation of preventive behaviour. A trained counsellor (health or
non-healthcare worker) can conduct HIV testing and counselling.

Definition of PMTCT counselling
It is a two way communication whereby the counsellor provides information on HIV
testing, ARV prophylaxis, infant feeding options, nutrition and follow up care and
support.


Who should conduct PMTCT counselling?
PMTCT Counsellors may be doctors, clinic officers, medical assistants or
nurse/midwives.
 The counsellor must be trained and have knowledge of:
    HIV transmission and prevention strategies
    HIV testing
    Infant feeding
    Clinical staging
    HIV programmes and associated interventions (to facilitate referrals)
 Counsellors should also have a genuine interest in helping people with HIV and AIDS



TC in the context of PMTCT
In the context of PMTCT, HIV TC is a flexible intervention that is integrated into settings
where pregnant women and their partners and other women of childbearing age receive
reproductive health services such as antenatal, labour, delivery and postpartum care as
well as family planning services. TC in the context of PMTCT includes counselling
around other PMTCT interventions such as ARV prophylaxis or therapy and infant
feeding counselling and support.

Importance of counselling in PMTCT
TC in PMTCT settings requires HCWs to guide clients through a decision-making
process to support the client in making the most appropriate choices for her and her
infant. Healthcare workers (HCWs) involved in PMTCT services have a vital role to play
in:
 Routine testing and counselling for HIV, including information on HIV prevention
    and PMTCT interventions
 Counselling on nutrition
 Counselling on antiretroviral prophylaxis or therapy (if eligible)


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   Couple counselling or partner involvement
   Counselling on infant feeding
   Counselling about positive living
   Counselling on family planning
   Informing the client of opportunities for support in the community e.g., HBC

As helpers and facilitators in the decision-making process, HCWs must work in ways that
promote a woman‘s control over her own life and respect her ability to make her own
choices. Testing and counselling is the foundation of and entry point to HIV prevention
and care services.

                 Figure 6.1: TC as the Entry Point into Prevention and Care Services

                                                  ACCEPTING
                                   LIVING
                                                   & COPING
                                 POSITIVELY                            SUPPORT
                                                   WITH HIV
                             Nutrition                        Family
                             Clean water                      Social fellowship
                             Reduced stress                   Peer HIV positive




                  RISK
               REDUCTION                                                      MEDICAL CARE
          Behaviour change                                                 STI/TB Care
          Disclosure of status                 Testing &                   TB prophylaxis
          Partner referral to HTC                                          OI prophylaxis
          Condom access                       Counselling
                                                                              ARV clinic




                                                                       COMMUNITY
                              PLANNING                               INTERVENTIONS
                             FOR FUTURE                             Sensitisation
                         Family Planning                         Mobilisation
                         Orphan care                             De-stigmatization
                                                 PREVENTION OF
                         Financial             MOTHER-TO-
                                                     CHILD
                                                 TRANSMISSION




The content of the pre- and post-test sessions is covered in Unit 4 of this module.



                     Trainer Instructions
                     Slides 10-17
Discuss HIV counselling in PMTCT settings.


                  Make These Points
   PMTCT pre-test information needs to be adapted to the individual, couple or group.
   Whether pre-test information is provided to a group, couple or individual, it is
    important that the HCW provide opportunities for client(s) to ask questions.




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Counselling clients in the PMTCT services
There are three primary counselling scenarios in PMTCT services:

Individual counselling
 Most counselling associated with the PMTCT service will be individual counselling.
 The PMTCT counsellor will help the client make a decision about HIV testing,
   provide information about HIV, PMTCT and discuss a plan to reduce HIV risk.

Group counselling
If demand for testing is high, pre-test education can be provided in groups. Group pre-test
sessions are efficient because they optimize human resources, while allowing for
interaction among participants. The groups can be easily integrated into the clinic flow.
Where the client-to-provider ratio is high, group information sessions enable HCWs to
provide the basic testing and counselling messages to many women at one time.

Couple counselling
HIV counselling in the antenatal setting inevitably targets women. However, many of the
issues raised and long-term implications of antenatal testing involve not only the woman,
but also her partner, their unborn child and, in some cases, the extended family.
 For this reason, the counsellor should always explore the possibility of couple
    counselling at the initial visit.
 Pregnant women should be encouraged to come together with their partners for pre-
    test counselling, testing and post-test counselling.
 If a woman feels unable or unwilling to involve her partner, this must be respected.
 If the partner has not been tested, it may be advisable to again suggest couple
    counselling during subsequent visits, since HCWs commonly have contact with a
    woman at least a couple of times during the antenatal period.

Discordance in couples
Discordance means that one                               Working with couples
partner is HIV-positive and the           Women coming for HIV or PMTCT counselling
other partner is HIV-negative. The        should be encouraged (but not forced) to come
reasons for discordance in couples        with their partners as a couple. It is critical that
are not fully understood at present,      counsellors have some knowledge of couple
but are believed to be linked to a        counselling.
combination of factors that may
include genetics, HIV type, the
extent to which the infection has progressed in the HIV-positive partner, and other
sexually transmitted diseases. Studies are underway to confirm reasons for discordance.
It is important to inform clients that their HIV status does not always reflect their
partner‘s status. There are many variables involved in the transmission of HIV. HCWs
need to be particularly careful if the client is pregnant and HIV-negative and any potential
sex partners are positive. If a mother is infected during her pregnancy, the chances of
MTCT are much higher due to the high amount of HIV in the blood with a new infection.
For that reasons it is always advisable to encourage HIV testing for both partners.




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Why encourage couple counselling?
 A change in one of the partner‘s sexual behaviour is bound to affect the other partner.
 When couples work together in partnership they are more likely to be successful in
  what they want to do.
 The issue of disclosure of HIV test results to the partner, which is not easy for most
  couples, is better handled if they agree to be seen as a couple.
 Couples are better able to cope with the difficult decisions that must be made in light
  of a positive HIV test result.
 If they are counselled together, they can support each other when making decisions,
  such as whether to take ARVs and infant feeding.
 Some people seek counselling as a couple because they recognize that their problems
  are rooted in their relationship rather than being attributable to individual issues.

                              Guidelines for working with couples
   Create a trusting relationship with the couple.
   Contract with both of them.
   Let them know that there will be equal time for both of them.
   Let them know each of their opinions is important.
   Mention the possibility of discordant results (if one partner is infected while the other
    is not) and prepare them for this possibility.
   Pay attention to both their verbal and non-verbal communication.
   Try and draw out (politely), the silent partner of the couple, if there is one, to share
    their feelings and opinions.
   Do not judge or take sides.
   Leave your values, prejudices and beliefs aside and work with those of the couple.


Family counselling
 Encourage women to involve a partner or family member in HIV counselling, this
  person can provide support following the testing.
 The counsellor should encourage adolescents to involve a supportive ―significant
  other‖. Younger women (particularly those under 16 years) may not have a permanent
  partner and may prefer to be supported by a sister or mother.



                 Trainer Instructions
                 Slides 18-24
Introduce the guiding principles of testing and counselling and informed consent.


                Make These Points
   Confidentiality is the first of the three guiding principles for testing and counselling in
    PMTCT settings.
   Confidentiality is important for establishing client trust.
   This trust is central to the decision to consent to testing. As such, confidentiality is
    one of the keys to ensuring successful PMTCT services.



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     Informed consent, the second of the guiding principles for testing and counselling in
      PMTCT, requires that the client receives clear and accurate information about HIV
      testing, and that the HCW providing the information respects the individual‘s right to
      decide whether to be tested.
     Ensure privacy when providing HIV test results. Whenever feasible, provide test
      results in a private venue/room.
     Assure the client that the session and the test results will be kept confidential.
     Inform the client that follow-up treatment, care and support are available, including
      support for disclosure when needed.


Guiding principles for testing and counselling in PMTCT settings
The guiding principles for testing and counselling in PMTCT settings are:
 Confidentiality
 Informed consent
 Post-test support and services

Confidentiality
 Confidentiality is one of the most important issues in a counselling situation. When a
   HCW is clear about the parameters of confidentiality, clients can trust that what they
   disclose about themselves will remain confidential within the treatment team.
 When clients know and trust that what they disclose will remain confidential, they are
   more likely to share important information about themselves.
Maintaining confidentiality is an important responsibility of all HCWs and is essential to
establishing and maintaining client trust. Information that is shared between HCWs and
clients must be kept private. Clients should be informed that personal and medical
information, including HIV test results, may be disclosed to other healthcare providers for the
purpose of ensuring that the client receives the appropriate medical care.
HCWs should emphasize, however, that only those HCWs who are directly involved in the
client's care will have access to the client‘s records—and only on a ―need-to-know‖ basis.
All medical records and registers, whether or not they include HIV-related information,
should be kept confidential and stored in a safe, secure place. When possible, the same
counsellor should provide pre-test, post-test and support counselling.
Informed consent
Informed consent is the second guiding principle of testing and counselling; it is the process
during which each client receives clear and accurate information about HIV testing to ensure
that the client understands she has the right and the opportunity to decline testing.
One of the important objectives of PMTCT is to make HIV testing a routine or normal part
of ANC. Consequently, in the context of PMTCT, written informed consent is not required.
However, it is the responsibility of the HCW to address the following elements of informed
consent:
     Ensure the client has an understanding of the purpose and benefits of testing,
      counselling and PMTCT services.
     Ensure the client has an understanding of the testing and counselling process.
     Respect the client‘s testing decision.




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Post-test support and services
Post-test support and services is the third guiding principle: the HIV test result should
always be offered in person. Along with the result, appropriate post-test information,
counselling and referral should also be offered.


               Make This Point
   Emphasize that the HCWs should show respect for their client during the counselling
    process.

                      Guiding principles for PMTCT counsellors
1. View each client and her situation as unique, and make every effort to perceive the
   situation from the perspective of the client.
2. Create a non-judgemental atmosphere in which the counsellor encourages the client to
   express herself openly and freely.
3. Direct efforts towards helping clients identify and fulfil their goals as well as their
   needs, within the limitations of their ability, potential, and circumstances.
4. Proceed as if the best solutions to a client‘s problems are to be found within the client
   herself.
5. Continually communicate an attitude of high regard for the client as a worthy person.
6. Demonstrate a belief in the client‘s ability to take responsibility for her choices,
   decisions and actions.
7. Structure each counselling session in a way that enables the client to develop and
   improve the life skills needed to cope with their problem and situation.
8. Emphasize that counselling is a sharing relationship and that all decisions will be
   mutually agreed between client and counsellor.




                 Trainer Instructions
                 Slide 25
Lead the participants through the confidentiality role play and the questions at the end of
the exercise. It is important to keep the focus of this exercise on confidentiality and not
on other issues related to HIV testing.


                             Exercise 6.1 Confidentiality role-play
Purpose            To review and apply the principle of confidentiality in a post-test
                   situation where the client tests positive for HIV.
Duration           25 minutes
Introduction       Ask participants to refer to the role play script. Introduce the characters
                   by reading the introduction to the exercise out loud.




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                         Exercise 6.1 Confidentiality role-play
Activities:         Ask participants to refer to the role-play script in their Participant
Part 1—Role          Manuals
Play                Move two chairs to the front of the room and arrange them to face
                     each other.
                    Ask the two volunteers to sit in the two chairs in the front of the
                     room.
                    Ask one of the two volunteers to role-play the healthcare worker and
                     the other the client.
                    Ask the volunteers to read and role-play their lines for the group.
                    After they finish, ask them to return to the group.
                    Thank them for their assistance and ask the group to applaud their
                     efforts.
Activities:         Ask the following questions, use the possible answers provided
Part 2—              below to guide the discussion:
Discussion             Why is Nurse Banda, the healthcare worker, concerned about not
                         having a separate space to meet with Chimwemwe, the client?
                       How do you think Chimwemwe felt about this space and the
                         privacy of this space?
                       Is the space appropriate for this interaction?
                       What can be done to improve privacy in this space?
                       What can healthcare workers and clinics do to keep a client‘s
                         HIV status confidential?
                    What other breaches of confidentiality occurred during this role
                     play? How should this be addressed in the clinic?
                    Ask participants if they were Chimwemwe, would they come back
                     for their next ANC appointment?
                    Ask the volunteers how they felt when playing their roles.
Debriefing          Write the words ―Challenges to Confidentiality‖ on a flip chart
                    Ask the participants to cite the greatest challenges to preserving
                     confidentiality in the clinical settings where they work.
                    Remind participants that if confidentiality is not kept, clients may not
                     return for important appointments.
                    Record the challenges on the flip chart.


                       Exercise 6.1 Confidentiality role-play script
Introduction: Chimwemwe is returning to the ANC clinic for a follow-up visit after
receiving a positive HIV test result. Today, she is 4 months pregnant. The healthcare
worker, Nurse Banda, is very busy this morning and is expecting the rest of the day to be
just as busy. She has asked the receptionist to organise the HIV reports. While organising
the reports, the receptionist recognizes Chimwemwe‘s name and notices that
Chimwemwe is HIV-infected.

When Chimwemwe arrives for her appointment, she notices that some of the healthcare
workers are looking at her and whispering. When Nurse Banda calls Chimwemwe for her
appointment, they are forced to sit in a corner of the waiting room because all of the
client rooms are occupied.


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                             Exercise 6.1 Confidentiality role-play script
Nurse Banda           Hello, Chimwemwe. I am glad to see you here on time for your follow-
                      up appointment. Have a seat.
Chimwemwe             Hello, Nurse Banda. I have been so sad and nervous about my recent
                      positive HIV test. What does this mean for me and my family?
                      Chimwemwe looks around and is very uncomfortable because she thinks
                      other clients can hear her.
Nurse Banda           I wish we had a private office to sit in Chimwemwe, but space is so
                      limited here. I am certain that no one will hear us talking back here.
Chimwemwe             I just want you to know, Nurse Banda, that if my husband finds out, he
                      will be extremely angry. Please tell me what to do.
Nurse Banda           I‘m sorry, Chimwemwe I hear you saying that telling your husband your
                      HIV status will be a very difficult thing to do.
                      She pauses, giving Chimwemwe a chance to hear what she has just said.
                      I know this is very difficult for you, but I am here to help you through
                      this. Let us talk about your concerns around telling your husband.
Chimwemwe             Oh, Nurse Banda, what will I do? My husband and I were so excited
                      about this pregnancy. Before we were married, I had another boyfriend,
                      and I didn‘t always use protection.
                      Chimwemwe starts to cry. All of the clinic staff is now watching
                      Chimwemwe.
Nurse Banda           You must be feeling very overwhelmed right now, Chimwemwe. Please
                      know that everything you tell me will be held in strict confidence,
                      including your test results. Let‘s now discuss some of the concerns you
                      have about disclosing to your husband. Will that be ok?


                              Possible answers to Exercise 6.1 Confidentiality role-play
Use possible answers for role-play questions to guide discussion if needed.
Why is Nurse Banda concerned about not having a separate space to meet with Chimwemwe?
     She is concerned about confidentiality and making Chimwemwe feel comfortable and safe enough to talk openly
      and honestly about her HIV status.
How do you think Chimwemwe felt about this space and the privacy of this space?
     Participants will discuss.
Is the space appropriate for this interaction?
     No. A space where clients can be seen or heard by others is not a good area to discuss HIV test results because it
      does not maintain client confidentiality.
What can be done to improve privacy?
     If this is the only place to meet, a screen to keep the client from being seen by others in the waiting room can be
      helpful. Talking softly and not using the client‘s name may also help. In some situations, it may be best to delay
      discussing sensitive issues like disclosure to one‘s partner. Nurse Banda should have been more aware of her
      surroundings and of Chimwemwe‘s concern about the space.
What can healthcare workers and clinics do to keep a client’s HIV status confidential?
     In addition to space and privacy issues, the group could discuss how to keep medical records confidential and
      record whether a client has disclosed her test results. The group could discuss how they protect privacy in their
      individual settings.
What other breaches of confidentiality occurred during the role play? How can this be addressed in the clinic?
     Clients have a right to have their medical information kept private. In this case, it appears that the receptionist
      shared Chimwemwe‘s confidential tests results with other staff members. Participants should discuss what rules




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                                 Possible answers to Exercise 6.1 Confidentiality role-play
     are in effect in their clinics to discipline this type of breach of confidentiality. Encourage participants to note that it
     is very possible that Chimwemwe no longer trusts Nurse Banda because what she is saying about her results being
     kept private is not true.
Ask participants if they were Chimwemwe, would they come back for their next ANC appointment?
    Participants will discuss.




                     Trainer Instructions
                     Slides 26-28
Discuss the importance, especially for pregnant women, of learning their HIV status.
Describe both ―Opt-out‖ and ―Opt-in‖ approaches to HIV testing, emphasizing Malawi‘s
opt-out approach.


                   Make These Points
      Explain that internationally there are two main approaches to developing an HIV
       testing and counselling component in ANC services: ―Opt-out‖ and ―Opt-in‖.
      Malawi uses the ―Opt-out‖ approach, which is commonly referred to as ―routine‖
       testing.
      Begin by defining and comparing the provider initiated ―Opt-out‖ and client initiated
       ―Opt-in‖ approaches to HIV testing using the content below.
        The opt-out strategy helps to normalize HIV testing as a routine component of
           ANC.
        Point out that ANC settings often choose to inform clients about HIV testing and
           the opt-out approach in a group format, followed by a brief pre-test counselling
           session.

 ―Opt-out‖ (routine) and ―Opt-in‖ (optional) approaches to HIV testing
in PMTCT settings
There are two approaches to HIV testing in the ANC and the labour and delivery settings.
Each provides easily understood information to the client about HIV and the risks and
benefits of testing. The approaches differ in how clients agree to test for HIV. The
differences are summarized as follows:
Opt-out or routine: HIV testing, in combination with information on HIV, is offered as
a routine part of a standard package of care. This information session may be provided
individually as in pre-test counselling or in a group. The client is given information about
the HIV test and unless she declines it, the test will be performed. The opt-out approach is
provider-initiated and emphasizes that HIV testing is an expected part of ANC. However,
testing is still voluntary under the opt-out approach: the client has a right to refuse testing.
If the client refuses testing, the provider should try to identify any barriers to testing and
problem-solve with the client.

In Malawi, routine or ―Opt-out‖ HIV testing is policy. As with all tests, the client
has the right to refuse the test.


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Opt-in: Here the client is also provided with information about HIV and testing.
However, the client is given the option of refusing or consenting to an HIV-test. This
approach is essentially client-initiated and women who ―Opt-in‖ explicitly request to be
tested, and their informed consent—written or oral—is clearly established. The opt-in
approach requires an active step by the individual client to agree to be tested.


               Opt-Out or Routine                                  Opt-In
      Client receives information about            Client receives information about
       HIV testing in PMTCT (either in a             HIV testing in PMTCT (either in a
       group or on an individual basis).             group or on an individual basis).
      Client is given the opportunity to ask       Client is given the opportunity to ask
       questions and the HCW ensures that            questions and the HCW ensures that
       the client understands HIV testing in         the client understands HIV testing in
       the context of PMTCT.                         the context of PMTCT.
      Unless client refuses, HIV test is           Client specifically requests the HIV
       performed.                                    test and gives verbal or written
                                                     consent.



                 Trainer Instructions
                 Slide 29
Before leading Exercise 6.2, ensure that participants understand the difference between
the opt-out/routine and opt-in approaches by reviewing the bullet points in the table
above.


              Exercise 6.2 Implementing routine testing: small group work
Purpose            To share ideas about practical ways to implement the opt-out or routine
                   testing strategy in a variety of ANC settings
Duration           25 minutes
Introduction       To the full group – present one example of the steps a client would go
                   through for HIV testing in an ANC setting – what happens first, second,
                   third, etc.:
                    Registration
                    Individual counselling, couple counselling and/or group information
                        session
                    HIV testing
                    History and physical exam
                    Test results and post-test counselling
                    ANC lab profile
                    Follow-up visit
                    In this exercise participants should assist one another in outlining the
                    flow of clients and identifying ways to improve the routine approach to
                    HIV testing and counselling where they work.


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               Exercise 6.2 Implementing routine testing: small group work
Activities          Small group discussion (15 minutes)
                     Divide the group into smaller groups, making sure you have
                      participants from different types of ANC settings represented in each
                      group.
                     Give each small group flip chart paper and markers.
                     Ask individuals in the group to discuss for a short time, how the flow
                      of clients works in their ANC setting. After each description, the
                      groups should identify how routine testing might be implemented or
                      improved upon in that setting. Ask them to identify volunteer(s) to
                      record the main points of the discussion.
                     Potential discussion questions:
                               o How to improve client flow?
                               o At what point do patients have the opportunity to ‗opt-
                                   out‘?
                               o How to reach women on the 2nd or 3rd visit who have not
                                   been counselled yet?
                               o How to organize the clinic to increase client‘s access to
                                   testing and counselling?
                               o How to reduce waiting times?
                               o What would be the ideal or model HIV testing and
                                   counselling system for ANC?
                     In the last 10 minutes - invite each group to report back to the larger
                      group and propose solutions for effective implementation of opt-out
                      testing.
                     Ask the larger group to comment on each small group‘s
                      recommendations and to propose solutions for effective
                      implementation of opt-out testing.
Debriefing           Briefly review the differences between HIV testing in different ANC
                      settings.
                     Summarize each set of proposed guidelines.
                     Emphasize the proposed solutions for barriers and other problems in
                      each setting.


                  Trainer Instructions
                  Slides 30-31
Summarize HIV testing and counselling.


Summary of Malawi testing and counselling procedure:
      Discuss the basic pre-test counselling information with the client including issues
       related to the HIV test, its benefits and consequences.
      Discuss the meaning of the test including the ―window period‖.
      Discuss advantages and disadvantages of knowing serostatus in the context of
       PMTCT.
      Clarify HIV testing procedures at the site.
      Encourage and promote couple counselling and shared confidentiality.


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   Provide an opportunity for the client to ask questions, to opt-out of testing, and
    emphasize the importance of obtaining results.
   Offer HIV testing in accordance with the National Standard Operating Procedures
    ensuring appropriate protection of client anonymity and confidentiality.
   Provide post-test counselling to those who test, regardless of result.




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UNIT 2            Counselling Skills

                Advance Preparation
                The trainer should become familiar with the exercises and appendices,
                gather the necessary props for the role plays, and identify potential
                volunteers or co-trainer(s) for the role plays. Decide ahead of time how to
                divide participants into small groups.
                Exercise 6.3: The trainer may want to consider inviting an experienced co-
                trainer or participant to assist with the demonstration of counselling skills.
                Participants should be encouraged to review the exercise and appendices the
                night before the training. Relevant appendices:
                 Appendix 6-A: Counselling Skills and Techniques Checklist
                 Appendix 6-B: Self-Concept of the Counsellor
                 Appendix 6-C: How to Facilitate a Role Play



                Total Unit Time: 100 minutes



               Trainer Instructions
               Slides 32-33
Introduce the unit and review objectives.

After completing the unit, the participant will be able to:
 Describe the counselling skills that are important when working in PMTCT settings.
 Describe the three stages of the counselling process.



                  Trainer Instructions
                  Slide 34
This unit focuses on the importance of developing good communication and counselling
skills. Try to ensure that the discussion addresses the scope of the participant‘s job roles.
Help participants to see counselling as a process that supports clients as they make
decisions. Spend the first 5 minutes asking participants about the basic communication
and counselling skills they use in their work and write them on a flip chart.


                 Make These Points
      Counselling helps all clients make informed changes in their behaviour to reduce the
       risk of HIV acquisition or transmission.
      Counselling provides an entry point to more comprehensive health care services,
       particularly HIV treatment, care and support.


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   Counselling provides an exchange of information between client and counsellor
    developing a relationship that assists both HCWs and clients make informed health
    care decisions.
   Counsellors must respect the client‘s right to decline HIV testing.


Role of the HCW in counselling
The role of a HCW is to support and assist the client‘s decision making process by:
 Listening to the client
 Understanding the choices that need to be made
 Helping the client explore her/his options and circumstances
 Helping the client develop self-confidence, enabling her/him to carry out their
   decisions
The HCW is not responsible for resolving all of the client‘s worries or concerns. The
HCW is not responsible for the client‘s ultimate decision.



                Make These Points
   Basic communication skills promote mutual understanding and trust in the counsellor-
    client relationship.
   Active listening includes both verbal and nonverbal forms of communication.
   Clarifying and summarising can help to put the topics discussed and conclusions
    reached in a meaningful order for the client.
   The counsellor must never ―rescue‖ the client or take on the client‘s problems.
   It is the responsibility of the client to decide on and implement his or her own
    solution.


                 Trainer Instructions
                 Slides 35-42
Explain that the basic communication and counselling skills routinely used by HCWs are
the building blocks for counselling about HIV testing.


Basic skills needed by a counsellor
Interpersonal communication skills
 Understand that the client may be nervous or embarrassed
 Receive client openly and with respect: be friendly, honest, genuine, courteous, have
   appropriate eye contact, and a relaxed body posture
 Empathize
 Display non-judgemental attitudes
 Engage client in conversation
 Actively listen and observe (both verbal and non-verbal forms of communication)
 Show emotional warmth and support




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Information-gathering skills
 Use predominantly open (versus closed) questions
 Use silence appropriately to allow for client‘s self-expression, dealing with impact or
   thinking through implications
 Clarify client expectations

Information-giving skills
 Have up-to-date knowledge about HIV and PMTCT
 Provide simple and clear information about HIV and PMTCT
 Reinforce important information
 Check for understanding and misunderstanding
 Summarize information given

Skills in dealing with special circumstances
 Accommodate language and communication difficulties
 Talk about sensitive issues in simple and appropriate terms with regard to the culture,
   educational level and beliefs (spiritual and traditional) of the client
 Prioritize issues to accommodate limited counselling time and brief client contacts
 Creatively overcome constraints such as time and privacy
 Appropriately manage client distress and other emotional reactions
 Involve partner or significant other, when appropriate or requested

Verbal and nonverbal communication
Besides transmitting information through words (―verbal communication‖), individuals
also send messages through their actions and behaviours. This is referred to as ―nonverbal
communication‖.

 Nonverbal communication includes:
  Body behaviour: body movements, posture and gestures
  Facial expressions: twisted lips, frowns, twinkles, smiles
  Voice tone: pitch, voice level and intensity, pauses, fluency
  General appearance: type of dress, way of walking, mannerisms
 Nonverbal cues and messages are interpreted differently in different cultures, so the
 counsellor should develop a working knowledge of the meaning of nonverbal
 communication for the environment in which she/he is working.

Listening skills
Good listening skills are the primary tool used to gather information about the client. The
skills involve listening to the client‘s words; their factual information; and the minute
details such as choice of words and emphasis on specific words. It also involves
recognizing the feelings that are conveyed, along with the actual words used.

Questioning skills
Counsellors must also be good information gatherers. There are many ways a counsellor
may ask a client for information, but often the type of question used either maximizes or
minimizes what is obtained.
 Open-type questions: Invites a descriptive response. For example, ―How are you
   sleeping these days?‖



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   Closed-type question: Allows for only a ―yes‖ or ―no‖ response. For example, ―Are
    you sleeping well these days?‖
   Leading -type question: Implies what kind of answer is expected. For example,
    ―You are not sleeping badly these days, are you?

Two other techniques used in gathering information from a client are:
 Circular questioning: The counsellor asks a series of open-ended questions, which
  allows the clients to learn something about themselves and their feelings. In the
  process, the counsellor also learns more about the client.
 Reflection: An open-ended question is asked by the counsellor, which gives a lead
  into a subject that needs further exploration. The counsellor then reflects back on the
  client‘s answer leading into a new question. For example, ―And so you were afraid
  that your husband was not being faithful to you then. How did you feel at the time?‖


                            Skills needed for group counselling
Providing group counselling requires the same skills as individual counselling as well as
the additional skills necessary to manage the complex group dynamics. Group
counselling requires an ability to:
 Deal with overly assertive, domineering individuals
 Ensure inclusion of quiet, shy, or overwhelmed individuals
 Encourage all participants to speak
 Cope with people who become emotionally distressed in a group
 Be inclusive of, and non- judgemental about the religious, cultural or personal beliefs
    of group members
 Allow the group to learn from each other, by refraining from ―lecturing‖ the group




                 Trainer Instructions
                 Slides 43-49
Define counselling as a relationship in which a counsellor helps the client to explore his
or her personal issues in order to make decisions and take action.
Introduce the different stages of counselling—exploration, understanding and action.

The process and the practice of counselling
Counselling is a relationship that is safe, client-centred and dynamic. Within it, a range of
skills and techniques are used to initiate a process of positive change, from:
 Dissatisfaction to satisfaction
 Pain to comfort
 Low esteem to high esteem
 Poor social skills to good social skills

The process of counselling can be described as occurring in three stages: Exploration,
Understanding and Action.




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Stage 1: Exploration – ―Helping the client tell her story‖
 At this beginning stage of the counselling process, the counsellor helps the client to
   tell her story and discuss her HIV status.
 A counsellor helps the client to develop an understanding of the difficulties faced and
   the possibilities for solutions in her life.
 It is the counsellor‘s job to help the client break through blind spots that prevent the
   client from seeing herself, her situation and her unused opportunities.
 Some clients are able to express themselves easily and reveal their concerns, while
   others are cautious and reluctant to do so.
 It becomes particularly important with the reluctant individuals that counsellors have
   the skills that make their clients feel comfortable enough to discuss their HIV status
   and ensuing concerns with the counsellor.
 To make this happen, counsellors need to establish effective relationships with their
   clients.
Steps to be taken by the counsellor at this stage:
The counsellor makes the client feel at ease by verbally welcoming her and
demonstrating positive nonverbal behaviours.
a) The counsellor displays non-judgemental attitudes and uses skills to help the client
   explain her concerns and problem(s).
b) The counsellor helps the client to explore the meaning of the experience she is going
   through, explore the severity of her problem, and enable her to express her feelings.
c) The counsellor explores the client‘s understanding by asking open-ended questions
   about what the client already understands about the problem and, in this process, the
   counsellor may give information to the client or correct misinformation.
d) The counsellor helps the client to analyse the problem. From this, the client should
   then be able to establish the cause and effect relationship. Establishing this
   relationship will help the client begin to think of effective strategies for dealing with
   the situation.

At the end of stage 1 both the counsellor and the client should have enough of an
understanding of the client‘s concerns to start thinking and formulating strategies for
dealing with the situation.

    Possible question for client: ―What are my problems, issues, concerns and
    opportunities?‖

Stage 2: Understanding – ―Helping the client consider options‖
 At this stage of the counselling process, the counsellor aims to help the client identify
   what she wants. What are her goals and objectives, based on her understanding of her
   problem(s)?
 This stage deals with outcomes, results and the client‘s preferred wants.
 Once clients understand their problems, they need help determining what options they
   have for dealing with the problem(s).
 The preferred situation provides answers to such questions as: ―What do you want?‖
   and ―What would things look like if they were better?‖


       The feminine pronoun is used to simplify the text, this should not be interpreted to preclude male
       clients. The importance of including partners and family in the testing and counselling process should
       be considered an assumption throughout this Training Package.


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    The counsellor guides the client to explore all the options and alternatives that would
     assist her with achieving the preferred situation.

Steps to be taken by the counsellor at this stage:
The counsellor discusses with the client which of the client‘s concerns are the most
urgent, i.e. the issues to be addressed immediately.
a) If someone is having a lot of problems, they may find it helpful to try and solve the
   least difficult problem first and in this way gain confidence to deal with other
   problems.
b) The counsellor guides the client to select the problem to be worked on.
c) The counsellor should ask open-ended questions to fully explore all the possible ways
   the problem could be resolved: ―What are the things you think you could do?‖ and
   ―What would happen if….?‖
d) The counsellor helps the client to consider and explore carefully all the implications
   and the likely outcome of each option. Information is provided as needed.

After this stage of the counselling session is completed, the client will have been helped
by the counsellor to think of a number of ways to cope with the problem. By exploring
implications, likely outcomes, and the advantages and disadvantages of each option, the
counsellor will have helped the person choose the best course of action to take with the
greatest likelihood of success.

    Possible question for client: ―What do I need or want in place of what I have?‖

Stage 3: Action – ―Helping the client make a plan‖
 This stage of the counselling process requires figuring out what needs to be done first,
   second, third and so forth and to make sure the selected line of action is implemented
   and accomplished.
 This stage deals with activities to achieve results.
 Clients may know what they want to accomplish and where they want to go, but still
   need help with determining how to get there.
 The counsellor‘s aim is to help the client translate strategies into actions.
Steps to be taken by the counsellor at this stage:
After defining the exact problem to be worked on in stage 2, the counsellor needs to assist
the client to choose the best course of action to resolve the problem. In other words, help
the client to plan.
a) The counsellor asks open-ended questions to help the client consider how she might
    act: ―What do you think might be the best thing to do?‖; ―What will you do now?‖;
    ―How will you do this?‖; ―Who might help you?‖; ―When will you do this?‖
b) The counsellor summarizes the plan the client has made and encourages her to come
    back again to discuss how the plan worked out. This is important because if the plan
    needs some adjustment, the counsellor will be able to help the client to determine
    what the new course of action should be, rather than the client abandoning the plan
    entirely out of discouragement from a lack of success.

    Possible question for client: What do I do to get what I want?

The basic counselling process forms the basis of all our counselling interventions. It is a
problem-solving approach to help a client find the best solution for her particular


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situation. This approach can be applied to any of the client counselling scenarios that a
counsellor may face in PMTCT services.



                  Trainer Instructions
                  Slides 50-52
Review professional code of conduct for counsellors in Malawi.

Professional ethics in counselling
      All helping professions must have a moral base; therefore, a counsellor‘s actions
       should be guided by certain principles to avoid doing anything that would harm the
       client or society at large.
      Always remember that a client is vulnerable and open to destruction as the result of
       irresponsible counselling practices, either intentional or unintentional.
      Professional ethics in counselling comprises values such as integrity, competence,
       confidentiality, responsibility and accountability.

Support for counsellors
Counsellors, like all caring professionals, can leave the counselling session stressed and
overwhelmed, unable to effectively perform their roles. Counsellors may also have
anxieties about HIV in their own family life. These unresolved worries may prevent them
from helping clients effectively.
It is strongly advised that measures for supporting the counsellor be built into their
activities. Regular supervision and peer support meetings reduce the chances of burnout
in the counsellor. Support activities can be any of the following:
      Individual support and supervision: Support and supervision whereby a more
       experienced supervisor with training in supervision skills is working with a
       counsellor.
      Team support and supervision: The same support and supervision can also be
       offered to a team of counsellors, in which an experienced supervisor provides support
       and supervision to a group of counsellors.
      Peer group support: Counsellors can support each other by drawing on their
       different strengths and experiences. Counsellors working in the same clinic or
       geographical area are strongly advised to practice this type of supervision on a regular
       basis even if they have team supervision and support. Peer group and team support
       and supervision is a cost-effective way to provide a supportive atmosphere for sharing
       experiences and anxieties as well as for problem-solving.

Support and supervision does not only help the counsellor restore balance but also helps
with professional growth. During support and supervision, counsellors can review
difficult cases and gain insight from fellow counsellors. This will allow for reflection
about proper use of counselling skills. In addition, the counsellor is challenged to reflect
critically on his or her own work.

Counselling for counsellors: For many counsellors, their job is a reminder of their
personal HIV-related concerns. Maybe the counsellor is worried about her risk of


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infection (at work or in her personal life), or has a partner or other family members with
HIV. Maybe she is HIV-infected and worried about her own health. Access to
counselling services away from their workplace must be considered.



                 Trainer Instructions
                 Slides 53-54
Have participants brainstorm common counselling mistakes and then expand the list
using the following information.


Common counselling mistakes
The principles of counselling are easy to learn but difficult to apply. Some common
counselling mistakes include:
 Controlling rather than encouraging the client‘s spontaneous expression of feelings
   and needs.
 Judging, as demonstrated by statements that indicate that the client does not meet the
   counsellor‘s standards.
 Moralising, preaching, teaching, or being patronising—telling people how they
   should behave or lead their lives.
 Labelling a client as opposed to finding out her individual motivation, fears or
   anxieties.
 Inappropriately reassuring a client—telling a client, ―You have nothing to worry
   about‖ when this may not be true.
 Not accepting the client‘s feelings—stating that the client should not be e.g., upset or
   scared.
 Advising, before the client has enough information or time to arrive at a personal
   solution.
 Interrogating—using questions in an accusatory fashion. Questions that start with
   ―Why…‖ risk sounding accusatory.
 Encouraging dependence—increasing the client‘s need for the counsellor‘s presence
   and guidance.
 Attempting to manipulate client to accept new behaviour through flattery or deceit.



                 Trainer Instructions
                 Slide 55
The following exercise (Exercise 6.3) gives participants an opportunity to practise
communication skills—specifically: paraphrasing, reflecting feelings, questioning and
clarifying. Before participants break into small groups, the trainer and a volunteer (either
a co-trainer or participant experienced in counselling) should demonstrate the role play
and debriefing in front of the large group. The demonstration will then function to model
the small group work that follows.

Role play scenarios are not provided for this exercise. When playing the ―client‖
participants should model their behaviour and script on a typical, or even an atypical,


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counselling client from their work situation (or if they lack counselling experience,
maybe a friend who tends to have a lot of problems). ―Clients‖ should ensure that they
role play a somewhat realistic person.

              Exercise 6.3 Basic counselling skills: demonstration and role play
 Purpose           To practise counselling skills with special emphasis on paraphrasing,
                   reflecting feelings, questioning and clarifying
 Duration          60 minutes
 Introduction      When introducing this exercise, emphasize to participants that a good
                   listener should:
                    Be respectful.
                    Pay attention to the client‘s internal viewpoint.
                    Keep a responsive tone of voice.
                    Use positive body language.
                    Provide positive feedback.
                    Use open-ended questions.
                    Paraphrase.
                    Reflect the client‘s feelings.
                    Manage one‘s initial resistance to things the client may say.
                    Avoid the phrases, ―I wouldn‘t do that…or ―don‘t do….‖
 Activities        Role play demonstration in large group
                   Invite a co-trainer or a volunteer from the group (preferably someone who
                   is experienced in counselling) to assist you in role playing the scenarios
                   below as a demonstration of basic communication and counselling skills.
                    Place two chairs facing each other. Ensure that all participants can see
                        the role play.
                    Refer participants to Appendix 6-A, Counselling Skills and Techniques
                        Checklist; ask them to use the Checklist as they observe the basic
                        communication and counselling skills demonstration.
                    The co-trainer or volunteer should then take 2-3 minutes to
                        demonstrate role playing each of the communication skills introduced.
                    After demonstrating all of the skills, the trainer should take five
                        minutes to debrief with participants, using the Counselling Skills and
                        Techniques Checklist. Ask participants to share their observations.

                   Role play in small groups
                    Divide the participants into groups of three. Tell them to practise the
                      same communication skills just demonstrated, they may use Appendix
                      6-A for reference.
                    Instruct each small group to identify a ―counsellor‖, ―client‖, and an
                      ―observer‖.
                    Provide each small group with flipchart paper to record key points
                      observed during the role play.
                    Remind participants of the importance of nonverbal communication;
                      (maintain a relaxed posture, lean slightly forward to express interest,
                      maintain appropriate eye contact, position chairs and room furniture to
                      facilitate discussion).



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              Exercise 6.3 Basic counselling skills: demonstration and role play
                         Ask each small group to identify a person who will record key
                          discussion points on flipchart paper. The recorder should be prepared
                          to report their observations to the larger group.
                         The ―counsellor‖ may want to start by asking, e.g., ―Why do you think
                          you may be at risk of HIV?‖ The ―client‖ should then take 3 minutes to
                          talk to the ―counsellor‖ about her or his personal concerns about HIV.
                          The ―client‖ should feel free to raise a range of concerns (reflecting
                          typical scenarios from the clients with whom they work).
                         The ―counsellor‖ will practise as many of the communication skills as
                          possible in the 3 minutes provided.
                         After 3 minutes, stop the exercise and ask the ―observer‖ to provide
                          feedback on each of the skills and techniques observed using the
                          Counselling Skills and Techniques Checklist (Allow 2 minutes for
                          feedback).
                         Repeat this exercise until everyone has had an opportunity to practise
                          all three of the roles.
                         Observe each of the small groups during their practice session and
                          provide feedback, if needed, to clarify the activity.

                      Debrief in large group
                       Bring participants back to the larger group and ask the recorder from
                          each group to take 3 minutes to report their key findings on interactions
                          that will assist all of the ―counsellors‖ with improving his/her skills.
                       Write these on a flipchart and lead an interactive discussion pointing
                          out strengths as well as areas identified where improvement was
                          suggested (five minutes).
 Debriefing           Summarize the key points from the group feedback. It is likely that some
                      of the observations will reflect values, attitudes, fears and prejudices of the
                      HCW practising their counselling skills.
                      Remind participants that improving counselling skills takes practice, as
                      well as continuous self-exploration. Refer participants to Appendix 6-B,
                      Self Concept Model.




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UNIT 3         HIV Testing

             Advance Preparation
             Exercise 6.4: The trainer should:
              If unfamiliar with the rapid testing procedure, recruit an expert in this
                field to conduct the demonstration and oversee the small group work.
              Gather rapid HIV test kits and supplies including anonymous blood
                sample or control sample to mimic client blood sample. (The trainer
                should have sufficient test kits to process one sample if only
                demonstrating the process; if each participant will be practising the
                testing procedure, there should be at least one test kit per participant).
              Review the testing steps for the rapid HIV tests according to national
                guidelines.



             Total Unit Time: 90-140 minutes


             Trainer Instructions
             Slides 56-57
Introduce the unit and review objectives.

After completing the unit, the participant will be able to:
 Describe the basic steps to HIV testing.
 Discuss the tests used for diagnosing HIV infection.
 Discuss parallel and serial HIV testing procedures.


               Trainer Instructions
               Slides 58-59
Introduce this unit by reviewing the objectives listed above. Begin by discussing HIV
testing and the factors that influence a programme‘s choice of HIV tests, using the
content below.

Overview of HIV testing
HIV tests detect antibodies or antigens associated with HIV in whole blood, saliva, or
urine. Blood sampling is the most common mode of testing. The results of different tests
can be combined to confirm HIV status. When properly administered, HIV tests offer a
high degree of accuracy. However, those who administer or handle HIV tests must be
trained and adhere to proper procedures to ensure that accuracy is preserved.

Several factors influence the selection of an HIV test by individual facilities and national
policymakers:
 National guidelines/policies


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   Availability and expertise of laboratory or other trained personnel
   Availability of supplies and laboratory support
   Evaluation of specific tests in the country
   Cost of test kits and supplies

                 Trainer Instructions
                 Slide 60
Describe the five main steps in HIV testing. Explain that, regardless of the type of test,
these basic steps are always followed.

The 5 basic steps in HIV testing
1. A specimen is obtained. Most often, blood is taken from a person's fingertip or arm.
   Specimens must be handled with care. Those taking or handling blood should wear
   gloves.
2. The specimen is processed. This can be done on site (at the ANC clinic or in the
   labour ward) or in a laboratory.
3. The test is administered by a HCW or laboratory technician trained in HIV testing
   procedures as per national guidelines and algorithm.
4. The client is told the result.
5. The HCW provides post-test counselling, support and appropriate referrals.


                 Trainer Instructions
                 Slides 61-65


                Make These Points
Explain that there are two main types of tests that are used to detect HIV infection,
antibody tests and viral tests:
 Antibody testing—an ―antibody‖ is a protein formed by the body‘s immune system in
    response to a foreign invader, like the HIV, which infects the body. Antibody tests are
    designed to detect the antibodies or proteins the body makes in response to HIV
    infection.
 Viral and antigen testing—an ―antigen‖ is a particle that is attached to a virus and
    serves as a marker of the invader, so it can be identified by the body‘s immune system
    and destroyed. Viral tests detect the presence of the HIV virus itself.
 Antibody tests are faster and less expensive than viral tests.
 Rapid HIV tests and the ELISA (enzyme-linked immunosorbent assay), both of which
    are antibody tests, are used in ANC sites in Malawi.

Tests used for diagnosing HIV infection
There are two types of tests:
 Antibody tests
 Viral tests



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HIV antibody tests
Antibody tests do not detect the HIV itself, but the immune system‘s response to the
presence of HIV. Under normal circumstances, antibodies against the HIV take a few
weeks to three months to develop after initial infection (the ―window period‖).

Types of antibody tests:
 HIV ELISA tests: this is the most efficient test for testing large numbers of
   specimens per day, but it requires laboratory facilities with expensive equipment,
   maintenance staff and a reliable power supply.
 Simple rapid HIV tests such as Uni-Gold, Determine and Bio-line: these do not
   require special equipment or highly trained staff and are easy to perform.
 Saliva or urine tests: these are not yet widely available.
 Western Blot: this is used to confirm positive results or for clarification where two
   antibody tests are discordant. Western blot tests are costly and are difficult to
   perform. They are used primarily for research and quality assurance purposes
   (Community Health Sciences Unit).

                      Rapid HIV tests have the following characteristics:
      Can be done in the clinic setting (e.g., the antenatal (ANC) clinic, HIV Testing and
       Counselling (HTC) centre or in labour and delivery)
      Highly accurate when performed correctly
      Usually performed on serum or whole blood (either by fingerprick or venous
       sample)
      Do not require special equipment, electricity, or refrigeration
      Can be done on a single specimen with no batching required
      Clinic staff can be trained to perform the tests



                             Benefits of rapid HIV testing include:
      Blood specimens can be analysed in the clinic
      Same-day results are more convenient for the patient and allow for immediate
       provision of post-test counselling and referrals for care and support
      Pregnant women who are HIV-positive can be educated about PMTCT interventions
       and possible treatment options
      HCWs do not need to track down test results from an outside laboratory
      There is less of a risk of specimen mix-up or specimens being misplaced.




                  Trainer Instructions
                  Slide 66
Discuss HIV viral tests using the content below (refer to the definitions above).




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HIV viral tests
HIV viral tests detect the presence of the virus itself. They are very sensitive, and can
detect relatively early infections. In comparison to antibody rapid tests; viral tests must be
done by trained personnel in a laboratory, test results are not given immediately, and the
tests are relatively expensive.

The most commonly used viral test for HIV detection is the PCR (polymerase chain
reaction) tests which detect viral DNA. PCR tests detect the presence of the virus in the
blood and are used for diagnosis of the infant less then 18 months.

There are other types of viral test that can be used to detect the amount of virus present in
someone who is HIV positive. These viral tests (RNA viral tests) are not commonly used
to determine if someone is HIV positive, but are used to identify the amount of virus in
blood (viral load tests) to assist with treatment for HIV.



                 Trainer Instructions
                 Slides 67-68
Review HIV testing procedures in Malawi.

Testing procedures
HIV testing should be done according to testing and counselling guidelines. Procedures
should ensure appropriate protection of client confidentiality. The types of test kits to be
used should be in line with what is in the TC guidelines. If whole blood rapid test has
been used, results should be communicated to a client only after two tests have been
performed and, in case the results are discordant, after a third tie-breaker test has also
been used.

Performing the HIV test
In order to test a person for HIV infection, a HCW must handle the testing devices
properly. The following are important points to remember:
 Observe infection control procedures and universal precautions
 Label properly
 Observe specimen collection procedures
 Use the required amount of blood per test
 Use the correct buffer solution in the correct amount for each test
 Read test after the prescribed timing
 Interpret results as per manufacturer‘s instructions
 Keep proper records
 Observe all disposal procedures
The following factors may affect test performance and results:
 Storage and handling of test kits
 Changes in the environment
 Accuracy of equipment; external and internal controls
 Shelf-life of the chemicals for the tests (reagents)
 Technique for sample collection
 Quality of sample



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      Use of equipment
The client should be as comfortable as possible during the test. The client should be
reassured that all efforts have been made to ensure the accuracy of their test result. This is
part of basic quality assurance.



                  Trainer Instructions
                  Slides 69-72
Discuss parallel testing procedures and interpretation of HIV test results.


                Make This Point
      Current national guidelines recommend parallel HIV testing using rapid HIV tests.


Definitions of parallel and serial testing
Parallel testing: clients are tested using two whole blood rapid HIV tests simultaneously
(in parallel) using a highly sensitive and a highly specific test. If the test results are
different, a third, different ―tiebreaker‖ test is performed.

Malawi national testing procedures utilize parallel testing.

Serial testing: clients are tested with a highly sensitive rapid HIV test. A negative result
is definitive and a positive result requires another specific rapid HIV test to confirm this
result (tests are performed in series).

Parallel testing procedure
Parallel testing procedure occurs when two different tests are performed at the same time
on the same sample. In parallel testing, the sample is tested by Test 1 (e.g., Determine) at
the same time that it is also tested using Test 2 (e.g., Uni-gold).
 If both Tests 1 and 2 give positive results, then the patient is assumed to be HIV
    positive.
 If both Tests 1 and 2 give negative results, then the patient is assumed to be HIV
    negative.
 If one of the test results is positive and the other negative, a tiebreaker test, such as
    Bioline, is performed to confirm the result.

(See Figure 6.2 for a summary of the national HIV rapid testing procedure).




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                          Figure 6.2 Parallel HIV Testing Algorithm




Serial testing procedure
Even though parallel testing is Malawi‘s recommended testing method, in some
countries, serial testing is preferred. In serial testing, if the first test is negative, the client
is considered HIV negative; a second test is not performed. If the first test is reactive, or
HIV positive, the blood sample (the same used for the first test) is tested again using a
different brand of rapid HIV test. If the second test is positive, the result is given to the
client as HIV-positive; if the second test is negative (discordant from Test 1), a third test
(usually with a different rapid test kit) known as a ―tiebreaker‖ is performed. The result of
the tiebreaker is the final HIV result.

                               Interpretation of HIV Results
   Positive: HIV antibodies are present in the blood. This means that the person is HIV-
    infected.
   Negative: HIV antibodies are not present in the blood. A negative result usually
    means that the person is not infected with HIV. However, in rare instances, a person
    with a negative may be in the ―window period.‖ This is the period of time between
    the onset of infection and the appearance of detectable antibodies in a specimen.
    Usually, people develop antibodies 3 weeks after being infected, but it may take as
    long as 3 months. In rare cases, this process can take up to six months. A person who
    tests HIV-negative but who has engaged in behaviour within the past 3 months that
    places him or her at risk for HIV, should be tested again in 3 months.
   Indeterminate: Result that is borderline, not definitely positive or negative.
   Discordant result: Two different HIV tests run on the same sample, one result is
    positive while the other one is negative.

A single negative test does not mean the person will never become infected with HIV.
There is no such thing as immunity to HIV infection.




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               Trainer Instructions
               Slide 73
Refer participants to the following material:
 Flow chart on parallel testing (Figure 6.2 above).
 Appendix 6-D Fingerprick Graphic
 Appendix 6-E Uni-gold Fact Sheet
                               
 Appendix 6-F Determine Fact Sheet

Lead a rapid test demonstration as described in Exercise 6.4, below. The second half of
the exercise, during which participants practise the rapid test procedure, is optional
depending on participant learning needs.


               Exercise 6.4 Rapid HIV test demonstration and practice
Purpose         To review the steps involved in rapid HIV testing, develop the skills for
                obtaining the sample and interpret test results
Duration        50 minutes for demonstration, 50 minutes for participant practice
                (practice component is optional)
Introduction     Determine which guidelines are in place for processing rapid HIV
                    tests in participants‘ facilities.
                 Explain that the group will examine several approved rapid HIV tests.
                 One test will be used to demonstrate the specimen collection process.
Activities      Demonstrate using one of the rapid HIV tests (large group):
                 Request that one participant volunteer to play the role of ―client‖.
                    Assure the volunteer that s/he will not actually be tested.
                 The trainer will assume the role of HCW who is collecting the
                    specimen.
                 Ask all other participants to observe the interaction.
                 Ask the volunteer to sit facing the HCW (the trainer).
                 Observe the steps of rapid HIV testing:
                     Assemble all materials—test kit, wipes, band aid, etc.
                     Confirm that the ―client‖ has received information on testing.
                     Confirm that the ―client‖ is not opting out of routine testing.
                     Ask if the ―client‖ has any questions.
                     Review steps of testing.
                     Allow the ―client‖ to select testing site (finger for pinprick).
                     Collect adequate sample per test instructions.
                     Complete test using buffer solution per test instructions.
                     Assure the ―client‖ that results will be available for interpretation
                       in less than 30 minutes.
                     Assist the ―client‖ with interpretation of test result.
                     Record test result.
                     Take the opportunity to explore the issue of partner testing with the
                       ―client‖.
                     Provide post-test counselling and support for the ―client‖.
                     Dispose of materials correctly.



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                 Exercise 6.4 Rapid HIV test demonstration and practice
                   Practice in small groups (optional)
                    Ask participants to break into groups of two, one should take the role
                      of ―client‖ and the other ―HCW‖.
                    Repeat the steps demonstrated during the large group. Give both
                      members of each small group the opportunity to role play the
                      ―HCW‖.
Debriefing         Review the following:
                    Parallel testing procedure and algorithm for rapid testing process
                    Confidentiality of testing
                    Informed consent procedures based on national policy
                    Post-test counselling procedures
                   Complete the exercise by reviewing the comfort level of both ―HCW‖
                   and ―client‖ when playing their respective roles during the exercise.




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UNIT 4            HIV Pre-Test and Post-Test Counselling

                Advance Preparation
                Review Exercise 6.5 HIV pre-test counselling role play scenarios for
                cultural relevance, determine whether they are appropriate for settings in
                which participants work, and adjust as necessary.

                Review Exercise 6.6 HIV post-test counselling role play scenarios for
                cultural relevance and edit as necessary. Have a flipchart or
                white/blackboard and markers or chalk available.
                Review Appendices 6-G, 6-H, and 6-I.


                Total Unit Time: 120 minutes



               Trainer Instructions
               Slides 74-75
Introduce the unit and review objectives.


After completing the unit, the participant will be able to:
 Discuss information covered during the HIV pre-test education session.
 List the important components of the post-test session.



                  Trainer Instructions
                  Slides 76-77

Introduce the necessary components of a pre-test information session.
Have participants turn to Appendix 6-G Providing Pre-test Information. Review the
specific content for pre-test information sharing and give participants a few moments to
read through the content.


                 Make These Points
      The HCW should cover the basic facts about HIV, including risk factors for
       transmission and how HIV can be prevented.
      The meaning of the test results should be discussed, including implications of the
       ―window period.‖
      An opportunity should be provided for the client to consent to HIV testing, and the
       importance of obtaining test results should be emphasized.



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Issues considered in the pre-test session

                        Group and individual pre-test session
                     For all pregnant women presenting to ANC:
   Discuss the basic pre-test counselling information:
     Basics of HIV and AIDS
     How HIV is, and is not, transmitted
     Prevention of HIV, including safer sex, including instruction and demonstration
       on using a condom
     The interaction between STIs and HIV transmission; and prevention and
       treatment of sexually transmitted infections (STIs)
     HIV testing procedures at site (when and how blood sample will be taken, when
       to expect the results), post-test counselling, and follow-up services
     Advantages and disadvantages of HIV testing and knowing one‘s sero-status in
       the context of PMTCT
     Discuss the meaning of the test, including the ―window period‖
     Mother-to-child transmission of HIV (MTCT): in utero, intrapartum and
       postnatally through breastfeeding
     Delivery by skilled attendant
     Birth preparedness (which includes male involvement)
   Discuss the available opportunities for reducing MTCT:
     Nutrition and self care (micronutrients: daily iron and folate for pregnant women
       attending antenatal services and a single dose of Vitamin A within 2 months of
       delivery)
     Use of antiretroviral drugs for PMTCT
     Modification of obstetric care
     Modification of infant feeding
   Encourage and promote couple counselling and shared confidentiality.
   Encourage consulting with partner before and/or after testing, including disclosure.
   Offer HIV testing in accordance with the national standard operating procedures,
    ensuring appropriate protection of client confidentiality.


Appendix 8-B (Conducting a PMTCT Health Education Session) includes tips on
facilitating a PMTCT health education session including additional guidance on content
and skills.



                 Trainer Instructions
                 Slide 78

Lead participants through the pre-test session role play. Participants should refer to the
―Group and individual pre-test session for all pregnant women presenting to ANC‖ box
(above) as well as Appendix 6-A (Counselling Skills and Techniques Checklists) and
Appendix 6-G (Providing Pre-Test Information).




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                    Exercise 6.5 HIV pre-test counselling role play
Purpose            To explore the process and content of the pre-test session and the
                   techniques/skills required for success
                   To demonstrate the importance of couple counselling
Duration           30 minutes
Introduction       The focus of this exercise is to practise pre-test counselling and the
                   pre-test education session.

Activities         Preparation in small groups
                    Divide participants into groups of 5-7.
                    Assign one person in each group to play the role of the ―HCW‖.
                      The ―HCWs‖ should go through the pre-test counselling steps
                      (listed above) for their ―clients‖.
                    One participant from each group should play one of the ―clients‖
                      (Nambewe, Patricia or Kenneth). Instruct the participants to begin
                      the role play as if the client has just arrived at the antenatal clinic.
                    Ask the remaining members of the group to observe the role play,
                      one observer should compare the dialogue with the ―Group and
                      individual pre-test session for all pregnant women presenting to
                      ANC‖ (above). Another observer should review the session using
                      Appendix 6-A (Counselling Skills and Techniques Checklists). If
                      there is a third observer they may want to refer to Appendix 6-G
                      (Providing Pre-Test Information).

                   Demonstrate ―common mistakes‖ in small groups
                    Instruct the ―HCWs‖ to demonstrate common mistakes made in
                     counselling (e.g., lack of privacy, interruption from phone calls,
                     lack of self-confidence, lack of empathy and being judgemental)
                     while presenting the pre-test session.

                   Demonstrate ―good practice‖ in small groups
                    Now ask ―HCWs‖ to shift their focus and demonstrate the positive
                       counselling skills they know or have just learned. Role play both
                       the individual counselling session (with Nambewe) and the couple
                       counselling session (with both Patricia and Kenneth), rotating the
                       role of ―HCW‖ for each role play.
                    Ensure that the content of the pre-test session for all pregnant
                       women presenting to ANC is covered during either or both of the
                       role plays.
                    Ask the observers to share their observations upon completion of
                       each scenario.
Debriefing         Ask participants the following questions, noting important points on
                   the flipchart or board:
                    How did the couples counselling session go?
                    How was the couple counselling different from the individual
                       sessions?
                    Did you encounter any issues when covering the content of the


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                       Exercise 6.5 HIV pre-test counselling role play
                           pre-test session for all pregnant women presenting to ANC?
                          What were the most important lessons learned?
                          Would this session be different (in content or expected client
                           reaction) if presented to a group of ANC clients rather then to an
                           individual or couple in a counselling session?

                      Summarize the session by reviewing the primary goals of counselling
                      in PMTCT: provide information, support decisions and prevent the
                      spread of HIV.

                      Note that the characteristics, skill-level and techniques used by the
                      counsellor will determine the tone and outcomes of the session.



                 Exercise 6.5 HIV pre-test counselling role play, scenarios
Scenario one:         Nambewe is 18 years old and 20 weeks pregnant with her first child.
                      She is still involved with her boyfriend, Phiri, the baby‘s father. This
                      is her first visit to the antenatal clinic. She doesn‘t know anything
                      about HIV testing or PMTCT, but wants to do what is best for her
                      baby.
Scenario two:         Patricia is 25 and pregnant with her second child. She has been
                      married to Kenneth for four years. On her first visit to the ANC clinic
                      last month (when she was 21 weeks pregnant) she listened to the
                      midwife‘s HIV information/education session, but decided not to
                      accept HIV testing until she had conferred with her husband. Now she
                      is attending for the second time; Kenneth has accompanied her to the
                      clinic. Kenneth has some serious questions about HIV testing of
                      pregnant women, and thinks it is somewhat of an invasion of privacy.
                      When it is their turn, both Patricia and Kenneth see the ANC nurse
                      together and the first issue on their agenda is the HIV test.



                 Trainer Instructions
                 Slide 79
Discuss post-test information and counselling for all women, using the content below.


                Make This Point
   Post-test counselling is important for all clients, whether their HIV test results are
    positive or negative.




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Post-test counselling: general principles
Post-test counselling is usually guided by the outcome of the HIV test, which could be
either negative or positive. In line with the basic principles of conducting post-test
counselling, the counsellor should:
      Ensure that the client is ready to receive results.
      Provide the results in a calm manner.
      Use simple language during the communication.
      Check for client‘s understanding of the results (if client does not understand, repeat
       pre-test counselling).
      Allow time for the meaning and implication of the result to settle in.
      Enquire if the client has any questions related to the results.
      Support the client after negative or positive results.



                  Trainer Instructions
                  Slide 80
Discuss post-test counselling for women who are HIV-negative, using the content below.


                 Make These Points
      Have participants review Appendix 6-H (Post-Test Counselling Checklists) and invite
       comments and questions. Use this time to reinforce key messages and correct any
       misconceptions about post-test counselling.

Post-test counselling for HIV-negative results
It is important for the counsellor to follow the general principles of post-test counselling
that are outlined above. However, while counselling a client with a negative HIV result,
the HCW should focus on the following areas:
 Ensure that the meaning of negative results is clarified. Provide information on re-
     testing, especially if the client is possibly in the window period.
 Discuss personal risk reduction plans that may include:
      Abstinence
      Mutual monogamy
      Safer sex practices, including condom use and demonstration
      STI prevention and management
 Encourage the client to bring in her partner for HIV testing.
 Counsel the client to exclusively breastfeed her baby up to six months and to continue
     breastfeeding up to two years and beyond.
 Offer nutrition counselling to the client.
 Discuss family planning after delivery.
 Discuss the immunization schedule for the baby.
 Counsel the client on the importance of staying HIV negative.
 Suggest that the client advocate and encourage others to come for HIV testing and
     counselling.
 Encourage the client to join a post-test club and/or support group.



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Detailed steps in providing post-test counselling for women who are HIV negative are in
Appendix 6-H (Post-Test Counselling Checklists).



                 Trainer Instructions
                 Slide 81
Discuss post-test counselling for women who are HIV-positive, using the following
content.
-
Post-test counselling with HIV-positive results
The basic principles of post-test counselling outlined above also apply when counselling
HIV-positive clients. However, in addition to the above, the following should be
addressed during the post-test counselling of an HIV positive client:
 Discuss the meaning of a positive result.
    Deal with immediate emotional reactions.
 Discuss personal risk reduction plan to prevent re-infection:
    Abstinence
    Safer sex practices including condom use; demonstrate how to use a condom
 Discuss with the client the ―significant other‖ she would like to share results with to
   ease decision-making for uptake of PMTCT services.
    Encourage the client to bring her partner for HIV testing and counselling
    Counsel the client on ARV prophylaxis (or, if eligible, ARV therapy) for PMTCT.
 Discuss infant feeding options:
    Exclusive breastfeeding for the first six months. Tell the client risks of mixed
       feeding.
    Early cessation of breast feeding and explain the risks of prolonged breastfeeding
       beyond six months
    Use of commercial infant formula
    Use of modified cow‘s milk (For details, please refer to the Module 4: Infant
       Feeding in the Context of HIV Infection)
 Counsel the client on nutrition.
 Discuss plans for delivery of the baby.
 Discuss future fertility intentions and family planning after delivery.
 Discuss immunization schedule for the baby.
 Discuss other issues related to follow-up care, access to healthcare services, and
   support groups that support positive living.

See the detailed checklist for providing post-test counselling for women who test HIV
positive in Appendix 6-H.



                 Trainer Instructions
                 Slide 82




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Discuss the disclosure process for women who are HIV-positive, using the following
content.

Disclosure of HIV status
During the initial post-test counselling session, the HCW may begin the discussion about
disclosure—informing others of her test result. By disclosing her HIV status to her
partner and family, the client may be in a better position to:
 Encourage her partner(s) to be HIV tested.
 Prevent the transmission of HIV to her partner(s).
 Access PMTCT interventions.
 Receive support from her partner(s) and family when accessing PMTCT and HIV
    care and support services.
It is important to respect the client's choice regarding the timing and process of
disclosure. A client may perceive disadvantages in disclosing her HIV diagnosis. In some
communities, clients who are HIV-infected and their families may face stigmatization and
discrimination. If the client has indicated that her partner(s) and family may react
negatively to her HIV status, the counsellor can help the client build skills to use when
she discloses her HIV status.



               Trainer Instructions
               Slide 83
Assist the participants as they practise providing post-test counselling. Refer to Appendix
6-H (Post-Test Counselling Checklists) during Exercise 6.6.

                      Exercise 6.6 Post-test counselling role play
Purpose          To demonstrate and practise post-test counselling through role playing
Duration         60 minutes
Introduction     This exercise will provide an opportunity for participants to practise
                 post-test counselling.
Activities       Role play demonstration in large group
                 To ensure that participants are clear on both the assignment and
                 process, the trainer and/or a co-trainer and two other participant
                 volunteers experienced in post-test counselling should demonstrate the
                 post-test session. (15 minutes).
                  Ask one volunteer to be the ―HCW‖, another to be the ―client‖, and
                    a third to be an ―observer‖.
                  Explain that the participants are playing roles that are not
                    necessarily a reflection of their own attitudes.
                  Encourage volunteers to pretend to feel, and act, like the characters
                    they are portraying.
                  Ask other participants to note their observations.
                  Present the following scenario:


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                         Exercise 6.6 Post-test counselling role play
                    Martha and Banda are expecting their first child. Banda is working in
                    Lilongwe and is away most of the week. The couple live next to Banda’s
                    mother, father and two sisters. At Martha’s second ANC visit she
                    learned about PMTCT during one of the group information meetings.
                    Although she decided not to test the first time, after thinking about it
                    more carefully she has returned to be tested for HIV. (Martha’s test
                    result is positive).

                        Ask the volunteers to demonstrate a post-test counselling session
                         with Martha. The ―observer‖ can also assist the ―HCW‖ if he or she
                         does not know what to say.
                        Relieve the volunteers of their roles.
                        Thank them for their help and good work and applaud them. Ask
                         participants for their feedback on the role play using Appendix 6-A
                         (Counselling Skills and Techniques Checklists) and Appendix 6-H
                         (Post-Test Counselling Checklist HIV-Positive Result) as a guide.
                    Take 5 minutes to debrief all three actors with the following questions:
                     How did you feel in your role?
                     What was the hardest part of counselling? (Address this question to
                       both ―HCW‖ and ―client‖).
                     How can basic communication skills be used during the counselling
                       session? (Be sure to ask ―the observer‖ for his/her reaction).
                     What positive reactions did you experience in the session?
                       (Addressed to both the ―counsellor‖ and ―client‖).
                     What would you do differently if you had the chance to do this
                       again?
                    After the demonstration activity, ask participants if they have any
                    questions. Limit the questions to no more than 3-4.

                    Role play in small groups
                    Divide the group into teams of six participants each.
                    Refer participants to Appendix 6-A (Counselling Skills and Techniques
                    Checklist), Appendix 6-H (Post-Test Counselling Checklists), and
                    Appendix 6-I (role play scenarios for post-test counselling).
                    Assign each team two scenarios: one from the scenarios for HIV
                    negative results, and one from the scenarios for HIV-positive results.
                    Instruct the teams as follows:
                     For each scenario, select one participant to play each ―client‖ and
                        one to play the ―HCW.‖
                     The ―client‖ and ―HCW‖ should be seated so they are facing each
                        other.
                     Use the Counselling Checklists.
                     If the ―HCW‖ has difficulty (if he or she doesn‘t know exactly what
                        to say or how to answer the client), another team member may help
                        by tapping the ―HCW‖ on the shoulder and assuming the ―HCW‖
                        role.


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                         Exercise 6.6 Post-test counselling role play
                    When the role play is finished, the pair should spend 5 minutes
                    reviewing their experience with the rest of their team, asking the
                    questions used in the large group demonstration.
                    Ask the participants to exchange roles and continue switching until
                    each member has had a chance to play the role of ―HCW‖ (using both
                    HIV-positive and HIV-negative scenarios), time permitting.
                    Trainers should visit each of the groups during this activity to ensure
                    that the participants understand the exercise and to answer any
                    questions.
Debriefing          Ask participants to consider the following questions:
                     How did you feel in your role as counsellor?
                     What was the hardest part of counselling?
                     How did you feel as the client? Were your needs met?
                     How can basic communication skills be better used during
                        counselling sessions?
                     What positive reactions did you experience in the session?

                    Record reactions and experiences on the flipchart.



                  Trainer Instructions
                  Slides 84-85

Using the content below, address the national guidelines for the testing and counselling of
women with unknown HIV status who present at the time of labour and delivery.


                Make This Point
      Emphasize the recommended four, focussed antenatal visits.


Subsequent ANC visits
Pregnant mothers should attend at least four, focussed antenatal visits during pregnancy.
However, many pregnant women attend ANC once, often late in pregnancy or attend
ANC early and do not make subsequent visits.



                Make This Point
      The national policy is to offer HIV testing and counselling to women who present in
       labour with unknown HIV status.




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Testing and counselling of women with unknown status at the time of
labour and delivery
In some settings, women who have not been tested during ANC or did not attend ANC may
present to the health service at the time of labour with unknown HIV status. The Malawi
national policy in this case is to offer HIV testing and counselling for women of unknown
status in early labour.

It is recommended that the routine approach to testing be used during labour and that
results be presented as soon as possible but detailed post-test counselling provided after
delivery. A discussion about antiretroviral prophylaxis in labour and delivery settings is
provided in Module 3 Specific Interventions to Prevent MTCT. Depending on the progress
of labour, it will be possible to provide ARV prophylaxis to mother and infant or it may
only be possible to provide ARV prophylaxis to the infant.



                 Trainer Instructions
                 Slides 86-88
Review the key points from this module.



                                   Module 6: Key Points
   Pre-test information, individual pre-test counselling, HIV testing, and post-test
    counselling should be available to all pregnant women in Malawi on an ―opt-out‖
    (routine) basis.
   The HCW and the facility must maintain the client‘s confidentiality at all times.
   Partner testing and couples counselling are encouraged.
   Rapid HIV tests with same day results are the recommended test for most ANC
    settings. When properly administered, these tests have a high degree of accuracy.
   In parallel testing, two HIV tests are conducted simultaneously on the same sample.
    Parallel testing is used in Malawi.
   Post-test counselling is important for all women:
     For women who are HIV-negative, emphasize the prevention of HIV infection
     For women infected with HIV, provide information on PMTCT and referrals to
        HIV care and treatment
   Disclosure skills-building should be encouraged for all women regardless of HIV
    status.




Module 6 Testing and Counselling                                                        6-43
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APPENDIX 6-A Counselling Skills and Techniques Checklists*

*Two checklists are provided: Checklist 1 offers detailed strategies, statements and
behaviours for assessing counselling skills; Checklist 2 offers a focused review of
strategies, statements and behaviours that is tailored to the content of Module 6.


                       Counselling Skills and Techniques Checklist

As you observe your colleagues role play, indicate the counselling skills and techniques
they utilize by placing a check in the appropriate box.
   Skills &
                               Specific Strategies, Statements, Behaviours
  Techniques
                      Greets the client; shakes their hand if appropriate
                      Offers them a seat
 Establishing a       Leans forward when talking
  relationship        Makes eye contact
                      Shows interest in the client
                      Other (Specify):
                      Looks at client
                      Body language indicates attentiveness to client
                      Makes eye contact to indicate care and interest
                      Facial expression indicates caring and interest in the client
                      Uses minimal encouragers such as yes, okay, etc.
   Listening
                      Checks with client to be sure they understand what the client is
                       saying
                      Occasionally summarizes client‘s statements
                      Other (Specify):

                      Comments on client‘s challenges while also indicating client‘s
                       strengths
                      Reflects statements back to client to let the client know they
  Empathizing
                       understand
                      Other (Specify):

                      Uses closed-ended questions to get basic information such as
                       demographic data
                      Avoids overuse of closed-ended questions
                      Uses open-ended questions to get more in-depth information
                       from client
  Questioning
                      Style of questioning reflects interest, care and concern rather
                       than interrogation
                      Asks questions that are relevant to the topic of discussion
                      Other (Specify).:




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 APPENDIX 6-A Counselling Skills and Techniques Checklists
                           (continued)


                           Counselling Skills and Techniques Checklist

As you observe your colleagues role play, indicate the counselling skills and techniques
they utilize by placing a check in the appropriate box.
   Skills &
                                    Specific Strategies, Statements, Behaviours
  Techniques
                        Checks understanding of what the client is saying by restating
                         what the client said using different words
                        Uses phrases such as: ―Are you saying that…?‖, ―Did I
Clarifying and
                         understand you when you said…?‖, ―Correct me if I am
Paraphrasing
                         wrong…‖
                        Other (Specify):

                        Comments on client‘s mood changes or emotional reactions to
                         assist client in expressing the feelings
Commenting on           Makes client aware of discrepancies between verbal and non-
  the process            verbal behaviour
                        Other (Specify):

                        Takes time to summarize the information the client shares
                        Checks with client to be sure they understand important concerns
 Summarizing             and issues
                        Other (Specify):

                        Waits after posing questions to clients
                        Allows the client space to consider questions and formulate
 Use of silence          answers
                        Other (Specify):

                        Identifies people in client‘s support system
 Widening the           Looks at immediate family as well as other support systems
   system               Other (Specify):

                        Inquires how client has handled similar issues in the past
                        Assesses client‘s problem-solving skills, asking the client to
  Taking one
                         think about potential solutions
    down
                        Other (Specify):

                        Gives client a opportunity to demonstrate problems
                        Gets client to practice potential solutions
  Enactment
                        Other (Specify):




 Module 6 Testing and Counselling                                                           6-45
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 APPENDIX 6-A Counselling Skills and Techniques Checklists
                            (continued)


                             Counselling Skills and Techniques Checklist

As you observe your colleagues role play, indicate the counselling skills and techniques
they utilize by placing a check in the appropriate box.

   Skills &
                                       Specific Strategies, Statements, Behaviours
  Techniques
                          Uses this technique to help client verbalize their thoughts about
                           what significant others may say
                          Uses this technique to help the client enact a solution to a
  Empty Chair
                           problem
                          Other (Specify):

                          Keeps the session balanced, ensures that all parties are heard
    Blocking              Other (Specify):

                          Makes sure each person in the session knows s/he is listening
                          Demonstrates interest and understanding in each person‘s
Shifting Alliance          position
                          Other (Specify):

 Source: National AIDS and TB Unit, Ministry of Health and Child Welfare, Zimbabwe, CDC and the François-Xavier
 Bagnoud Center at the University of Medicine and Dentistry of New Jersey (2003). Zimbabwe PMTCT Trainer-of-
 Trainer Curriculum.




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APPENDIX 6-B Self-Concept of the Counsellor

The graphic model and its explanation
The self-concept model is a map or illustration that can enable people to understand
themselves better. It is divided into four equal and interrelated parts: self-image, ideal
self, body image and self-esteem. The four parts of the self-concept have three intrinsic
circles superimposed on them: the public, the private and the hidden domains.

 Self-image                                                                   Body image




     Ideal self                                                                Self-esteem




Public domain
All the information here is public or can easily be made public by the person. The person
here has little control over personal information such as, sex, age, race, colour, tribe,
residence and occupation.

Private domain
Information here is confidential. The person has control over what to tell others and
discloses this information to only a chosen few. It includes secrets or intimate thoughts
such as ―I am a failure, rich, in love with…, hate….am poor‖.

Hidden domain
Information here is not in the person‘s awareness. It is information from early childhood
memories, which may be painful, embarrassing or humiliating to remember and so the
person has learned to repress these thoughts. Examples include incest and sexual abuse in
childhood. This person may need professional help from a therapist.

Self-image
Self-image comprises the statements that describe who we are, for example, ―I am a
nurse, a mother, a wife, a grandmother, HIV positive‖. Or, ―I am bright, foolish, clever,
patient, jealous, a good cook, lazy, hard-working, or impatient.‖




Module 6 Testing and Counselling                                                         6-47
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APPENDIX 6-B Self-Concept of the Counsellor (continued)

Ideal self
Every person has someone they would like to be like or something they aspire to have,
for example: ―I would like to be rich, married, a mother, a responsible father, an
employer;‖ ―I would like to complete college, build or buy a house, get a promotion, look
nice;‖ ―I would like to be slimmer, fatter, or more attractive‖.

Body image
Body image is what we think our body looks like. How we think our body looks is not
always straightforward or acceptable to us. Some people are not happy with their body
weight or size or shape despite being told that they are all right. They may not like the
fact that they are too thin, fat, short, tall, dark or light complexioned.

Self-esteem
After knowing ourselves, it is important to find out what we like about who or what we
are. This is our total worth or our pride, values, enjoyment or respect about/of oneself. If
both our self-image and our body image correspond with our ideal self, then our self-
esteem is reasonably high. If our public domain and private domain are not much
different, meaning that we are open and have nothing much to hide from people, then our
self-esteem is also high.




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APPENDIX 6-C How to Facilitate a Role Play

The role play method
The role play is a simulation or demonstration method. A real life situation is presented as
a skit by usually two or three volunteer trainees to the whole group. The role play
situation dramatizes different roles not only for those playing the roles (the actors), but
also for those watching the role playing activity (the audience). Often, two short role
plays are used to contrast a negative example, showing incorrect behaviour, with a
positive example, showing the correct behaviour.

Steps in conducting role plays
1. Choose a problem situation that is:
     Related to your objectives
     Interesting to your participants
     Suitable for acting
2. Collect all the props and objects you will need for the session (props and objects
    make the role play more realistic).
3. Plan some questions you can ask after the role play.
4. Describe the characters and roles to the participants.
5. Choose two or three participants to act as the characters in the role play.
6. Encourage the people who are acting to let themselves feel and act like the characters
    they are supposed to be.
7. Ask the other participants to choose one of these characters. Then ask them to
    compare their feelings and reactions with those of the person acting out that character
    in the role play.
8. Be sure that everyone can see and hear well enough to follow the role play.
9. Watch carefully to see if the actors are raising issues that are appropriate to the main
    problem. It is a good idea to ask other participants to take notes during the role play.
    Then refer to their notes during the discussion that follows.
10. Watch everyone else during the role play to see if they are still interested, or are
    becoming bored and restless.
11. Stop the role play when you feel the actors have shown the feelings and ideas that are
    important in the problem situation, or when the other participants become bored and
    restless.
12. Thank the actors for their help and good work.
13. Ask the actors and other participants to discuss their feelings. Ask them what they
    discovered by doing this activity.
14. Ask participants how this is related to what they already know, and how this
    information can help them in their daily life and jobs.




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APPENDIX 6-C How to Facilitate a Role Play (continued)

The purpose of a role play
The purpose of a role play is usually to have participants ―experience‖ a concept or idea
by either acting it out before other participants or observing others act out the situation.
Role playing is useful in teaching communication and decision-making skills as well as
attitudes.

Consider the following when planning a role play:
      Be sure you understand the purpose of the role play: what will the participants learn
       from it?
      Be sure you are familiar with the different roles to be acted out.
      Try to imagine the action that will take place.
      Imagine what you will do if the point is not made.

Consider the following when setting up a role play:
      Decide how participants will be selected: a) by their small groups; or b) by trainer. If
       trainer selects role players, they may be briefed prior to role play action.
      Explain the purpose of the role play to participants.
      Make sure all the participants know what a role play is. Review briefly if necessary.
      Identify the role players and the roles they will be playing.
      Describe the ―scene‖ to the participants.
      Set up the ―stage‖ where the action will take place so that all participants can see and
       hear.
      If participants are to observe anything special, let them know. Give instructions if
       necessary.

Consider the following while conducting the role play:
      Stop the action when you feel the role play has illustrated the problem or issue, or if
       the participants become bored and restless (most role plays last approximately 5
       minutes).
      Thank the role players for their help and good work.

Consider the following when processing the role play:
Select one of the following options:
 Involve participants in a total group discussion of the role play based on the issues or
    problems you intended to highlight in the role play action. Use open questions.
 Assign questions for participants to discuss and answer in their small groups. Allow
    time for groups to respond to questions; then take responses from each group in turn.
    When reports are finished, open the discussion to the entire group.
 Remember to ask the role players how they felt about the roles they played.


Source: Train-Up with Teachback!. Training of Trainers Workshop Curriculum. Caribbean. CHART/I-TECH/CDC.
March 2004.




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             APPENDIX 6-D Fingerprick Graphic

                                                  Fingerprick
                                      Always use universal safety precautions.
April 2004                                                                                            World Health Organization




 1.     Collect supplies.                       2.   Position hand palm-side up.            3.   Apply intermittent pressure to
                                                     Choose whichever finger is least            the finger to help the blood to
                                                     calloused.                                  flow.




 4.    Clean the fingertip with alcohol.        5.   Hold the finger and firmly place       6.   Firmly press the lancet to
       Start in middle and work outward              a new sterile lancet off-center on          puncture the fingertip.
       to prevent contaminating the area.            the fingertip.
       Allow the area to dry.




 7.     Wipe away the first drop of             8.   Collect the specimen. Blood may        9.   Apply a gauze pad or cotton
        blood with a sterile gauze pad or            flow best if the finger is held             ball to the puncture site until
        cotton ball.                                 lower than the elbow.                       the bleeding stops.




 10.    Properly dispose of all contaminated supplies.

             Source: WHO, HHS-CDC. Providing Training and Supervision for HIV Rapid Testing. Draft May 2005.




             Module 6 Testing and Counselling                                                                       6-51
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APPENDIX 6-E Uni-Gold™ Recombigen® HIV Rapid Test Fact Sheet

                               Uni-Gold™ Recombigen® HIV Rapid Test
                              For use with whole blood, serum, or plasma
                                          Store Kits: 2 - 8° C
                                                                                World Health
                                                                                Organization
      Check kit before use. Use only items that have not expired or been damaged.
      Bring kit and previously stored specimens to room temperature prior to use.
      Always use Universal Precautions when handling specimens. Keep work areas
       clean and organized.

This outline is not intended to replace the product insert or your standard operating
                                   procedure (SOP)




1. Collect test items     2. Prick the finger to    3. Collect the blood   4. Place the tip of the   5. Squeeze the bulb
and other necessary lab   make it bleed. Wipe       into the fingerstick   pipette into the          until the sample is
supplies.                 away the first drop of    sample transfer        sample, taking care       fully discharged into
                          blood with a sterile      pipette provided.      not to squeeze the        the sample port.
                          gauze pad. Allow a        Hold the Pipette       bulb. Maintain this       Allow the sample to
                          new drop of blood to      bulb gently in a       position until the        absorb into the
                          form. Avoid               horizontal position    flow of sample into       paper in the sample
                          ‗milking‘ the finger.     to the sample to be    the pipette has           port. Ensure air
                                                    collected. This is     stopped. The sample       bubbles are not
                                                    important, as the      should fill to the        introduced into the
                                                    specimen may not       mark on the pipette.      sample port.
                                                    be adequately          The sample should         Dispose the pipette
                                                    drawn in the           be used                   in biohazard waste
                                                    pipette if the         immediately.
                                                    pipette is held in a
                                                    vertical position.




6. Holding the dropper    7. Set the timer for 10
bottle of Wash            minutes. Read test
Solution in a vertical    results after 10
position, add 4 drops     minutes but not
of Wash Solution to       more than 12
the Sample Port.          minutes incubation
                          time.




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           APPENDIX 6-F Determine Fact Sheet

                                                 Determine HIV Rapid Test
                                        (For use with whole blood, serum, or plasma)
                                                     Store kit: 2 - 30° C
           April 2004                                                                   World Health
                                                                                        Organization
              Check kit before use. Use only items that have not expired or been damaged.
              Bring kit and previously stored specimens to room temperature prior to use.
              Always use universal safety precautions when handling specimens. Keep work
               areas clean and organized.

           This outline is not intended to replace the product insert or your standard operating
                                              procedure (SOP).




1. Collect test items and other           2. Use one strip per test and be sure   3. Label the test strip with client
   necessary lab supplies.                   to preserve the lot number on the       identification number.
                                             remaining packet of strips.




4. Pull off the protective foil           5. Collect 50 µl of specimen using      6. Apply the specimen to the
   cover.                                    either a pasteur or precision           absorbent pad on the strip.
                                             pipette.




7. For whole blood only add 1             8. Wait 15 minutes (no longer           9. Read and record the results
   drop of chase buffer to the               than 60 minutes) before reading         and other pertinent info on the
   specimen pad.                             the results.                            worksheet.




           Module 6 Testing and Counselling                                                            6-53
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     APPENDIX 6-F Determine Fact Sheet (continued)

                                     Determine HIV Rapid Test Results
                                   Positive
   Two lines of any intensity appear in
    both the control and patient areas.

                                  Negative
   One line appears in the control area
        and no line in the patient area.

                                    Invalid
No line appears in the control area. Do
not report invalid results. Repeat test
   with a new test device even if a line
            appears in the patient area.
     Source: WHO, HHS-CDC. Providing Training and Supervision for HIV Rapid Testing. Draft May 2005.




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APPENDIX 6-G Providing Pre-Test Information

Example of an information session
Introduction
Information sessions can be offered either one-to-one or as a group in the ANC clinic
setting. As a guide, key topics are outlined below in a question and answer format.
What is the difference between HIV and AIDS?
HIV is the virus that causes AIDS. Someone can be infected with HIV and not know it.
An infected person might not feel ill for many years. AIDS develops when an HIV
infected person‘s defence system is severely weakened.
There is no cure for HIV and AIDS, but medications are available that can help prevent
related infections and slow the progression of HIV, and that help people who are HIV
positive stay healthy for many years.

What is happening in our country? How many people are HIV-infected?
Presently, HIV prevalence in adults (15 to 49 years) in Malawi is one of the highest in the
world, estimated in 2005 at approximately 14% with a range from 12 to 17%. This
represents a total number of 790,000 infected adults and a total of 930,000 persons living
with HIV/AIDS in the population. The 2005 prevalence estimates also indicate that HIV
infection among adults in urban areas is higher (20.4%) than in rural areas (13%).

What are some common myths about HIV?
Share commonly held beliefs and myths about HIV and AIDS.

How can you get HIV?
The most common way to get HIV is by having unprotected sex with a person who is
HIV-positive. A mother who is HIV-positive can transmit HIV to her baby. Mother-to-
child HIV transmission can take place during pregnancy, labour and delivery, or while
breastfeeding.

HIV infection can also be transmitted if someone uses an un-sanitised knife, scalpel,
needle, or any other sharp object that had been used previously on a person with HIV, to
cut or pierce the body. This includes medical, ceremonial, or religious procedures in the
community or healthcare or any other setting. Similarly, HIV can be transmitted if one
uses a needle/syringe or any other equipment for injecting that was used on an HIV
positive person, to inject drugs or any other substance (vaccines, vitamins). HIV can be
transmitted to a person who receives blood that has not been screened for HIV.

What are some ways to prevent HIV infection?
 Sexual abstinence—not having sex.
 Practising faithfulness between two uninfected partners.
 Using condoms every time you have sex with someone you are not certain is HIV
  negative.
 Limiting sexual contact to one partner who is HIV negative.
 Avoiding drug abuse.
 Not sharing contaminated needles.




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APPENDIX 6-G Providing Pre-Test Information (continued)

What kinds of things may put you at risk for HIV?
 Having unprotected sex with a person with HIV infection; unprotected vaginal sex is
  risky, unprotected anal sex is even riskier.
 Having multiple sex partners increases the risk that one of them will be HIV-infected.
 Having sex with anyone who has more than one partner (even if you are
  monogamous)
 Abusing drugs or alcohol; sharing contaminated needles.
 Not knowing whether your partner is HIV negative or positive.
 Having a sexually transmitted infection (e.g., gonorrhoea or syphilis) can increase the
  risk of getting HIV by 2–5 times.

What are ways to decrease the risk of getting HIV?
 Be in a mutually monogamous relationship with someone who has tested HIV-
  negative
 If you are not in a mutually monogamous relationship or if either of you has not yet
  tested for HIV, use condoms consistently and correctly
 Talk to your partner about HIV testing.
 Talk about HIV concerns with a partner or friend.
 Reduce alcohol and/or drug use.
 Avoid places where you are more likely to participate in high-risk behaviours.
 Abstain from sex or use condoms every time until you and your partner have been
  tested.
Emphasize the importance of making small, reasonable changes rather than setting
unrealistic goals, such as never having sex again. Ask clients to share their plans with a
close friend or someone they trust.

How do babies get HIV from their mothers who are HIV-infected?
 If a woman is HIV-infected and pregnant, there are three ways her baby can get HIV:
  during pregnancy, during labour and delivery, or during breastfeeding.
 Although the risk of infecting the baby is always present, about 60% of women who
  are infected with HIV give birth to babies who are HIV negative.
 The good news is that there are medicines that can greatly reduce the risk of a mother
  transmitting HIV to the baby during delivery. These medicines offer new hope to
  families.

What is the Prevention of Mother-to-Child Transmission of HIV, or PMTCT
service?
This programme helps reduce the chance that babies born to women who are infected
with HIV will not be infected. The programme has four parts:
 HIV testing and counselling to identify women with HIV and educate them on how to
   reduce the likelihood that HIV will be transmitted to their babies
 Antiretroviral medicine to reduce the baby‘s risk of getting HIV from its mother
 Counselling and support for safer infant-feeding practices
 Referral to treatment, care and support programmes




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APPENDIX 6-G Providing Pre-Test Information (continued)

How is HIV testing conducted?
 Testing is offered to all pregnant women attending ANC in Malawi. Everyone has the
  right to refuse HIV testing.
 The test tells if a woman is infected with HIV or not. On very rare occasions, if a
  woman has been infected recently, the test results may indicate that she is negative
  even though she is HIV-infected. Therefore, it is recommended that a woman who
  has recently been at risk be retested 3-6 months from her most recent risk exposure.
 A positive HIV test means a woman has the HIV virus in her blood. It does not mean
  she has AIDS; it does not tell her when she will get sick.
 Share the site‘s testing process: type of test (whether rapid or ELISA) and how long it
  will take for the results to come back.

What are the advantages of knowing the test results?
 Knowing her HIV status can help a woman make informed decisions about her
  pregnancy.
 If she is HIV-infected, knowing her status can help her access HIV services for
  herself and prevent transmitting HIV infection to her baby.
 Knowing her HIV status allows her to reduce the risk of infecting other people.
 Early testing makes it easier to plan for the future.
 If a woman finds out she is HIV negative, she can learn how to stay uninfected and
  keep her family safe from HIV infection.
 There are many preventive healthcare services that can improve a woman‘s quality of
  life and prolong her life.
 Increasingly, medications for the treatment of HIV infection are becoming available.
  These medications reduce the damage that HIV does to the body and prolongs life.

What are the disadvantages of testing for HIV?
 A client might experience a little discomfort or bruising during the blood sampling
  process (a fingerprick or blood taken from the arm).
 Programmes may not be readily available for help or treatment, but she can be
  referred.

Who can receive information about your test results?
Test results are confidential and become part of a client‘s medical records. They can only
be shared with HCWs who are involved in care and treatment—and only on an ―as-
needed‖ basis. The client has the right to decide if anyone other than HCWs may receive
this information, and they are entitled to receive support during the disclosure process.




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APPENDIX 6-G Providing Pre-Test Information (continued)

What types of services are available in your community for the person who is HIV-
infected?
Discuss locally available referrals for PLWHA and their families, such as those that offer
any of the following services:
 Nutritional support
 Couples counselling
 ARV treatment and prophylaxis to prevent transmission to the infant
 Medicines to prevent opportunistic infections
 Spiritual support, referral to a faith-based organization
 Peer support groups
 Classes to learn safer infant-feeding practices
 Safe water programs




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APPENDIX 6-H Post-Test Counselling Checklists

HIV-negative result
Counselling is a relationship and provides an opportunity to establish a rapport with the
client, answer questions and make sure the client understands the information you are
providing.
In many ANC clinics in Malawi, rapid HIV tests are used. This offers an opportunity for
clients who are tested to receive their results the same day. In many settings the client is
taught to read his/her own test results.
 Greet the client.
 Ask whether the client has any questions before they read the results. Answer
    questions and let the client know counselling will continue to be available to help
    with important decisions regardless of the test results.
 Review the group pre-test information/counselling session. Let the client know you
    are doing this to make sure they remember important information.
 Inform them that the HIV test result is ready for them to interpret. Ask the clients
    what their results are. Confirm the results with the client. Yes your test is ―negative‖.
 Pause and wait for the client to respond before continuing. Give the client time to
    express any emotions.
 Explore the client's understanding of the meaning of the results.
 Discuss and support the client's feelings and emotions.
 Clarify that this means that as of 3 months ago (date) they were not infected with
    HIV.
 If there was a recent risk of exposure, discuss the need to re-test.
 Talk about specific risk reduction strategies with the client:
     Refer partner for testing
     Have sex with only one partner known to be HIV negative
     Use of condoms [include condom demonstration]
     Limiting the number of sexual partners
 Talk with the client again about disclosure and about partner testing.
 Discuss discordance
 Inform the client that counselling is available for couples.
 Emphasize the importance of protecting herself from infection while pregnant or
  breastfeeding, and explain how doing that will lower the risk that her infant will
  become HIV-infected.
 Ask whether the client has questions or concerns. Give the client contact information
  for the clinic should any new concerns arise.
 Discuss support issues, and available community resources available as well as
  subsequent counselling sessions.
 Remind clients and their families that counselling or referral to counselling will be
  available throughout the pregnancy to help them plan for the future and to remain
  uninfected.




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APPENDIX 6-H Post-Test Counselling Checklists (continued)

HIV-positive result
Counselling is a relationship and provides an opportunity to establish a rapport with the
client, answer questions and make sure the client understands the information you are
providing.
In many ANC clinics in Malawi, the rapid HIV test is being utilized. This offers an
opportunity for clients who are tested to receive their results the same day. In many
settings they are taught to interpret their own result form.
 Greet the client.
 Ask whether the client has any questions before they read the result form. Answer
    questions and let the client know counselling will continue to be available to help
    with important decisions regardless of the test result.
 Recap the group pre-test information/counselling session. Let the client know you are
    doing this to make sure they remember important information.
 Indicate that the HIV test result is ready for them to interpret. Ask them if they are
    ready. Confirm the test results with the client.
 Pause and wait for the client to respond before continuing. Give the client time to
    express any emotions.
 Check the client's understanding of the meaning of the results.
 Explore and support the client's feelings and emotions.
 Inform the client of essential PMTCT issues. Discuss and support initial decisions
    about:
     Antiretroviral treatment and prophylaxis
     Infant-feeding options
     Childbirth plans
     Adequate nutrition
     Address ―positive living‖; provide referral for preventive healthcare services
     Prompt medical attention, prophylaxis and treatment of opportunistic infections
     Stress management and support systems
 Explain that the woman‘s test results do not indicate whether her partner is infected
    and that her partner will need to be tested.
 Discuss disclosure and support issues.
 Address risk reduction that is necessary to protect her partner(s) and herself from re-
    infection:
     Condom use (male and female condoms) [include condom demonstration]
     Reducing the risk of infecting others; and screening and treatment for other
        sexually transmitted infections
 Identify sources of hope for the client, such as family, friends, community-based
    services, spiritual supports and treatment options. Make referrals when appropriate.
 If the client already has children, discuss and plan for testing of children.
 Ask whether the client has questions or concerns. Give the client contact information
    for the clinic should concerns arise.
 Remind mothers and families that counselling will be available throughout the
    pregnancy to help them plan for the future and obtain necessary services.




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Malawi PMTCT Trainer Manual



APPENDIX 6-I              Role Play Scenarios for Post-Test Counselling

Scenarios for HIV-negative test results
Scenario 1
Maria is 17 years old and has been dating her boyfriend for one year. She started having
unprotected sexual relations with him three months ago, and is now pregnant. She
suspects that her boyfriend may be at risk for HIV since he has not been faithful to her,
although he denies this. During her first visit to ANC, she decided to be tested, just in
case she is infected.

Scenario 2
Jenny is a student in computer school and is in her third trimester. Although she is in a
committed relationship with the father of her child, in the past she had multiple sexual
partners and engaged in unprotected sex. After attending her first ANC visit she
understood that she might be at risk for HIV and she does not want to put her partner or
baby at risk. She decides to be tested.

Scenarios for HIV-positive test results
Scenario 1
Rosemary is a commercial sex worker and sees many men each week. She has tried to get
them to use condoms but many of them refuse. She is in her 28th week of pregnancy; this is
her first visit to the ANC clinic. She is worried about her baby‘s safety and has agreed to be
tested for HIV.

Scenario 2
Patricia and Mark have been married for six years and have three children. She is now in
her second trimester and suspects they may be having twins. Last year, the couple had
separated for approximately four months. During that time, Mark had sexual relations
with someone whom, he later found out, was HIV-infected. Patricia is aware of this and,
because of the pregnancy, knows that the baby is at risk for HIV-infection if she has HIV.
Mark has refused testing, but she was tested and he has accompanied her to the clinic
today to hear her results.

Scenario 3
Nabanda works in housekeeping at the ANC clinic. She is well liked by all the staff and
recently found out she is going to have her first baby. She knows, because of previous
behaviours, that she needs to be tested for HIV. She approached one of the HCWs and
asked for her help getting tested. She is very concerned that other staff may find out and
wants test results kept confidential between her and this one HCW.




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References

Ministry of Health. 2004. Voluntary Counselling and Testing, A Training Manual for site counsellors and
         supervisors for Malawi. 2nd Ed.

Ministry of Health. 2004. HIV/AIDS Counselling and Testing, Guidelines for Malawi. 2nd Ed.

National AIDS Commission in conjunction with Ministry of Health and Population. 2002. HIV Blood HIV
         Rapid Testing for VCT Services: Trainers Guide for Training of Nurses and Clinicians.

WHO, HHS-CDC. Draft 2005. Providing Training and Supervision for HIV Rapid Testing. May


Resources

Key Resources:
Family Health International. 2004. HIV Voluntary Counseling and Testing: A Reference Guide for
        Counselors and Trainers. Family Health International: Research Triangle Park, NC. Retrieved 22
        February 2006 from http://www.fhi.org/en/HIVAIDS/pub/guide/vcttoolkitref.htm

WHO. 2004. Rapid HIV Tests: Guidelines for Use in HIV Testing and Counselling Services in Resource-
      Constrained Settings. WHO: Geneva. Retrieved 28 February 2006 from
      http://www.who.int/hiv/pub/vct/en/rapidhivtestsen.pdf

WHO. 2003. The right to know: New approaches to HIV testing and counseling. WHO: Geneva. Retrieved
      22 February 2006 from http://www.who.int/hiv/pub/vct/pub34/en/print.html

CDC Global AIDS Program, WHO, et al. 2005. Testing and Counselling for Prevention of Mother-to-Child
       Transmission of HIV. CDC, WHO, UNICEF, USAID. Visit
       http://www.womenchildrenhiv.org/wchiv?page=vc-10-00 for ordering information.

CDC. 2004. Introduction of routine HIV testing in prenatal care--Botswana, 2004. MMWR Morb Mortal
       Wkly Rep 53(46): 1083-6. Retrieved August 2006 from
       http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_
       uids=15565017

CDC. 2001. Revised Guidelines for HIV Counseling, Testing, and Referral. Recommendations and Reports.
       CDC: Atlanta, GA. Retrieved 22 February 2006 from
       http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5019a1.htm.

Commonwealth Regional Health Community Secretariat. 2002. HIV/AIDS Voluntary Counselling and
      Testing: Review of policies, programmes and guidance in East, Central and Southern Africa. .
      Commonwealth Regional Health Community Secretariat: Arusha, Tanzania. Retrieved 22
      February 2006 from http://www.crhcs.or.tz.

Family Health International. 2005. HIV Voluntary Counseling and Testing: Skills Training Curriculum--
        Facilitator's Guide. FHI: Arlington, VA. Retrieved 24 February 2005 from
        http://www.fhi.org/NR/rdonlyres/esaykh67z7kitivgipm6kmm4guku6b3o73kf4rrmehlkvzckyotw3c
        yk2a5tiniguuwtu25lrjbnna/VCTFaciliatatorsGuide1.pdf.

Family Health International. 2004. Preparedness of voluntary counseling and testing centers in Kenya to
        provide family planning. Family Health International: Research Triangle, NC. Retrieved 22
        February 2006 from
        http://www.fhi.org/NR/rdonlyres/ejobkq4x3inuglidaqj6l242xa2nsqlwqrcxq6lfyy223zyaip322gej6h
        gduhai7znlimhlve3fbm/FPVCTresearch.pdf.




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Kankasa, C and et al. 2002. Why do women accept VCT during antenatal care? The experience from the
        prevention of mother-to-child transmission of HIV program in Zambia. Horizons
        Project/Population Council: Washington, DC.

Pronyk, PM, JC Kim, et al. 2002. Introduction of voluntary counselling and rapid testing for HIV in rural
        South Africa: from theory to practice. AIDS Care 14(6): 859-65.
        http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_
        uids=12511218

UNAIDS. 2001. Counselling and voluntary HIV testing for pregnant women in high HIV prevalence
      countries: Elements and issues. UNAIDS: Geneva. Retrieved 22 February 2006 from
      http://www.etharc.org/vct/couns&test_en.pdf

UNAIDS and WHO. 2004. UNAIDS/WHO Policy statement on HIV testing. WHO, UNAIDS: Geneva.
      Retrieved 28 February from http://www.who.int/hiv/pub/vct/en/hivtestingpolicy04.pdf




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