PREVENTING MOTHER-TO-CHILD TRANSMISSION OF HIV A Practical Guide

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					                  PREVENTING
                MOTHER-TO-CHILD
              TRANSMISSION OF HIV
                A Practical Guide to
               Counseling and Testing
                    Procedures
                    2nd Edition




American International Health Alliance
                                                             Preventing
                                                           Mother-to-Child
                                                         Transmission of HIV
                                                          A Practical Guide to
                                                         Counseling and Testing
                                                              Procedures
                                                                        2nd Edition




This guide was developed using the most recent treatment information available at the time of production by profes-
sionals in Ukraine for colleagues working in similar healthcare settings. In the rapidly changing field of HIV care and
treatment, information can become outdated quickly. We encourage users to compare this data and its date of issuance
with the latest information found on www.aidsknowledgehub.org and other relevant sites. AIHA disclaims any respon-
sibility for any errors, omissions, or other possible problems associated with this publication. February 2005.


                                                             This guide is made possible through support provided by
                                                             the US Agency for International Development (USAID),
                                                             Bureau for Europe and Eurasia. The opinions expressed
                                                             herein are those of the author(s) and do not necessarily
                                                             reflect the views of USAID.
                                   Since 1992, the American International Health Alliance (AIHA) has es-
                                   tablished and managed more than 100 volunteer-driven partnerships be-
                                   tween healthcare institutions in the United States and their counterparts
                                   in Central and Eastern Europe and Eurasia. AIHA partnerships involve
                                   the twinning of hundreds of health systems, educational institutions, and
                                   communities, as well as the participation of thousands of clinicians, ed-
      Developed by:
                                   ucators, and other health-related professionals. AIHA assistance has en-
  N.N. Nizova, MD, PhD,
                                   abled the US healthcare sector to help address local healthcare issues by
        professor,
                                   providing effective and coordinated assistance to the countries of these
   Odessa State Medical
        University                 regions. AIHA also sponsors a number of supportive and collaborative          AIHA’s Regional Model for Preventing
                                   activities, including conferences, workshops, and a multilingual Web-
    S.P. Posokhova, MD,            based clearinghouse of medical information. In an extraordinary               Mother-to-Child Transmission of HIV in
                                   demonstration of private-public collaboration and commitment, the US
   Candidate in Medical
Sciences, Assistant Professor,     health sector is contributing more than one dollar in resources ranging       Odessa, Ukraine
                                   from equipment and supplies to in-kind time for every federal dollar
   Odessa Oblast Clinical
                                   provided in support of the twinning programs.
           Hospital
                                   AIHA’s twinning partnerships have made many important contributions
                                   to health reform efforts in Central and Eastern Europe and Eurasia,           Central and Eastern Europe and Eurasia are currently
        Edited by:                 including: (1) restructuring national, oblast (state), and city healthcare
 V. Zaporozhan, MD, PhD,           delivery systems by, for example, organizing regional perinatal and emer-
                                                                                                                 experiencing the fastest increase of HIV infection in
  member of the Ukrainian          gency networks; reorganizing key in- and outpatient hospital services at      the world, bringing the total number of people living
Academy of Medical Science         institutional and multi-institutional levels; and introducing new levels of
                                   care and services including hospice care and home health visits by nurs-
                                                                                                                 with the virus in the region to 1.5 million.1 Although
                                   es; (2) developing a network of more than 25 free-standing Women’s            the number of children born to HIV-positive mothers
        Odessa 2002                Wellness Centers that provide comprehensive health care tailored to the
                                   specific needs of women; (3) reorganizing and improving health profes-        in this area is still relatively low, two-thirds of the re-
          2nd edition,             sions education by establishing some of the first residency-based training    ported cases are in Ukraine2 (population: 48 million,
                                   programs in the region for family physicians and other primary care
        Odessa 2005                providers; (4) supporting the development of the region’s first schools       2002).3 According to UNAIDS statistics, HIV
                                   and programs in health management, health administration, and public          prevalence in Ukraine is approaching 1% of the adult
                                   health; (5) establishing new skills-based training centers and programs
                                   for the in-service training of physicians, nurses, feldshers, and adminis-    population.4 The number of children born to HIV-
                                   trators, such as the region’s first programs in basic emergency care, dis-
                                   aster response, infection control, and neonatal resuscitation; (6) opening
                                                                                                                 positive women in the country increased nearly 90%,
                                   more than 23 high-quality, model Primary Care Centers that provide            from 737 reported cases in 2000, to 1,379 in 2002.5
                                   comprehensive medical care and emphasize community-based health
                                   promotion and wellness programs; (7) developing successful “healthy
                                                                                                                 The percentage of HIV cases registered among preg-
                                   communities/healthy cities” twinning relationships that enable commu-         nant women has also skyrocketed, in some regions
                                   nities to address their own unique health and social welfare problems; (8)
                                   creating more than 130 Learning Resource Centers to promote evidence-         rising above 0.4 percent.6
                                   based clinical practices and offer support to the dozens of nursing and
                                   other associations created to encourage professional development and
                                   broad health reform initiatives; and (9) developing a number of opera-        Odessa oblast has one of the highest HIV infection
                                   tional comprehensive, community-based model programs that target              rates in the country (361.3 per 100,000 people oblast-
                                   specific health priorities such as tuberculosis, cardiovascular disease,
                                   family violence, post-traumatic stress syndrome, diabetes, asthma, and        wide)7 and the number of children infected through
                                   preventing the risk of mother-to-child transmission of HIV.
                                                                                                                 vertical transmission has grown significantly during the
                                   AIHA operates primarily under cooperative agreements with the United
                                   States Agency for International Development (USAID)—the US govern-
                                                                                                                 last three years, with the number of births to HIV-
Cover photo by Barry Kinsella.     ment agency that finances programs and projects that promote broad-           positive mothers rising from 0.8% in 2001 to 1.0% in
Image of mother and child          based and sustainable economic growth worldwide—and the US Depart-
courtesy of Barbara Comnes,        ment of Health and Human Services, Health Resources and Services              2003.8 For comparison, in 2001, 0.4% of pregnant
Painet Inc.                        Administration (HRSA). Additional funding has been provided through           women tested positive for HIV in Ukraine; in 2002,
Translation by EnRus Translation   grants from the US Department of Energy, the Library of Congress’s Open
Agency (www.enrus.ru), Moscow.     World Leadership Center, and various foundations. (February 2005)             0.5% of pregnant women had a positive status.9



                                                                                                                 Counseling and Testing Procedures
In response to this public health crisis, AIHA initiat-    and massing a body of evidence-based resources and
ed a pilot project in 2001 aimed at preventing             informational materials.
mother-to-child transmission (MTCT) of HIV in
Odessa. Supported by USAID, AIHA’s project is an           Tasked with developing a cadre of well-trained,
integral part of a larger effort involving international   knowledgeable, and skilled professionals who will
donors including UNAIDS, WHO, UNICEF, Médecins             work in close collaboration with community-based
Sans Frontiéres (MSF; also known as Doctors With-          organizations dedicated to providing care and social
out Borders), and Ukrainian government agencies            support to HIV-positive individuals, the Knowledge
and nongovernmental organizations. MSF, for exam-          Hub will be part of a synergistic network that includes
ple, is providing Odessan women with supplies, such        international experts, two similar centers—one fo-
as antiretroviral (ARV) drugs and infant formula           cusing on harm reduction and the other on surveil-
crucial to preventing MTCT, and AIHA is cooperat-          lance—and a cadre of strategic partners including
ing closely with MSF to provide related technical as-      AIDS Foundation East West (AFEW), International
sistance and training for healthcare workers to            Association of Physicians in AIDS Care (IAPAC),
Odessa healthcare institutions.                            and AIDS Healthcare Foundation-Global Immunity
                                                           (AHF-GI).
In 2003, the World Health Organization Regional
Office for Europe (WHO/Euro) joined with AIHA to           AIHA’s project in Odessa focuses primarily on imple-
establish the independent, non-governmental Re-            menting systemic and institutional changes related to
gional Knowledge Hub for Care and Treatment of             the prevention and treatment of HIV/AIDS by:
HIV/AIDS in Eurasia. Operating with funds provid-
ed by Deutsche Gesellschaft für Technische Zusam-            ❙ reorganizing and strengthening clinical service
menarbeit (GTZ) and USAID, the Knowledge Hub                   delivery to ensure that measures to stop vertical
serves as a crucial capacity-building mechanism for            transmission of the disease are integrated into
reaching WHO’s “3 by 5” targets for the region.                the obstetric, pediatric, and new family-centered
                                                               primary care systems;
Based in Ukraine at the Kiev Medical Academy of
Post Graduate Education and closely affiliated with          ❙ revising treatment protocols to ensure that they
the Ukrainian National AIDS Center, the main objec-            are evidence based and effective within the re-
tive of the Knowledge Hub is to create the human               gion’s changing social and economic context; and
resource capacity necessary to provide care to HIV-
infected individuals by developing expertise among           ❙ developing training materials and curricula for
healthcare professionals, cultivating training capacity,       health professionals in important areas such as



        Preventing Mother-to-Child Transmission of HIV     Counseling and Testing Procedures
    counseling, obstetrics, occupational health,          these important areas, additional emphasis is being
    women’s health, pediatric care, and family            placed on nursing, pediatrics, and laboratory
    planning.                                             support, as well as the development of high-quality
                                                          primary care for mother and child.
This effort builds upon more than a decade of highly
successful AIHA programmatic activity throughout          As is the case in other AIHA twinning programs, US         [P]reliminary results
Ukraine, in general, and in Odessa, in particular.        institutions and health professionals involved in the
                                                          Ukraine PMTCT project are voluntarily providing            at the end of 2002
With USAID support, AIHA is applying its propri-          professional support and material resources—
etary twinning methodology—supplemented by                including basic workplace infection control barriers
                                                                                                                     indicated a 75%
expert resources—to the prevention of mother-to-
child transmission (PMTCT) project in Odessa.
                                                          and other important supplies—matching US
                                                          government funding on a dollar-for-dollar basis.
                                                                                                                     decrease in
Boulder Community Hospital and its collaborating                                                                     HIV-positive infants
institutions, including the University of Colorado        As a result of the coordinated efforts by AIHA and
Health Sciences Center and Children’s Hospital of         others, the Odessa Oblast Hospital has been able to        born to HIV-positive
Denver, are serving as the lead US partners under a       quickly demonstrate dramatic success in the preven-
subgrant from AIHA. These partners, working closely       tion of MTCT; preliminary results at the end of 2002       women at the
with their counterparts in the Odessa Oblast Health       indicated a 75% decrease in HIV-positive infants born
Administration, the State Medical University of           to HIV-positive women at the hospital.10 Having
                                                                                                                     hospital.
Odessa, and the Odessa Oblast Hospital—one of the         demonstrated initial success in preventing MTCT
largest public hospitals in the region—are providing      among participating women, the project is increasingly
training and capacity building related to the model       focused on systematically identifying all women in the
program. In addition, AIHA is drawing upon the            city and oblast who are at risk, enrolling them in fami-
expertise of individual health professionals and key      ly planning and prenatal services, and ensuring 100%
public institutions across the United States to supple-   case management through delivery and postdelivery.
ment and expand upon this training and to provide         The project is also striving to provide all HIV-positive
expertise in the are of HIV/AIDS treatment and care.      mother/child pairs with high-quality family care and, if
                                                          necessary, specialized treatment.
Training to date has been specifically designed to
increase the proficiency of medical professionals         In 2003, AIHA established the Southern Ukraine
from Odessa in the areas of obstetrics and gynecology,    AIDS Education Center (SUAEC) in Odessa to
neonatology, counseling, and clinical practice guide-     disseminate the PMTCT model through hands-on,
lines. While future training will continue to focus on    skills-based and methodological trainings. SUAEC



        Preventing Mother-to-Child Transmission of HIV    Counseling and Testing Procedures
                                                                       5. R.A. Moiseyenko, “Implementation of the National Program,
currently serves as a regional training center for the                     ‘Reproductive Health 2001–2003’,” Report to the Conference on
                                                                           Monitoring and Assessment of the Vertical Transmission Prevention
Knowledge Hub in the areas of PMTCT and                                    Program in Ukraine, Kiev, Ukraine (in Ukrainian), April 2003.
pediatric AIDS.                                                        6. R.A. Moiseyenko, “Prevention of HIV Transmission from Mother to
                                                                           Child in Ukraine,” report to the Regional Conference for Eastern
                                                                           Europe and Central Asia “Care, Support, and Treatment for People
An overall goal of AIHA’s model PMTCT project is to                        Living with HIV/AIDS,” November 2002, Ukraine [Доклад на
develop materials that can be used throughout the                          региональной конференции для стран Восточной Европы и
                                                                           Центральной Азии “Уход, поддержка и лечение для людей,
region. Companion products are a critical output of the                    живущих с ВИЧ/СПИДом”, ноябрь 2002, Украина].
project, and collaboration and consensus-building                      7. Ukrainian AIDS Center Reports, 2003.
                                                                       8. Annual Reports of Odessa Oblast AIDS Center, 2001-2003 [Годовые
with the Ukrainian Ministry of Health and others is
                                                                           отчеты Одесского областного центра СПИДа, 2001-2003].
a key component of the project’s work plan. Practical                  9. Ministry of Health of Ukraine, Organization of PMTCT System in
materials such as this guide are being developed                           Ukraine, 2003.
                                                                       10. Ministry of Health of Ukraine,“Organization of Mother-to-Child
using a collaborative approach in which the Ukrain-                        Transmission Prevention System in Ukraine: An Overview,” Preven-
ian authors’ drafts are circulated to US counterparts                      tion of HIV Infection in Infants Review Meeting, Kiev, Ukraine,
                                                                           September 16–18, 2003.
for review and comment. All documents are made
available in both English and Russian.

Companion products and further information about
the model PMTCT project, the Regional Knowledge
Hub for the Care and Treatment of HIV/AIDS in
Eurasia, USAID, and AIHA’s partnership programs,
and the HRSA-funded HIV/AIDS Twinning Center
Program in Africa, Asia, and the Caribbean can be
found at www.aiha.com. Further information about
the Regional Knowledge Hub for the Care and Treat-
ment of HIV/AIDS in Eurasia can be found at
www.aidsknowledgehub.org (July 2004).

References
1. UNAIDS/WHO, AIDS epidemic update. December 2003.
2. R. Malyuta, “HIV Infection Among Women and Children: Review of
   Epidemic Development in Europe and NIS,” presentation, May, 2003.
3. Intergovernmental Statistical Committee of the CIS
   [Межгосударственный статистический комитет СНГ], 2003.
4. UNAIDS, Report on the Global HIV/AIDS Epidemic, 2002.




         Preventing Mother-to-Child Transmission of HIV                Counseling and Testing Procedures
Acknowledgements

The authors wish to extend their thanks for the
review of the first edition of this guide to:

• Jill K. Davies, MD, assistant professor, Division
  of Maternal Fetal Medicine, Department of
  Obstetrics and Gynecology, University of
  Colorado School of Medicine, Denver, Colorado

• Kay Kinzie, RN, pregnancy coordinator, Denver
  Children’s Hospital, Denver, Colorado

• Laure Lisk, RN, MS, director, Women and
  Family Services, Boulder Community Hospital,
  Boulder, Colorado

• Charles Steinberg, MD, physician, director,
  Beacon Clinic, Boulder Community Hospital,
  Boulder, Colorado

• Mary Macsalka, MD, physician, Boulder
  Community Hospital, Boulder, Colorado

The authors also wish to thank Barbara Fisher,
vice president, Boulder Community Hospital, for
her contribution to this project.



Counseling and Testing Procedures
Table of Contents

Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . i
Glossary of Terms . . . . . . . . . . . . . . . . . . . . . . . . . . . iv
Acronyms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii

Chapter 1: Introduction and
Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
   C&T as the Starting Point for Preventing and
   Treating HIV (UNAIDS 2000) . . . . . . . . . . . . . . . 2
Goals and Purpose of the Practical Guide . . . . . . . . 4

Chapter 2: What is C&T?
Definitions, Goals, and Principles . . . . . . . . . . . . . . . 5
    Components of the C&T Process . . . . . . . . . . . . . 6
    Common Counseling Mistakes . . . . . . . . . . . . . . . 7
Minimum Requirements and Algorithm . . . . . . . . . 8
Pre-test Counseling . . . . . . . . . . . . . . . . . . . . . . . . . 11
    Testing and Counseling Algorithm . . . . . . . . . . . 12
Diagnosis of HIV Infection . . . . . . . . . . . . . . . . . . . 17
Post-test Counseling . . . . . . . . . . . . . . . . . . . . . . . . . 22
    Possible Patient Reactions to
    Positive Test Results . . . . . . . . . . . . . . . . . . . . . . . 24
Voluntary Partner Notification of
HIV Test Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25




Counseling and Testing Procedures
                                                Table of Contents


Chapter 3: C&T and Prevention of
Vertical Transmission of HIV
Incorporating C&T into Prenatal Services . . . . . . . 29
Features of Counseling of HIV-Positive
Women on Pregnancy . . . . . . . . . . . . . . . . . . . . . . . 33
Family Planning Counseling . . . . . . . . . . . . . . . . . . 36
Breast Feeding and Infant Nutrition . . . . . . . . . . . 38
                                                                           Preface
ART and the Health of the Mother . . . . . . . . . . . . 39

Chapter 4: Provision of C&T in                                             The HIV epidemic in Eurasia continues to grow.
Perinatal Service                                                          Statistics show that 1.8 million people in Western
Staffing and Coordination of Services . . . . . . . . . . 41               and Central Europe and Eurasia were infected with
Facilities and Location . . . . . . . . . . . . . . . . . . . . . . . 44   HIV by the end of 2002. In Eurasia, the epidemic is
Equipment and Supplies . . . . . . . . . . . . . . . . . . . . . 44        growing faster than anywhere else in the world.
    Assessing the Quality of Organization of C&T . . . . 45                From 1996 to 2000, the HIV infection rate grew
    Measures of the Effectiveness of C&T . . . . . . . . 45                1,300 percent over the course of 5 years. More
Monitoring and Quality Control . . . . . . . . . . . . . . 45              than half of the reported HIV cases—54%—were
    Completeness of Counseling . . . . . . . . . . . . . . . . 47          recorded among intravenous drug users (IDUs),1
                                                                           which is certainly linked to the growth in intra-
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49    venous drug use. A sentinel surveillance study of
                                                                           IDUs revealed a jump in the prevalence of HIV
Additional Reading . . . . . . . . . . . . . . . . . . . 52                infection in this population in 2000. In particular,
                                                                           it rose from 12 to 19.3% in St. Petersburg in 2000
Appendices
                                                                           alone, and in Svetlogorsk, Belarus, the infection
Appendix 1: Counseling and Testing Protocol . . . . 53
                                                                           rate was 62%. At the same time, Belarus and
Appendix 2: Suicide Risk Factors . . . . . . . . . . . . . . 57
                                                                           Ukraine showed a change in the breakdown of
Appendix 3: HIV Screening Procedures . . . . . . . . . 59
                                                                           principal HIV transmission routes: the proportion
Appendix 4: Informed Consent Form . . . . . . . . . . 61
                                                                           of HIV cases transmitted sexually is growing. Even
                                                                           though absolute numbers remain low, more and
                                                                           more people are becoming infected with HIV
                                                                           through sexual contact, and more and more preg-
                                                                           nant women are testing positive for HIV, implying
                                                                           that the epidemic is spreading throughout the
                                                                           population.2



          Preventing Mother-to-Child Transmission of HIV                   Counseling and Testing Procedures                      i
                                                  Preface    Preface



     Many factors are responsible for the rising HIV         in the first nine months of 2003, that number was
     epidemic in the region. One is the opening of           at 1,648.6–8
     borders between countries, which has allowed
     population migration and energized the narcotics        A key element in fighting the HIV epidemic is
     trade, as well as promoted economic instability,        preventing the transmission of the virus. This
     leading to growing unemployment—especially              strategy includes a series of interrelated steps—all
     among young people—and to deteriorating public          of which must be carried out in tandem:
     health care. One of the most important factors is       ❙ modification of risky behaviors;
     poor HIV/AIDS literacy and knowledge of safe            ❙ ensuring the availability and use of condoms;
     behaviors among the younger generation. For             ❙ diagnosis and treatment of STIs;
     example, in Tajikistan, only 10% of girls aged          ❙ voluntary HIV testing and counseling;
     15–19 had even heard of AIDS, and in Azerbaijan         ❙ prevention of transmission from mother to child;
     and Uzbekistan, fewer than 60% are aware of its         ❙ safeguarding the blood supply and blood-
     existence as a disease. Familiarity with HIV               derived products;
     prevention measures is also extremely low. In           ❙ reducing the risk of infection among IDUs; and
     particular, only 9% of Ukrainian girls know how         ❙ eliminating the stigmatization of HIV-positive
     to protect themselves from the virus, and only             persons.9, 10
     28% of young women say their partners used
     condoms during their first sexual contact.3             This guide is devoted to the guidelines and specific
                                                             methods for counseling and testing (C&T) at-risk
     Overall, the prevalence of HIV infection among          patients. It also discusses the relationship of C&T to
     pregnant women in Eurasia is relatively low; the        other components of HIV prevention strategy,
     high prevalence rates in Russia and Ukraine,            especially its role in preventing vertical transmission.
     however, stand out against this backdrop. In 1998,
     Ukraine reported 686 HIV-positive pregnant              References
                                                             1. R. Malyuta, “HIV Infection among Women and Children: Review of
     women; by 2002 the number had increased to                  Epidemic Development in Europe and NIS,” presentation, May, 2003.
     2,022.4 In 2001, Russia reported more than 2,500        2. UNAIDS, “Report on the Global HIV/AIDS Epidemic,” 2002.
                                                             3. ibid.
     HIV-positive pregnant women.5                           4. “Organization of Mother-to-Child Transmission Prevention System in Ukraine:
                                                                 An Overview,” (Ministry of Health of Ukraine, Review Meeting: Prevention of
                                                                 HIV Infection in Infants, Kiev, Ukraine, September 16–18, 2003).
                                                             5. Malyuta, 2003, op. cit.
     The prevalence of HIV infection among children is       7. Russian AIDS Center, www.nospid.ru/statistics/russia.
                                                             8. Ukrainian Centre for AIDS Prevention, Ministry of Health of Ukraine (as of Oc-
     also rising. In Ukraine, the number of HIV-positive         tober 2003). For comparison, prevalence data for 2003 for Kiev Oblast is 60.7
                                                                 per 100,000 and 194 per 100,000 for the Crimea.
     children rose from 378 in 1998 to 1,379 in 2002,        9. Malyuta, 2003, op. cit.
                                                             10. Family Health International, 2003.
     and in Russia, from 81 in 1998 to 2,777 in 2002;



ii          Preventing Mother-to-Child Transmission of HIV   Counseling and Testing Procedures                                                   iii
                                        Glossary of Terms    Glossary of Terms



     GLOSSARY OF TERMS                                       ing and testing,” and “voluntary and confidential
     Counseling: A confidential conversation between         counseling and testing” (VCCT) are synonymous.
     a counselor and client aimed at providing psycho-       (Definition from Increasing Access to Knowledge of
     logical support for and giving information on a         HIV Status: Conclusions of a WHO Consultation,
     particular topic to the client. Counseling helps        Dec. 3-4, 2001.)
     clients develop skills for overcoming the difficul-
     ties of life circumstances and enables them to          HIV: Human immunodeficiency virus; a retro-
     make critical decisions based upon accurate and         virus that causes AIDS. In this guide, HIV refers
     complete information. In relation to HIV, counsel-      to HIV-1, as cases of vertical transmission of HIV-2
     ing can help prevent the spread of the infection by     are extremely rare.
     encouraging a client’s sense of responsibility for
     his/her behavior and, when necessary, guiding           HIV status: (divided into four categories)
     him/her to change risky lifestyle behaviors.             s   Indeterminate status: A person who has not
                                                                  been tested for HIV, whose results of an HIV
     Counseling and testing (C&T): A process                      screening are unknown, or who has received a
     through which patients learn whether or not they             positive result on an HIV quick test.
     are HIV-positive, what that means for their future,      s   HIV-infected: A person who is infected with
     and the various decisions they may need to make              HIV, who may or may not know it.
     after being given more information about their           s   HIV-negative: A person who has tested
     diagnosis. In HIV testing, blood or another                  negative for HIV and knows the results of the
     biological fluid is checked for the presence of HIV          test. In the case of a child, the parent(s) have
     antibodies or virus antigens. HIV testing must be            been notified.
     strictly voluntary and performed only with the           s   HIV-positive: A person who has tested positive
     informed consent of the patient. Counseling                  for HIV, has a confirmed diagnosis, and
     accompanying HIV testing comprises’ a series of              knows the results of the diagnosis. In the case
     confidential meetings between a patient and                  of a child, the parent(s) have been notified.
     counselor that allows the patient to determine the
     level of his/her knowledge about HIV; assess            Infant: A child from birth to the age of 12
     his/her behavior from the standpoint of the risk of     months.
     infection and transmission; decide whether
     or not to be tested; and receive psychological          Informed consent: Permission given by a
     support when test results are given. The terms          patient to a healthcare worker to perform HIV
     “HIV testing and counseling,” “voluntary counsel-       testing, certifying that the decision to be tested



iv          Preventing Mother-to-Child Transmission of HIV   Counseling and Testing Procedures                       v
                                         Glossary of Terms    Acronyms



     has been made on a voluntary basis, after giving         ACRONYMS
     conscious consideration to all relevant informa-         AIDS: acquired immunodeficiency syndrome
     tion/facts. Because the knowledge and experiences
     of individuals are different, it is important that       ARV: antiretroviral
     health-care workers provide the patient with in-
     formation the patient considers important. This          ART: antiretroviral therapy
     may include details about the risks and advantages
     of being tested; the option to decline testing because   C&T: counseling and testing
     of specific, personal situations; and the availability
     of testing options. Only after the patient feels fully   DNA: deoxyribonucleic acid
     informed can a decision about testing be made.
     Informed consent must always be obtained for HIV         ELISA: enzyme-linked immunoassay
     testing, because the HIV virus is a life-threatening
     disease that can have dangerous consequences for         HCI: healthcare institution
     the patient. (Definition from Increasing Access to
     Knowledge of HIV Status: Conclusions of a WHO            HIV: human immunodeficiency virus
     Consultation, Dec. 3-4, 2001.)
                                                              MTCT: mother-to-child transmission (of HIV);
     Mother-to-child transmission (MTCT): In this             also known as vertical transmission
     guide, MTCT refers to the transmission of HIV
     from an HIV-positive woman to her child during           NGO: nongovernmental organization
     pregnancy, delivery, or breast feeding. A woman
     can become infected with HIV through unprotect-          OI: opportunistic infection
     ed sexual contact with an HIV-positive partner, a
     blood transfusion, contact with non-sterile instru-      PCR: polychain reaction
     ments, or a medical procedure. She may not know
     her HIV status. The term MTCT, also known as             PMTCT: prevention of mother-to-child
     vertical transmission, does not carry any hint of        transmission (of HIV)
     judgment.
                                                              RNA: ribonucleic acid
     Vertical transmission: See mother-to-child
     transmission.                                            STI: sexually transmitted infection




vi          Preventing Mother-to-Child Transmission of HIV    Counseling and Testing Procedures              vii
                                                 Acronyms



       UNAIDS: Joint United Nations Program on
       HIV/AIDS

       WHO: World Health Organization                         Chapter 1: Introduction
                                                              and Background

                                                              HIV counseling and testing (C&T) has proven its
                                                              importance in terms of both preventing HIV and
                                                              delivering medical care to those infected with the
                                                              virus. C&T makes it possible to be screened for
                                                                                                                     For the HIV-positive
                                                              HIV, learn the results in confidence, obtain coun-
                                                              seling regardless of the results, and if the test is   person, the
                                                              positive, be referred for continuous treatment,
                                                              psychological counseling, social assistance, and       advantage of C&T is
                                                              emotional support.1, 2 For the HIV-positive per-
                                                              son, the advantage of C&T is the ability to obtain     the ability to obtain
                                                              appropriate medical care at an early stage of the
                                                              infection, which also allows for the treatment and
                                                                                                                     appropriate medical
                                                              prevention of diseases associated with HIV infec-      services and care at
                                                              tions.3 In addition, HIV-positive pregnant women
                                                              who learn their serological status can help prevent    an early stage of the
                                                              transmission of the virus to their child.
                                                                                                                     infection.
                                                              Knowing one’s HIV serological status allows indi-
                                                              viduals to take steps to protect themselves and
                                                              their sex partner(s) against HIV infection. C&T
                                                              enables persons who test negative for HIV to con-
                                                              sult with a specialist and learn what they can do to
                                                              protect themselves from becoming infected.4 C&T
                                                              enables persons who test negative for HIV to con-
                                                              sult with a specialist and learn what they should



viii         Preventing Mother-to-Child Transmission of HIV   Counseling and Testing Procedures                                          1
                                                                                                                                    Chapter 1          Introduction and Background



                                                     do to protect themselves from future HIV infec-                                                   of preventing HIV and STI infection(s), nutritional
                                                     tion. The latest research has shown that C&T may                                                  counseling, and family planning assistance.7, 8
                                                     be the most economical means of preventing HIV
      C&T may be the                                 transmission in use today.5, 6                                                                    Referral to some or all of these services as part of a
                                                                                                                                                       unified care process is one of the C&T counselor’s
     most economical                                 As the diagram shows, C&T is the starting point for                                               key tasks. To refer people for care and support in
                                                     medical and psychological care, legal assistance, and                                             an efficient and timely manner, the counselor must
means of preventing                                  material support. In particular, C&T is the jumping-                                              have details about the available relevant services

HIV transmission in                                  off point for comprehensive long-term clinical care
                                                     and support for pregnant women. C&T for pregnant
                                                                                                                                                       and comprehensive knowledge about the organiza-
                                                                                                                                                       tions that provide them.9
                     use today.                      women provides access to care and prevention of
                                                     HIV-related diseases, prevention of mother-to-child                                               UNAIDS emphasizes that a country’s national
                                                     transmission of HIV (PMTCT), training in methods                                                  C&T policy should adhere to a set of basic
                                                                                                                                                       guidelines. In particular, a country must


                        C&T AS THE STARTING POINT FOR                                                                                                  ❙ ensure access to high-quality and confidential
                  PREVENTING AND TREATING HIV (UNAIDS 2000)                                                                                              C&T services;

                                                             Acceptance of and coping                                                                  ❙ guarantee informed consent and confidentiality
                                                                  with serostatus
                          Planning for the future (care of
                                                                                                                                                         in clinical care; medical studies; collection of
                                                                                         Promotes and facilitates behavior
                          orphans, dependents and family,                                 change (sexual, safe injecting)                                donor blood, blood products, and organs; and
                                making wills, etc.)
                                                                                                                                                         in other cases when the person’s identity could
        Normalization and destigmatization                                                                     Prevention of MTCT                        be learned from the results of an HIV test;
                   of HIV/AIDS                                      C&T
                 Peer,                                            and its
  social, and community support;                               links with                                        Provision of maternity services for   ❙ raise standards for the quality of commercial
including support groups for people                                other                                               people living with HIV
           living with HIV                                       services                                                                                and independent (home) HIV-test kits and
                                                                                                                                                         safety measures concerning their possible im-
              Access to family planning                                                                    STI prevention, screening, and
                                                                                                                     treatment                           proper use;

                                 Access to condoms                                      Early management of opportunistic
                                 (male and female)                                                 infections                                          ❙ promote community involvement in epidemio-
                                                             Access to early medical care                                                                logical oversight and studies; and
                                                         including ARVs, preventive therapy
                                                                for TB, and other OIs

                                                                                                                                                       ❙ prevent forcible and mandatory HIV testing.10



2                                                                 Preventing Mother-to-Child Transmission of HIV                                       Counseling and Testing Procedures                        3
                                               Chapter 1



    Pursuant to Article 4 of the Ukrainian Law, “On
    the Prevention of AIDS and the Social Protection
    of the Public,” the state guarantees the accessibili-
    ty, quality, and efficacy of medical examinations,
    including those that are anonymous, with the
    provision of pre- and post-test counseling.11           Chapter 2: What is C&T?
    GOALS AND PURPOSE OF THE
    PRACTICAL GUIDE
    The goal of this guide is to improve the system of      DEFINITIONS, GOALS, AND
    voluntary HIV testing and counseling for HIV            PRINCIPLES
    infection in the city and oblast of Odessa, and in      Counseling and testing is a process that provides          One of [C&T’s] most
    other similar, resource-limited settings. Incorpo-      individuals with both the information and the
    rating the processes detailed in this guide into        time for reflection they need to make an informed          critical objectives is
    antenatal care will enable service providers to         decision about whether or not to be tested for
    include an important component of PMTCT in              HIV. This decision must be made alone by the in-
                                                                                                                       to open the door to
    existing HIV/AIDS prevention programs.                  terested party, and he/she must be assured that the
                                                                                                                       comprehensive
                                                            process is confidential.12
    This guide is intended for healthcare workers—                                                                     medical services for
    obstetricians, gynecologists, family doctors, and       From a clinical point of view, C&T is more than just
    infectious disease specialists—who provide volun-       drawing blood samples, analyzing them, and talking         HIV-positive persons.
    tary HIV testing and counseling to pregnant             with patients. One of its most critical objectives is to
    women as part if an integrated PMTCT program.           open the door to comprehensive medical services for
                                                            HIV-positive persons. This spectrum of care includes
                                                            access to PMTCT, prevention of opportunistic infec-
                                                            tions (OIs), and many other services.13 It is impor-
                                                            tant to note that the C&T strategy includes all
                                                            persons—both those who test positive and those
                                                            who test negative for HIV. C&T helps patients attend
                                                            to psychological stress, face the real threat of HIV
                                                            infection, and alter their mindset. In other words, the
                                                            C&T process offers a comprehensive approach to
                                                            addressing HIV/AIDS.14-16 In particular, C&T



4          Preventing Mother-to-Child Transmission of HIV   Counseling and Testing Procedures                                               5
                                                                                       Chapter 2   What is C&T?



HIV counseling is a                ❙ motivates individual to change at-risk behaviors
                                                                                                                                 COMMON COUNSELING MISTAKES
                                     or continue safe ones;
              confidential                                                                             •   Controlling the conversation; not encouraging a patient’s spontaneous expression
                                                                                                           of his/her feelings and needs.
dialogue between a                 ❙ improves the safety of donated blood;
                                                                                                       •   Condemnation of a patient or expressing dissatisfaction with his/her actions,

              patient and          ❙ improves the health status of HIV-positive                            thoughts, choices, etc.

                                     individuals by offering access to early treatment                 •   Lecturing on morals, sermonizing, heavy-handed caretaking, or instructing a pa-
counselor that helps                 and prevention of HIV-related diseases;                               tient on how he/she should behave or live.

                                                                                                       •   Attaching negative labels to a patient, instead of clarifying the patient’s motiva-
       the patient cope            ❙ provides emotional support; and                                       tions, fears, and concerns.
                                                                                                       •   Unwarranted reassurance; filling the patient with unwarranted optimism.
    with psychological             ❙ enhances public awareness of PMTCT.                               •   Rejecting a patient’s feelings.

       stress and make                                                                                 •   Providing advice before a patient has received sufficient information and had time
                                   Within the C&T framework, HIV counseling is a                           to make his/her own decision.
decisions related to               confidential dialogue between a patient and coun-                   •   Interrogating; asking questions in an accusatory tone.
                                   selor that helps the patient cope with psychological                •   Encouraging dependency.
               HIV/AIDS.           stress and make decisions related to HIV/AIDS. The
                                                                                                       •   Cajoling or attempting to coax a patient toward a new type of
                                                                                                           behavior by using flattery or deception.


                                                                                                           Source: Counseling Before and After HIV Testing: A Guide [Руководство «Консультирование до и после теста на
                                                                                                           ВИЧ-инфекцию»]. Moscow: SPIDInfosvyaz, 2000.
                       COMPONENTS OF THE C&T PROCESS
     Characteristics Explanation
     Time              The counseling process should not be hurried. Patients should
                       have time to think over and express their opinions and feelings.            counseling process includes a personalized assess-
     Acceptance        Both HIV-positive and -negative patients should feel that the               ment of a patient’s risk of contracting/transmitting
                       counselor accepts them as they are.
                                                                                                   HIV and, if applicable, helps the patient to change
     Access            Patients should feel that they can always ask for advice or
                       counseling.                                                                 behaviors that put him/her at risk. The goal of C&T
     Consistency       Information must be presented consistently, in an understandable            is to prevent HIV transmission, provide immediate
     and clarity       form, taking into account the patiient’s level of education.                medical care to HIV-positive persons, normalize so-
     Trust             A trusting relationship should be established between the patient           cial mores and stigmatizations related to the disease,
                       and the counselor.
                                                                                                   and provide emotional support.17, 18
     Confidentiality   Confidentiality must be guaranteed.




6                                           Preventing Mother-to-Child Transmission of HIV         Counseling and Testing Procedures                                                                                     7
                                                                   Chapter 2     What is C&T?



                         Prevention of HIV is obstructing the transmission       his/her HIV serological status, which necessitates
                         of the virus                                            moving beyond a single strictly regulated model
                         ❙ from an HIV-positive person to his/her sex            of C&T.27, 28 C&T methodologies that are ethically
                            partner(s), whether their status is HIV-negative     acceptable, progressive, practical, and effective
                            or indeterminate;                                    must be created to fit the unique features of indi-
                         ❙ from an HIV-positive mother to her child; or          vidual medical institution. Within these institu-
                         ❙ from an HIV-positive or -indeterminate patient        tions, the C&T procedures must be standardized
                            to a HIV-negative person(s) for example, a sex       and offered to patients
                            partner(s) or other patient(s).19, 20                ❙ when the patient wishes to use methods of
                                                                                    preventing HIV transmission or infection;           While offering HIV
                         Providing immediate care to an HIV-positive             ❙ based on medical indications discovered in the
                         individual means beginning                                 course of treatment; and                            testing under certain
                         ❙ clinical care (antiretroviral therapy [ART], PMTCT,   ❙ for PMTCT.29
                            and prevention of OIs);                                                                                     circumstances should
                         ❙ family planning assistance;
                         ❙ emotional, psychological, and social support; and
                                                                                 While offering HIV testing under certain circum-
                                                                                 stances should become a norm, actual HIV testing
                                                                                                                                        become a norm,
                         ❙ legal assistance as soon as possible.21-23            must be done only with a patient’s informed            actual HIV testing
                                                                                 consent and in strict confidence. Although the
    C&T is also aimed    As noted above, C&T is also aimed at modifying soci-    procedure for obtaining informed consent will          must be done only
                         etal mores. This means combating the stigmatization     inevitably be different at each medical institution,
         at modifying    of HIV-positive persons, disseminating knowledge        it should, however, include the following: the         with a patient’s
                         about HIV/AIDS to the general public, and protect-      patient is given adequate information about
       societal mores.   ing human rights. The ultimate goal of C&T is to        HIV/AIDS, is aware of the positive and negative
                                                                                                                                        informed consent
                         promote the treatment of HIV infection. That is, to     consequences of determining their HIV status,
                                                                                                                                        and in strict
                         promote the distribution, improve the quality, and      and is not coerced into being tested.30
                         reduce the side effects of ART, preventive treatment,                                                          confidence.
                         the use of antiretrovirals for PMTCT, and the selec-    Limited resources make compliance with the
                         tion of an optimal method for feeding infants.24-26     minimal C&T standards listed below especially
                                                                                 important.
                         MINIMUM REQUIREMENTS AND
                         ALGORITHM                                               ❙ C&T must be voluntary.
                         Improved access to treatment and other types of
                         medical care depends on a patient’s knowledge of



8                               Preventing Mother-to-Child Transmission of HIV   Counseling and Testing Procedures                                           9
                                               Chapter 2     What is C&T?



     ❙ Each patient must give informed consent before          persons belonging to other groups at high risk
       being tested. To do so, patients must be given          for HIV infection.
       sufficient information regarding the positive
       and negative consequences of learning their           ❙ Targeted public-relations programs should be
       HIV status. Informed consent may be given               developed to attract those who rarely seek
       only under conditions that exclude compulsion.          medical care, specifically IDUs, sex workers,
                                                               and young people.
     ❙ During pre-test counseling, patients must be in-
       formed of the goals of the program, the testing       ❙ To increase requests for C&T services, testing
       procedure, possibilities for treatment, and the         and counseling should be a component of mul-
       availability of various types of social support.        tiple healthcare and social service programs,
                                                               particularly those that work to reduce harm to
     ❙ Post-test counseling must provide patients with         IDUs.31, 32
       appropriate information and necessary referrals.
                                                             Because various C&T models are used throughout
     ❙ When HIV test results are positive, patients          the world, testing and counseling protocols vary
       must receive referrals to medical care and social     because of available resources and methods of
       support services.                                     testing. In particular, the US Centers for Disease
                                                             Control and Prevention (CDC) disseminate vari-
     ❙ HIV test results must be communicated confi-          ous alternative C&T protocols using standard and
       dentially. Test results must only be accessible to    rapid methods of diagnosing HIV.33
       health-care workers directly involved in a pa-
       tient’s treatment.                                    The recommended testing and counseling procedure
                                                             is illustrated by the C&T Algorithm found on page
     ❙ During HIV counseling, the counselor must             12 and is set forth in the Counseling and Testing
       discuss a series of important issues with a pa-       Protocol (see Appendix 1, page 53).34
       tient, taking into account a patient’s particular
       risk group for example, whether or not they are       PRE-TEST COUNSELING
       an intravenous drug user (IDU), sex worker,           Improving the availability and use of C&T
       prisoner, tubercular patient, or child.               requires support for existing anonymous testing
                                                             centers, as well as the development of alternative
     ❙ The opportunity for C&T should be offered             opportunities for rapid testing and counseling at
       primarily to IDUs, sex workers, prisoners, and        medical institutions that serve high-risk popula-



10          Preventing Mother-to-Child Transmission of HIV   Counseling and Testing Procedures                    11
                                                                                                 Chapter 2   What is C&T?



                       TESTING AND COUNSELING ALGORITHM35                                                    from patients are conducted in a group setting,
      Individual Pre-Test Counseling                                 Group Pre-Test Counseling               after the lecture each patient should be offered an
            Provided on request                             In women’s counseling; in tuberculosis, drug
                                                                                                             opportunity to speak individually with a coun-
     at all institutions, including after                  dermatology & STD clinics; in prisons hospital
              group counseling                                 and in the context of various intitiatives    selor in a confidential setting. It should be noted
                                                                                                             that group discussions are permissible only at the
                                                                                                                                                                     [G]roup discussions
                                                                                                             pre-test counseling stage. Post-test counseling         are permissible only
                                                                                                             must always be done individually.37 It is desirable
           Refusal of Testing
             Discuss how to
                                                    Consent to Testing
                                                        Perform test
                                                                                     Refusal of Testing
                                                                                  Discuss how to minimize    for the pre- and post-test counseling to be con-        at the pre-test
       minimize risk of infection.                  (protocol attached)               risk of infection      ducted by the same specialist.38
 Refer to various services as necessary
                                                                                                                                                                     counseling stage.
                                                                                                             With appropriate training, counseling may be
                                                                                                             provided by health-care workers at anonymous
                                                                                                                                                                     Post-test counseling
                Negative Result                                                   Post Result
                 Discuss how to
            minimize risk of infection
                                                                         Provide post-test counseling
                                                                       prevent adverse consequences;
                                                                                                             offices and at in- and outpatient clinics by doctors,
                                                                                                                                                                     must always be
     Refer to various services as necessary                           refer to HIV-positive care services    nurses, social workers, and appropriate non-
                                                                                                             governmental organizations (NGO) employees.39           done individually.
                                                                                                             All patients invited to undergo testing have the
                                                                         Refer to regional HIV/AIDS
                                                                    prevention and treatment center for
                                                                                                             right to decline. All those who refuse testing must
      NGO providing support to the HIV                             confirmation of HIV infection diagram     be furnished with information on how HIV is
                 positive                                         and provision of necessary medical care
                                                                                                             transmitted and prevented, as well as told where
                                                                                                             they can get additional information about HIV
                                                                                                             should the need arise.40-42
                                            tions. This, in turn, requires the availability of
                                            individual counseling programs and the introduc-                 Counselors must advise patients about the basic
                                            tion of group counseling models.36                               principles of HIV testing and discuss how HIV is
                                                                                                             transmitted, ways to protect oneself against the
                                            Group discussions simplify the pre-test counseling               infection, and the types of medical care and psy-
                                            procedure, thereby saving time and money. But,                   chological and social assistance that HIV-positive
                                            because group counseling is carried out in lecture               individuals can receive. Patients must be given
                                            format, a patient may be deprived of the opportu-                contact phone numbers and the addresses of
                                            nity to discuss and fully assess the reality of the              approprivate medical institutions and psychological/
                                            possibility of being HIV-positive. If preliminary                social support services.
                                            discussions aimed at obtaining informed consent



12                                                 Preventing Mother-to-Child Transmission of HIV            Counseling and Testing Procedures                                            13
                                                  Chapter 2     What is C&T?



     Providing and Obtaining Information                        ❙ assess the patient’s level of knowledge about
     Pre-test counseling discussions—whether con-                 HIV/AIDS and his/her ability to cope with a
     ducted individually or in a group—must address:              possible crisis
                                                                   s explore what the patient knows about

     ❙ behaviors associated with the risk of HIV infection            testing and its benefits
                                                                   s ask what prompted the patient to seek C&T

     ❙ the benefit of testing and the range of care                s identify specific behaviors or symptoms that

       available to patients who test positive for HIV                caused the patient to seek C&T
                                                                   s assess the patient’s level of knowledge about

     ❙ HIV transmission routes, preventive measures,                  HIV transmission routes and their links to
       and the testing procedure                                      risky behavior
                                                                   s clarify how the patient expects he/she will

     ❙ possible consequences of being testing (mental                 react to a positive or negative test result
       health, personal life, practical considerations, etc.)      s ask whether people close to the patient are able

                                                                      to support him/her if the result is positive.
     ❙ procedures for obtaining informed consent and
       releasing/receiving test results.43                      In addition, pre-test counseling should include
                                                                active steps to prevent HIV infection. To this end,
     During individual counseling                               if possible, give all counseled individuals condoms
                                                                and invite IDUs to participate in targeted
     ❙ obtain the patient’s life history, including             risk-reduction programs.44
        s past and present sexual behaviors and risks

          of HIV infection                                      Obtaining Informed Consent
        s compliance with safe sex practices                    A crucial step in pre-test counseling is obtaining
        s presence of many or of HIV-positive sex               informed consent. This requires
          partner(s)                                            ❙ giving the patient enough time to think about
        s risky behavior (intravenous drug use,                    the issues addressed during pre-test counseling;
          involvement in the sex business, etc.)
        s history of blood transfusions and/or organ            ❙ making sure the patient has correctly under-
          transplantation                                         stood the information provided and any misun-
        s history of invasive procedures                          derstandings are corrected;




14           Preventing Mother-to-Child Transmission of HIV     Counseling and Testing Procedures                       15
                                                                                                                Chapter 2   What is C&T?



                                             ❙ asking the patient directly whether he/she                                   where a positive test result is to be given. For the
                                               consents to the testing; and                                                 same reason, counselors should identify patients
                                                                                                                            who are afraid of being abused if they are found to
                                             ❙ having the patient complete a written consent                                be HIV positive.
                                               form.45
                                                                                                                            With the patient’s consent, C&T can be offered to a
                                             Preventing Adverse Consequences                                                spouse, sex partner(s), relative(s), and/or friend(s).
                                             Finally, pre-test counseling must include steps to                             Sometimes a person who has sought testing and
                                             prevent adverse consequences.46 First, the counselor                           counseling wants a sex partner, relative, or friend
                                             should explain the negative consequences that may                              to come with them to the counseling session(s).
                                             occur if the test result is positive for example, suici-                       Such inclusion is appropriate and often brings
                                             dal thoughts; aggression against the patient or those                          considerable benefit.47
                                             around him/her; and the criticism, condescension,                                                                                        The result of an HIV
                                             and/or avoidance of partner(s) and others. Some-                               DIAGNOSIS OF HIV INFECTION
                                             times this information affects a patient’s decision to                         C&T includes the primary diagnosis of an HIV              test is considered
                                             be tested. For future reference, counselors should                             infection using serologic studies. The initial test for
                                             always assess the risk of suicide (see Appendix 2,                             HIV is performed using ELISA; a positive result is
                                                                                                                                                                                      positive only if the
                                             page 57) and note any inclination on the part of the                           confirmed with the Western blot test. The result of
                                                                                                                                                                                      ELISA and Western
                                             patient toward an aggressive reaction. It is extreme-                          an HIV test is considered positive only if the ELISA
                                             ly important to know a patient’s state of mind                                 and Western blot test results are positive. As a rule,    blot test results are
                                             when going into a post-test counseling session                                 serologic tests reveal HIV 3–12 weeks after infection.
                                                                                                                                                                                      positive.
                                                                                                                            ELISA
     Effective pre-test counseling conducted in accordance                                                                  ELISA is based on the determination of serum
     with all the listed requirements enables patients to
                                                                                                                            levels of antibodies to HIV. If the HIV specimens
     • learn about the testing methodology
                                                                                                                            reveal immunoenzyme fluorescence, the more
     • assess the risk of discovering their HIV status
     • understand the significance of the test results
                                                                                                                            intense the fluorescence, the higher the HIV anti-
     • recognize the possible consequences of testing                                                                       body titer. An ELISA result is considered positive
     • make a conscious decision about being tested                                                                         if the minimum threshold fluorescence level is
     • improve their knowledge of issues related to HIV/AIDS                                                                exceeded. If the ELISA result is positive, the same
     • form an idea of safe behavior, and change or try to change behavior that
         carries with it a high risk of HIV infection                                                                       blood sample is analyzed two more times. If both
                                                                                                                            results of the repeat ELISA tests are negative, the
     Source: The Impact of Voluntary Counselling and Testing. A Global Review of the Benefits and Challenges.
     UNAIDS Best Practice Collection. UNAIDS, August 2001.
                                                                                                                            blood is considered uninfected. If either one of



16                                                        Preventing Mother-to-Child Transmission of HIV                    Counseling and Testing Procedures                                                 17
                                                 Chapter 2    What is C&T?



     the repeat ELISA tests is positive, the result is        using specially chosen primers (thermostable
     confirmed using the Western blot.                        DNA-polymerase), the preserved segment of DNA
                                                              is amplified (many copies are synthesized), which
     Western Blot                                             substantially increases the test’s sensitivity. The
     The Western blot is a method of studying HIV pro-        resulting copies are revealed using a hybridization
     tein antigens. During the test, proteins are broken      test: The copies are sorbed onto special filters, and
     down by electrophoresis and transferred to a mem-        DNA probes are added. If HIV genetic material is
     brane, a strip of nitrocellulose. The membrane is        absent, the labeled probes are retained on the
     incubated in a solution containing the blood serum       filter. The conclusion of whether or not the cells
     under investigation. If the serum contains HIV an-       contain DNA is drawn by determining what
     tibodies, the antibodies will bind to the respective     portion of the labels remain on the filter.48
     HIV antigens and will then be disclosed using ra-
     dioisotope or enzyme techniques. As a rule, when         The following factors are considered when setting
     HIV is present, the serum reveals antibodies to HIV      up HIV testing:
     surface antigens (gp160, gp120, gp41) and to the
     nuclear antigen (p24). The result of a Western blot      ❙ the prevalence of HIV infection in a given
     is considered positive when two or three kinds of          population
     antibodies to HIV antigens are found. If no anti-
     bodies to any HIV antigens are found in the serum,       ❙ the sensitivity and specificity of the methods
     the Western blot result is considered negative. The        used to disclose HIV antibodies
     presence of antibodies to only one HIV antigen is
     regarded as a doubtful result. In that case, dynamic     ❙ the goals of the testing (mass screenings, HIV
     observation with a repeat Western blot or tests for        diagnosis, etc.).
     HIV antigens or DNA is required.
                                                              Because HIV testing within the context of the C&T
     The primary diagnosis of HIV infection is made           setting is aimed at diagnosing HIV infection,            [M]ethods of
     by discovering viral particles. Researchers use a        methods of detecting HIV must be highly sensitive
     qualitative test for proviral DNA and viral RNA—         (reliably detect all positive results) and highly        detecting HIV must
     polymerase chain reaction (PCR)—to confirm               specific (rule out the possibility of false-positive
     positive Western blot results or when dubious            results). In every country, the development of opti-     be highly sensitive
     results from a Western blot or ELISA test need to
     be verified. Lymphocytes and monocytes are first
                                                              mal methods of screening for HIV must be the job
                                                              of government agencies and institutions. Test pro-
                                                                                                                       and highly specific.
     lysed, and their DNA (or RNA) is extracted. Then,        tocols must specify the scientific validity of the HIV



18           Preventing Mother-to-Child Transmission of HIV   Counseling and Testing Procedures                                              19
                                                 Chapter 2     What is C&T?



     test method, the network of laboratories where test-      method has good sensitivity, good specificity, and
     ing is performed, the presence and capabilities of a      is cost effective. If blood for the test is drawn from   The accuracy and
     reference laboratory for quality control, the labora-     a vein, enough serum is obtained for a second
     tories’ throughput (the number of patients that can       HIV test or other STI test(s), if necessary. If blood    reliability of HIV
                                                a-vis pa-
     be tested per day); the testing process vis-´             is taken from a finger, there is not enough materi-
     tients (whether results are obtained on the same          al for a second rapid test, so if one is needed, a pa-   screening using the
     day or patients must be invited back), and the long-
     term cost.49 The standard model of HIV testing in
                                                               tient must return to the clinic. If the result of the
                                                               first rapid test is positive, patient education can be
                                                                                                                        parallel and serial
     Ukraine occurs at stand-alone anonymous HIV               conducted while waiting for the second test.             test methods have
     screening clinics, offices that ensure confidential
     HIV C&T, and health-care institutions.                    Parallel Testing                                         been shown to be
                                                               When diagnosis is made using the parallel test
     At all these institutions, patients are offered a stan-   method, each blood sample is simultaneously stud-        nearly identical. At
     dardized model of individual pre- and post-test           ied by two test systems. If the results do not match,
     counseling, and the testing is done using ELISA.50        which happens in about 1% of the cases, a third
                                                                                                                        the same time, many
     The deployment of treatment and prevention pro-           rapid test is performed. The accuracy and
                                                                                                                        patients are more
     grams often requires additional testing facilities be     reliability of HIV screening using the parallel and
     opened, for example, close to high-risk populations.      serial test methods have been shown to be nearly         confident with the
                                                               identical. At the same time, many patients are more
     There are two rapid diagnosis methods of testing          confident with the parallel test method because they     parallel test method
     for HIV: the serial and the parallel test methods.        think that two tests are better than one. Accordingly,
                                                               the parallel test method can be used to attract pa-      because they think
     Serial Testing                                            tients and build public confidence in C&T. Another
     The serial test method assumes that each patient is       positive aspect of parallel testing is that the blood
                                                                                                                        that two tests are
     administered a rapid HIV test. If the result is posi-     sample will always be taken from the hand and            better than one.
     tive, a second test is given using a different test       enough will be taken for two tests at once. Conse-
     system. If the data from the first and second tests       quently, the patient will not be called back to the
     do not agree, a third test is performed using still       clinic if an additional test needs to be done, which
     another test system. Thus, two or three rapid tests       helps keep patient confidentiality. In addition, be-
     are done in succession. This method was recom-            cause parallel testing provides a final result sooner,
     mended by WHO in 1997 and by the CDC in                   from a psychological point of view it is a better op-
     1998. Serial tests use plasma or serum, not whole         tion for patients. Finally, unlike samples drawn from
     blood. Research has shown that the serial test            a vein, blood samples taken from a finger are easier



20           Preventing Mother-to-Child Transmission of HIV    Counseling and Testing Procedures                                              21
                                                 Chapter 2    What is C&T?



     to store under complex conditions (for example, in         use, etc. Provide information about ways of
     mobile labs or doctors’ offices). However, the serial      obtaining relevant help.
     test method is more economical than the parallel
     test method, as it requires a smaller outlay for test    ❙ Remind the patient of the importance of pro-
     systems and consumables (needles, scarifiers, etc.).51     tected sex, review proper condom usage, and, if
                                                                appropriate, provide materials for preventing
     POST-TEST COUNSELING52                                     HIV infection (condoms, needles, etc.).
     Ideally, post-test counseling should be performed
     as soon as the test results are received and at the      An HIV-positive Result
     same institution the patient contacted for C&T.          To maintain strict confidentiality, counseling must   [A] positive test
     Where possible, pre- and post-test counseling            only be done one-on-one; a positive test result
     should be conducted by the same specialist. The          may not be communicated by telephone.                 result may not be
     content and protocol of the post-test counseling
     session depends on the results of the HIV test.          Content and Structure
                                                                                                                    communicated by
                                                              ❙ Allow the patient to make himself/herself com-      telephone.
     An HIV-negative Result                                     fortable in the office, and then precisely and
     Content and Structure                                      clearly communicate the result.
     ❙ Communicate the results and make sure the
       patient understands what you have said.                ❙ Give the patient time to digest the result. Do
                                                                not discuss the disease’s possible development
     ❙ Explain that there is a “window period” during           nor the patient’s life expectancy at this stage.
       which the infection is undetected and that it is
       desirable to be retested in 3-4 months.                ❙ Assess the risk of adverse consequences (exis-
                                                                tence of suicidal thoughts, unfavorable psycho-
     ❙ Remind the patient of how HIV is transmitted             logical reactions, lack of emotional support
       and possible ways of protecting one’s self               from family and friends).
       against infection.
                                                              ❙ Explain, in detail, the difference between HIV
     ❙ Remind the patient about risk factors, discuss           infection and AIDS.
       intentions to change behavior(s) related to the
       risk of contracting HIV, and if appropriate,           ❙ Using precise and understandable language
       propose contacting a support group or under-             explain the features of an HIV infection (length
       going treatment for an STI, intravenous drug             of course, staging, etc.).



22          Preventing Mother-to-Child Transmission of HIV    Counseling and Testing Procedures                                         23
                                                                                                           Chapter 2   What is C&T?



                                            ❙ Advise the patient that he/she will be a source                            counseling. Refer the patient to organizations
                                              of HIV infection for the rest of his/her life, and                         that provide support to HIV-positive
                                              that steps must be taken to protect a sex part-                            individuals.
                                              ner(s) from HIV.
                                                                                                                       ❙ Discuss health-care options and inform the          Every person has the
                                            ❙ Have an open discussion about who should be                                patient that they need to schedule regular meet-
                                              informed of the infection and the possible reac-                           ings with an HIV treatment specialist.              right to keep their
                                              tion of various people (employers, health-care
                                              workers, etc.).                                                          ❙ Maintain positive and constructive ideas and
                                                                                                                                                                             HIV-test result secret.
                                                                                                                         thoughts throughout the entire counseling
                                            ❙ Explain where and how the patient can obtain                               session.
                                              psycho-emotional support, assistance, and crisis
                                                                                                                       Persons who find out they are HIV-positive need
                                                                                                                       health-care and social assistance and support.
                                                                                                                       They need to be referred to appropriate institu-
          POSSIBLE PATIENT REACTIONS TO POSITIVE TEST RESULTS
                                                                                                                       tions; for example, a health-care facility for fur-
      Shock: Numbing, deafening silence, emotional instability, distancing, despair.
                                                                                                                       ther treatment, psychosocial care and support
      Denial: “This can’t happen to me!”
                                                                                                                       services, support groups organized by NGOs, and
      Bitterness: Destructive behavior; the ability to injure oneself and/or others.
                                                                                                                       social support services, in the event of housing
      Suicidal thoughts and behavior: The risk of suicide is considerably
      higher in people who have learned that they are HIV-positive.                                                    and/or financial problems or the need for home
      Fear: Of death, an incurable disease, being rejected.
                                                                                                                       care.
      Withdrawal: Refuse social contact.
      Pain and loss: Very deep feelings of pain and loss.
                                                                                                                       VOLUNTARY PARTNER
      Guilt: Related to possible transmission of HIV to others or for behavior that could
                                                                                                                       NOTIFICATION OF HIV TEST
      have led to the HIV infection.                                                                                   RESULTS
      Depression                                                                                                       Every person has the right to keep their HIV-test
      Lowered self-esteem: Distance from neighbors, colleagues, acquaintances, and                                     result secret. Issues related to voluntary communi-
      loved ones can produce a feeling of loss of social status and confidence in oneself,                             cation of HIV test results have colossal impor-
      which leads to lowered self-esteem.
                                                                                                                       tance. At the same time, it is important to encour-
      Hypochondria: Excessive concern with the state of one’s health, in which even the
      slightest physical changes can cause worry.                                                                      age communication of test results—whether
                                                                                                                       positive or negative—to partners if one hopes to
     Source: Counseling Before and After HIV Testing: A Guide [Руководство «Консультирование до и после теста на
                                                                                                                       change high-risk behavior.
     ВИЧ-инфекцию»]. Moscow: SPIDInfosvyaz, 2000.




24                                                      Preventing Mother-to-Child Transmission of HIV                 Counseling and Testing Procedures                                           25
                                               Chapter 2     What is C&T?



     As a rule, people communicate test results to their     to imagine their reactions to positive and negative
     spouse, sex partner(s), and/or loved ones. The          test results for one or both of them as a way to
     benefits of doing so are emotional and material         prepare in advance for any possible outcome.
     support, as well as reducing the risk of transmis-      Couples counseling can prevent a conflict if one
     sion to a sex partner(s). The decision whether or       of the partners proves to be infected. Even if both
     not to tell others about an HIV-positive status is      partners test negative, the benefit of couples coun-
     often difficult and compounded by fears of alien-       seling is still valuable because they learn about
     ation, censure, violence inflicted by others, and job   safe sexual behavior and can make appropriate
     loss. Even so, ultimately most people decide to tell    decisions together. Couples counseling also
     others the result of their test; 24–79% tell loved      permits family planning issues to be worked
     ones, and up to 75% tell their partner(s).53            through completely.

     It is easier to change risky sexual behavior when       Teenagers
     both sexual partners know the test result. If a         When counseling teenagers it is important to keep
     positive test result can be communicated without        in mind their mental state given their age, their
     causing any adverse consequences—a breakup,             susceptibility to peer pressure, and the possible vi-
     rejection, violence, etc.—then the partner(s)           olence they might experience within their family.
     might also agree to be tested and counselled.54
                                                             IDUs
     C&T for Special Populations                             When counseling IDUs, it is important to discuss
     Although C&T principles, standards, and algorithm       issues related to reducing the risk of HIV infection
     are always the same, providing testing and counsel-     and transmission in detail. Counselors need to
     ing for certain populations requires special consid-    have a comprehensive understanding of current
     eration. It should be kept in mind that under certain   and available harm-reduction drug programs. It is
     conditions, HIV counseling may be done without          advisable to enlist appropriately trained former
     testing. Its purpose in this context is to promote      drug users in the counseling of this group.
     changes in sexual behavior—particularly the use of
     condoms—that decrease the risk of acquiring HIV.        Commercial Sex Workers
                                                             Safe sexual practices are the most important topic of
     Couples/Sex Partners                                    discussion when counseling sex workers. In addition,
     It is desirable to counsel couples (sex partners)       the special position of this group must be consid-
     together, both before and after HIV testing. In         ered: the illegality of their activities, their social isola-
     pre-test counseling, the couple should be asked         tion, and their lack of legal and social protection.



26          Preventing Mother-to-Child Transmission of HIV   Counseling and Testing Procedures                               27
                                               Chapter 2



     Blood Donors
     Combating the transmission of HIV that occurs
     through blood and blood products requires em-
                                                             Chapter 3: C&T and
     phasis on the importance of counseling donors. In       Prevention of Vertical
     addition to carefully selecting blood donors from
     groups at low risk for HIV infection, all donors        Transmission of HIV
     should be offered C&T.

     Pregnant Women
     The testing and counseling of pregnant women            INCORPORATING C&T INTO
     deserves special attention. Counselors working with     PRENATAL SERVICES
     this group must explore MTCT, breast feeding, pe-       A pregnant woman’s choice of whether or not to be
     diatric AIDS, family planning, safe sexual practices,   tested has medical implications for herself and her
     and healthy lifestyle choices, for example, STI         child. If she refuses to be tested and she is HIV-
     prevention, nutrition, smoking cessation, and           positive, there is a greater risk that her child will
     refraining from drug use and alcohol abuse.55-57        contract the disease. Studies have shown that when
                                                             a pregnant woman learns about HIV testing and its
                                                             relevance to the health of herself and her child,
                                                             most women get tested and, if the result is positive,
                                                             consent to the preventive course of treatment rec-
                                                             ommended by a doctor.58, 59 Health-care workers
                                                             must understand that most women undergoing
                                                             prenatal care take time to decide on whether or not
                                                             to undergo C&T. Often a pregnant woman initially
                                                             refuses to have an HIV test, but after some time
                                                             passes and she has thought it over, she changes her
                                                             mind and agrees to a test when it is offered again.

                                                             Whether or not C&T can be successfully imple-
                                                             mented within a maternal and child health facility
                                                             is determined by a variety of factors. First of all,
                                                             the introduction of C&T requires training person-
                                                             nel and ensuring quality control, as well as steps



28          Preventing Mother-to-Child Transmission of HIV   Counseling and Testing Procedures                       29
                                                                     Chapter 3     C&T and Prevention of Vertical Transmission of HIV



 For a woman to be         to prevent the stigmatization of HIV-positive           ❙ encourages women to notify sex partners, giving
                           women and their children at the facility. To ensure       these partners an opportunity to present for C&T.61
           able to take    support for women and improve the effectiveness
                           of C&T, it is important to involve men in the C&T       For pregnant women who seek prenatal observa-
 advantage of steps        and, if appropriate, PMTCT processes.60                 tion and care, C&T simplifies access to various
     aimed at reducing                                                             forms of assistance.62
                           For a woman to be able to take advantage of steps
      the risk of MTCT,    aimed at reducing the risk of MTCT, she must know       If the test result is negative, a woman receives:
                           her serologic status. Therefore, C&T must be avail-     ❙ preventive training aimed at preserving her
  she must know her        able to all pregnant women and take their particular        HIV-negative status
                           needs into account. C&T offers pregnant women
       serologic status.   series of advantages. Knowing their HIV status          ❙ normal prenatal and postnatal care and obstetric

Therefore, C&T must        ❙ allows women to receive counseling about ways
                                                                                     services


     be available to all     to prevent HIV infection and reduce behaviors         ❙ family planning counseling.
                             that increase the risk of contracting HIV, if the
      pregnant women         results are negative                                  If the test result is positive, a woman receives:
                                                                                   ❙ referral to a psychologist and to other social
         and take their    ❙ encourages women to seek counseling and treat-            services that provide assistance to HIV-positive
                             ment immediately, if the results are positive             individuals
particular needs into
               account.    ❙ permits women to be immediately treated and           ❙ information about PMTCT medical interven-
                             their children to be subsequently observed              tions and how to prevent transmission

                           ❙ opens the way to PMTCT regimens                       ❙ prenatal care and obstetric services specifically
                                                                                     designed for HIV-positive women
                           ❙ enables women to make future plans regarding
                             fertility                                             ❙ health care for HIV-related diseases

                           ❙ can convince women to take steps to prevent           ❙ nutritional counseling and information on how
                             transmission of HIV to sex partner(s)                   to maintain one’s health

                                                                                   ❙ family-planning counseling and care.



30                                Preventing Mother-to-Child Transmission of HIV   Counseling and Testing Procedures                       31
                                               Chapter 3     C&T and Prevention of Vertical Transmission of HIV



     Preserving HIV-negative Status                          ing post-test counseling about the need to use
     Helping people protect themselves from HIV is           condoms to prevent HIV transmission to their
     one of the most important objectives of C&T.63          sex partners. This is especially important when
     It is extremely important during prenatal care to       their partners are not infected or have an un-
     explain to women who test negative for HIV the          known HIV status.64
     risks of her contracting the infection during the
     prenatal period. If she does so, she must under-        FEATURES OF COUNSELING OF
     stand that she can pass the infection onto her          HIV-POSITIVE WOMEN ON
     child during delivery or through breast feeding         PREGNANCY
     (when the likelihood of MTCT is high). Coun-            Noted below are specific issues that should be
     seling provides women with the information              addressed when counseling HIV-positive pregnant
     they need to avoid high-risk activities that will       women. It is important to note that MTCT can
     help keep her status negative. For this reason,         occur in utero during any trimester, during deliv-
     C&T must be used both during and after preg-            ery, or while breast feeding. Women should also
     nancy to teach methods of preventing HIV and            be told about current methods of preventing
     STI infection.                                          MTCT, including ART, the use of safer delivery
                                                             methods, and preferred infant feeding practices.
     Promoting Safe Sex and the Use of
     Condoms                                                 Effect of Pregnancy on the Course
     During prenatal care, all women, regardless of          of HIV
     their HIV test results, should be counseled on          During pregnancy, all women, regardless of their
     safe sexual practices. The infection of an HIV-         HIV status, experience a decline in the absolute
     negative woman during the prenatal period or            CD4+ lymphocyte count. This may result from
     while breast-feeding is extremely dangerous from        hemodilution; there is no reason to believe that
     the standpoint of MTCT. Counselors should en-           pregnancy accelerates the reduction in the CD4+
     courage women who do not know the HIV status            count. In the absence of treatment, the level of
     of their sex partners or suspect that their part-       HIV RNA (viral load) in HIV-positive women is
     ners are infected to convince their partners to use     relatively stable for the duration of the pregnancy.
     condoms. The sex partners of pregnant women             Most studies have shown that pregnancy does not
     must be told the importance of complying with           affect the course of HIV infection. That is, it does
     safe sex practices. Married couples should be en-       not affect mortality, progression of the HIV infec-
     couraged to participate in a C&T program. HIV-          tion, development of AIDS, and the reduction of
     positive women should receive explanations dur-         viral load to below 200 cells per microliter.



32          Preventing Mother-to-Child Transmission of HIV   Counseling and Testing Procedures                      33
                                                                   Chapter 3     C&T and Prevention of Vertical Transmission of HIV



 Women who learn         Understanding and Acceptance of a                       Referral to Appropriate Healthcare
                         Positive Result                                         Facilities and Social Support Services
       in the prenatal   Women who learn in the prenatal period that they        A healthcare worker who has evaluated a woman’s
                         are HIV-positive need special support. They re-         prognosis must determine the forms of support
period that they are     quire additional counseling (both individual and        she will need. HIV-positive pregnant woman re-
     HIV-positive need   group), as well as medical and psychological care.      quire comprehensive and long-term assistance. It
                         In terms of health care, HIV-positive pregnant          is important to consider her needs both in terms
      special support.   women must be offered treatment aimed at PMTCT.         of her pregnant status and her overall health,
                         As a rule, aggression toward, depression about, and     keeping in mind concern for other family mem-
                         rejection of the positive result are a person’s first   bers and the importance of support from family,
                         reaction to hearing that they are HIV positive.         friends, and society. It is critical that counselors
                                                                                                                                         When offering ART,
                         These reactions are often more exaggerated in           encourage women to contact local social service
                                                                                                                                         a counselor should
                         pregnant women who are already psychologically          and support groups and provide them with refer-
                         grappling with the physical effects and outcome of      rals, if necessary.67                                   provide a detailed
                         the pregnancy, the health of her unborn child, and
                         the welfare of any other children. Positive test        Explanation of the Need for Proposed                    explanation of
                         result can evoke extreme emotional feelings.65          Medical Intervention
                                                                                 An HIV-positive woman should be informed about          what it entails,
                         Voluntary Notification of Partners                      possible care and treatment options so that she can
                         Preventing MTCT—and in particular, providing            make independent, conscious decisions about her
                                                                                                                                         emphasizing that
                         ART and encouraging nutritional supplements—            pregnancy. When offering ART, a counselor should        ART is a complex
                         can be extremely difficult if a woman conceals her      provide a detailed explanation of what it entails,
                         HIV-positive status from her spouse/ partner. Her       emphasizing that ART is a complex process that          process that requires
                         decision about whether or not to inform others is       requires strict adherence to doctor’s recommenda-
                         usually affected by personal circumstances and          tions and prolonged observation. It is extremely        strict adherence
                         social factors. The disclosure of an HIV-positive       important to follow the rules of any intervention
                         status is often fraught with adverse consequences for   therapy, and a woman is more likely to follow all the   to doctor’s
                         women; for example, humiliation, violence, or the
                         breakup of a relationship. Mechanisms must be de-
                                                                                 instructions she is given if healthcare workers them-
                                                                                 selves understand the advantages of the chosen pro-
                                                                                                                                         recommendations
                         veloped to protect the woman, and the advantages        tocol and inform their patients of these advantages.    and prolonged
                         and disadvantages of communicating the test result
                         to her partner(s) must be weighed very carefully for    HIV-positive pregnant women need to under-              observation.
                         each individual.66                                      stand that the use of ART drugs to prevent trans-



34                              Preventing Mother-to-Child Transmission of HIV   Counseling and Testing Procedures                                            35
                                                                     Chapter 3     C&T and Prevention of Vertical Transmission of HIV



                           mission is not always successful. Although a short      Reproductive Choice
                           course of nevirapine and zidovudine reduces the         A conversation on reproductive choice with an HIV-
                           risk of MTCT, its efficacy is not absolute, and         positive woman who is pregnant or wishes to be-
                            approximately 10% of newborns born to moth-            come pregnant requires the counselor to be tactful
                           ers who undergo this therapy are still infected.        and pay attention to the individual personality of
                           For this reason, a future mother should be              each woman—her age, mental and physical health
                           warned that her child, like herself and her family      status, reproductive history, and experience using
                           members, will need ongoing emotional and social         contraception should all be considered. During the
                           care and support.68                                     counseling session, it is important to evaluate the pa-
                                                                                   tient’s psychological state, provide her with the latest
                           Plans for the Future                                    data about how HIV infection may effect the course
                           HIV-positive women, recognizing the possibility         of pregnancy and her health, explain the risk of
                           of deteriorating health and premature death, often      transmitting HIV to partners and infants, and dis-
       Family-planning     worry about the fate of their children. Women           cuss issues of aid for children who have lost parents.
                           who seek C&T in the prenatal period feel these
     counseling should     concerns less, but even so, healthcare workers          Contraceptive Counseling
                           must be ready to discuss such issues. In addition,      Contraceptive counseling is an important part of
          be offered to    HIV-positive women, especially those who have           family planning. It should be offered to all women
women both before          survived the death of friends or relatives from         who seek C&T, particularly to HIV-positive
                           HIV/AIDS, worry about the prospects of their            women and even those who are already pregnant.
     and after delivery.   own life. When possible, healthcare workers             Counselors must know what contraceptive options
                           should refer women experiencing such anxiety for        are acceptable for HIV-positive individuals.
                           appropriate care. It is particularly beneficial to
                           provide a woman with legal assistance so that she       ❙ The condom, a barrier method, is the principal
                           can make a will and get other legal advice.69             form of contraception recommended for use by
                                                                                     HIV-positive persons; latex condoms are
                           FAMILY PLANNING                                           preferred.
                           COUNSELING
                           Family-planning counseling should be offered to         ❙ The advisability of HIV-positive women using
                           women both before and after delivery. In the post-        combined oral contraceptives is in dispute, as
                           natal period, such counseling is especially impor-        these agents do not protect against HIV trans-
                           tant to women who have decided for safety                 mission.
                           reasons to refrain from breast feeding.



36                                Preventing Mother-to-Child Transmission of HIV   Counseling and Testing Procedures                          37
                                               Chapter 3     C&T and Prevention of Vertical Transmission of HIV



     ❙ The intrauterine coil, or IUD, is not recom-          infant, the counselor must explain that from the
       mended because it increases the risk of pelvic        standpoint of MTCT it is far less dangerous to          If, for any reason—
       inflammatory disease and does not prevent             breast feeding exclusively than it is to administer
       HIV transmission.                                     mixed feedings of breast milk and formula. In           religious, moral,
                                                             addition, feeding with strained and heat-treated
     ❙ Lactational amenorrhea is an unacceptable             milk, although it does carry a lower risk of MTCT,
                                                                                                                     ethical, economic,
       form of birth control because it increases the        has no advantages over milk formula.
                                                                                                                     etc.—a woman
       risk of MTCT and does not protect the partner.
                                                             Healthcare workers need to support the mother,          decides to breast-
     BREAST FEEDING AND INFANT                               no matter her choice. Some women may choose to
     NUTRITION                                               breast feed because they face difficulties related to   feed her infant, the
     C&T counselors need to be prepared to answer            the acquisition of formula and/or adherence to
     questions that arise about infant feeding and to        rules for preparing it.                                 counselor must
     know the risks and advantages of breast feeding,
     as well as alternative feeding methods. Counseling      ART AND THE HEALTH OF THE
                                                                                                                     explain that from the
     an HIV-positive woman on nutritional issues re-         MOTHER                                                  standpoint of MTCT
     lated to her child is done in two phases: during        Pregnant women who are given ARV drugs should
     pregnancy and after delivery.70                         receive a detailed explanation of all the nutritional   it is far less
                                                             consequences of ARV therapy. To help women
     When discussing infant feeding, women should be         make a choice about whether to take ARV drugs           dangerous to breast
                                                             to prevent MTCT, the availability and safety of the
     ❙ informed about the risk of transmitting HIV           milk formula should be discussed, taking each           feeding exclusively
       through breast feeding or feeding with unsteril-
       ized breast milk;
                                                             woman’s specific health status and social condi-
                                                             tions into account.
                                                                                                                     than it is to
                                                                                                                     administer mixed
     ❙ told that boiled breast milk has no advantage
       over milk formulas; and                                                                                       feedings of breast
     ❙ told that milk formula will not harm her baby’s                                                               milk and formula.
       health in any way.

     If, for any reason—religious, moral, ethical, eco-
     nomic, etc.—a woman decides to breastfeed her



38          Preventing Mother-to-Child Transmission of HIV   Counseling and Testing Procedures                                             39
Chapter 4: Provision of
C&T in Perinatal Service


STAFFING AND COORDINATION
OF SERVICES
Healthcare workers at prenatal care clinics where      [T]hose who work at
C&T is offered and PMTCT protocols are admin-
istered need special training. They must know the
                                                       prenatal clinics must
specific characteristics of the course of HIV/AIDS,    acquire any new
HIV transmission routes, infection risk factors;
modern and available methods of care, and
                                                       skills they need to
meaning and content of prenatal and postnatal          explain the principles
counseling. In addition, those who work at prena-
tal clinics must acquire any new skills they need to   and organizing logic
explain the principles and organizing logic for        for administering ART
administering ART and other methods of PMTCT
and to offer counseling on preventing the sexual       and other methods of
transmission of HIV, family planning, and various
methods of feeding newborns.
                                                       PMTCT and to offer
                                                       counseling on
HIV-positive women frequently do not consider
counseling an important element of their care. In
                                                       preventing the sexual
addition, healthcare workers often accord prefer-      transmission of HIV,
ence to traditional medical procedures over C&T.
If health care providers, such as Ob/Gyns, are         family planning . . .
assigned additional responsibilities for C&T and
PMTCT, they sometimes do not devote enough



Counseling and Testing Procedures                                         41
                                                                        Chapter 4     Provision of C&T in Perinatal Service



                            time to that counseling. Studies have shown that          contradicts the personal opinion of the counselor
                            healthcare workers interested in counseling work,         or a medical recommendations. This often happens
                            who are trained appropriately become very sensitive       when discussing feeding methods with mothers.

     Counselors will be     and professional counselors. Counseling should not        Some data indicate that healthcare workers dis-
                                                                                                                                               High-quality
                            be a compulsory part every healthcare provider’s          cussing HIV-related problems with patients begin
     able to work more      job responsibility; rather, staff who feel a calling to   to experience worry and fear about contracting the       counseling and the
                            counsel should be given an opportunity to work            infection themselves.74 High-quality counseling and
      effectively if they   in this area.71                                           the ability of counselors to cope with stress and        ability of counselors
                                                                                      avoid emotional depletion can be ensured by ap-
have an opportunity         Contemporary views on how to organize C&T                 propriate training and by monitoring workload to         to cope with stress
                            require that academic curricula for doctors, nurs-        see that counselor does not become overburdened.75
            to alternate    es, and social workers include a course on HIV
                                                                                                                                               and avoid emotional
       counseling with      infection that addresses the basics of counseling.        Service Coordination and                                 depletion can be
                            All counselors must continually improve their             Communication
        other activities.   skills, take additional courses, and keep abreast         A system to provide perinatal care to HIV-positive       ensured by
                            of modern methods of counseling by participating          pregnant women must be organized so that the work
                            in conferences that involve discussion of clinical        of all its constituent services is coordinated and in-   appropriate training
                            cases and clinical rounds.72                              terconnected. Providers of each service must know
                                                                                      the needs and requirements of the other services.        and by monitoring
                            Support for the Counselors
                            Specialists who spend their entire work day pro-          Optimizing the Staff’s Work
                                                                                                                                               workload . . .
                            viding HIV counseling often experience a serious          Within a facility, different healthcare workers often
                            psychological burden. To minimize “burnout” and           provide the pre- and post-test counseling, man-
                            retain valuable experienced staff, regular activities     agement of prenatal care services, ART, nutritional
                            to support counselors should be organized and             counseling, and postnatal management. The system
                            carried out. It has been found that such activities       of care for HIV-positive women must be organized
                            are quite feasible and effective, even in overloaded      so that healthcare workers have access to the data
                            hospitals that serve areas with high HIV preva-           and case histories they need to perform their
                            lence.73 Counselors will be able to work more             duties while maintaining patient confidentiality.
                            effectively if they have an opportunity to alternate      The danger of unintentionally breaking confiden-
                            counseling with other activities. Another stress re-      tiality is real, and it is important to remember that
                            lated to counseling patients is the need to be ready      a woman’s needs may be forgotten when she is
                            to discuss and support a patient’s viewpoint that         managed by a team of healthcare workers. Thus,



42                                  Preventing Mother-to-Child Transmission of HIV    Counseling and Testing Procedures                                              43
                                                                       Chapter 4     Provision of C&T in Perinatal Service



         The danger of     cooperation and communication among all mem-
                                                                                               ASSESSING THE QUALITY OF ORGANIZATION OF C&T
                           bers of the medical team must be appropriately
         unintentionally   organized and encouraged.
                                                                                         ❙   Coverage and availability
                                                                                         ❙   Quality and content
              breaking                                                                   ❙   Reliability of chosen HIV testing strategy, including outside quality control
                           FACILITIES AND LOCATION                                       ❙   Frequency of use of PMTCT measures, such as ARV prevention and nutritional
confidentiality is real,   At many institutions, prenatal care is not provided               counseling
                           in a confidential setting. However, confidentiality is        ❙   Stress and overload in counselors and other workers involved in C&T

and it is important to     essential to properly and effectively conduct C&T
                                                                                                        MEASURES OF THE EFFECTIVENESS OF C&T
                           and to institute measures to provide PMTCT. As a
      remember that a      discussion of risk factors or sexual relationships is
                                                                                         ❙   Reduction in frequency of MTCT
                                                                                         ❙   Long-term care for the mother and child (increase in HIV infection awareness,
                           an integral part of C&T, without confidentiality a
 woman’s needs may         woman may conceal vital information. To provide
                                                                                             expansion of safe-sex practices, family-planning assistance, and measures aimed
                                                                                             at reducing pediatric morbidity and mortality)

     be forgotten when     appropriate conditions for C&T, it often becomes
                           necessary to allocate additional space or retro-fit           Source: UNAIDS, Tools for Evaluating HIC Voluntary Counselling and Testing. UNAIDS Best Practice
she is managed by a        clinical facilities into separate counseling offices.76       Collection (2000); www.unaids.org/publications/documents/health/counselling/Tools.pdf.



     team of healthcare    Women often bring their children with them to the
                           prenatal clinic waiting room. Creating a special          MONITORING AND QUALITY
               workers.    waiting area where children can play under the su-        CONTROL
                           pervision of medical staff or women waiting to be         Monitoring and evaluation is a critical tool for im-
                           seen frees counselors and patients from distractions.     proving the quality of C&T. Assuring the quality of
                                                                                     counseling must be a priority for HIV testing and                       To provide and
                           Finally, the location and hours of the C&T facility       counseling centers involved in counselor training.
                           must meet the needs of the community.77                   To provide and maintain the highest standard of                         maintain the highest
                                                                                     counseling, it is necessary to monitor and evaluate
                           EQUIPMENT AND SUPPLIES                                    the service, including looking at how informative it                    standard of
                           As a rule, counseling does not require expensive ma-      is, whether it consistently adheres to informed
                           terials or equipment. Counselors may need audiovi-        consent rules, and whether it offers counseling
                                                                                                                                                             counseling, it is
                           sual materials and handouts—booklets, fact sheets,        before HIV testing. To address this, we recommend
                                                                                                                                                             necessary to monitor
                           brochures, posters, video tapes, and other aids for       Tools for Evaluating HIC Voluntary Counselling and
                           the patient, as well as appropriate equipment to use      Testing. UNAIDS Best Practice Collection (Geneva:                       and evaluate the
                           them, such as a television and VCR. Database man-         UNAIDS, 2000). It is equally important to monitor
                           agement requires a computer and a printer.                and subject testing to quality control; for example,                    service . . .

44                                 Preventing Mother-to-Child Transmission of HIV    Counseling and Testing Procedures                                                                      45
                                                                    Chapter 4     Provision of C&T in Perinatal Service



                          to look at the efficacy of laboratory test methods
                                                                                                              COMPLETENESS OF COUNSELING
                          and the availability of consumables. 78
                                                                                      These are some questions to ask when evaluating the effectiveness of counseling.
                                                                                      Was there a discussion with a counselor before you were tested for HIV?
     C&T for PMTCT is     C&T monitoring must include a study of the
                                                                                      Evaluation of pre-test counseling:
                          scope and content of the counseling provided, the           Were the following issues addressed?
     beneficial both to   quality of the laboratory services, the scope and             ❙ Behavior associated with high risk of infection, and reasons for HIV testing
                          availability of C&T services, and the effectiveness           ❙   HIV transmission routes, steps to prevent infection, HIV testing procedure,
     pregnant women       of MTCT preventive measures.79 Evaluating the
                                                                                            significance of positive and negative test results, possible consequences of
                                                                                            learning one’s HIV status

 and to women who         effectiveness of the actual counseling involves
                          polling patients. A patient survey should be
                                                                                        ❙
                                                                                        ❙
                                                                                            Patient’s ability to cope with news of a positive test result
                                                                                            Possible needs and availability of sources of support

         may become       designed to determine the helpfulness and com-                ❙
                                                                                        ❙
                                                                                            Personal risk reduction plan
                                                                                            Further actions
                          pleteness of the information provided, as well as
       pregnant in the    patient satisfaction with the quality of the C&T            Was there enough time to fully understand these issues?
                          program.80                                                  Was informed consent really given without any compulsion?
                future.                                                               Did the counselor verify the patient’s mastery of the information and correct misun-
                                                                                      derstandings of any facts?
                          In conclusion, it should be noted that C&T for
                                                                                      Was there a discussion with a counselor after the testing?
                          PMTCT is beneficial both to pregnant women and
                          to women who may become pregnant in the                     Evaluation of post-test counseling:
                                                                                      Was the test result communicated in simple and understandable language?
                          future. Ideally, women should have access to C&T
                                                                                      Did the counselor confirm that the patient acknowledged their test result?
                          before pregnancy occurs, so that they have an
                                                                                      Was the significance of the test result, the consequences of learning one’s HIV
                          opportunity to make thoughtful choices regarding            status, and the people who would be informed of the test result discussed?
                          pregnancy and family planning. C&T will help                Was attention paid to how the patient emotionally reacted to their result?
                          HIV-positive women who are not pregnant to                  Were options for immediate support offered?
                          consciously make reproductive choices and study             Were future prospects for medical care and support discussed?
                          possible family planning options. In the C&T                Satisfaction with the Quality of C&T
                          framework, various PMTCT schemes—in particu-                Issues of quality can be addressed by getting feedback on
                          lar the use of a short course of zidovudine and                ❙ Convenience of obtaining services
                                                                                        ❙   Wait time
                          nevirapine—can be discussed with pregnant HIV-
                                                                                        ❙   Counselor
                          positive women.81 Even during C&T, it is preferable           ❙   Recommendations received
                          to begin discussing various infant feeding options
                          with the future mother. When possible—and with
                          the woman’s consent—counseling sessions should              Source: WHO, HIV/AIDS Treatment and Care Protocols for Countries of the Commonwealth of
                                                                                      Independent States, August 2003.
                          be held with both partners present. This enables



46                               Preventing Mother-to-Child Transmission of HIV   Counseling and Testing Procedures                                                             47
                                               Chapter 4



     them to jointly discuss reproductive health
     options. Counseling for women should not be
     limited only to discussion of PMTCT measures;
     discussions should reflect the diversity of the
     woman’s roles and duties in society and offer a
     comprehensive approach to meeting the needs and         References
     protecting the health of HIV-positive women.82, 83

                                                             1.    UNAIDS, The Impact of Voluntary Counselling and
                                                                   Testing: A Global Review of the Benefits and Challenges,
                                                                   UNAIDS Best Practice Collection, August 2001; www.
                                                                   unaids.org/publications/documents/health/counselling/
                                                                   JC580-VCT-E.pdf.
                                                             2.    UNAIDS, Voluntary Counselling and Testing (VCT):
                                                                   UNAIDS Technical Update. UNAIDS Best Practice Collec-
                                                                   tion, 2000; www.unaids.org/publications/documents/
                                                                   health/counselling/JC379-VCT-E.pdf.
                                                             3.    UNFPA, HIV Prevention Now. Program Briefs No 5: Vol-
                                                                   untary Counselling and Testing (VCT) for HIV Prevention,
                                                                   April 2002.
                                                             4.    UNAIDS, 2000, op. cit.
                                                             5.    UNAIDS, Report on the Global HIV/AIDS Epidemic, 2002.
                                                             6.    Family Health International (FHI) IMPACT Project, Vol-
                                                                   untary Counseling and Testing (VCT) for HIV, June 2001.
                                                             7.    UNAIDS, Report on the Global HIV/AIDS Epidemic, 2002.
                                                             8.    UNAIDS, HIV Voluntary Counselling and Testing: A Gate-
                                                                   way to Prevention and Care, UNAIDS Case Study,
                                                                   UNAIDS Best Practice Collection, June 2002
                                                             9.    UNAIDS, 2000 op. cit.
                                                             10.   ibid.
                                                             11.   Ministry of Health, Ukrainian Center for Combating
                                                                   AIDS, HIV Infection in Ukraine: Testing, Prevention,
                                                                   Treatment, 2001 (in Ukrainian).
                                                             12.   UNAIDS, 2000, op. cit.
                                                             13.   UNAIDS, Gateway to Prevention, June 2002, op. cit.
                                                             14.   Family Health International (FHI), Comprehensive
                                                                   HIV/AIDS Prevention, Care, and Support Programming,
                                                                   2003.
                                                             15.   UNFPA, op. cit.
                                                             16.   UNAIDS, Gateway to Prevention, June 2002, op. cit.
                                                             17.   FHI, 2003, op. cit.
                                                             18.   UNFPA, op. cit.
                                                             19.   FHI, 2003, op. cit.




48          Preventing Mother-to-Child Transmission of HIV   Counseling and Testing Procedures                                49
                                                       References      References


     20.   UNAIDS, Gateway to Prevention, June 2002 op. cit.           51.   FHI, 2001, op. cit.
     21.   ibid.                                                       52.   WHO, 2003, op. cit.
     22.   Ministry of Health of Ukraine, “Organization of Mother-     53.   MOH of Ukrainian and UNICEF, 2003, op. cit.
           to-Child Transmission Prevention System in Ukraine: An      54.   M. Temmerman et al., “The Right not to Know HIV Test
           Overview,” Prevention of HIV Infection in Infants Review          Results.” Lancet 345, pp. 696-697 (1985).
           Meeting, Kiev, Ukraine, September 16–18, 2003.              55.   UNAIDS, 2000, op. cit.
     23.   UNAIDS, 2002, op. cit.                                      56.   FHI, 2001, op. cit.
     24.   FHI, 2003, op. cit.                                         57.   MOH of Ukrainian and UNICEF, 2003, op. cit.
     25.   UNFPA, op. cit.                                             58.   UNICEF, UNAIDS, WHO, 2001, op. cit.
     26.   UNAIDS, Gateway to Prevention, June 2002, op. cit.          59.   WHO, 1999, op. cit.
     27.   MOH of Ukraine, 2001, op. cit.                              60.   R. Malyuta, “HIV Infection Among Women and Chil-
     28.   FHI, 2001, op. cit.                                               dren: Review of Epidemic Development in Europe and
     29.   WHO, HIV/AIDS Treatment and Care Protocols for                    NIS,” presentation, May 2003.
           Countries of the Commonwealth of Independent States,        61.   MOH of Ukrainian and UNICEF, 2003, op. cit.
           August 2003.                                                62.   UNAIDS, 2000 op. cit.
     30.   ibid.                                                       63.   FHI, 2001, op. cit.
     31.   ibid.                                                       64.   MOH of Ukrainian and UNICEF, 2003, op. cit.
     32.   UNICEF, UNAIDS, WHO, Local Monitoring and Evalua-           65.   WHO, 1999, op. cit.
           tion of the Integrated Prevention of Mother to Child HIV    66.   MOH of Ukrainian and UNICEF, 2003, op. cit.
           Transmission in Low-income Countries, 2001; www.            67.   WHO, 2003, op. cit.
           unaids.org/publications/documents/mtct/ME2001.doc.          68.   WHO, 1999, op. cit.
     33.   CDC, RESPECT-2, 1999. www.cdc.gov/hiv/projects/             69.   MOH of Ukrainian and UNICEF, 2003, op. cit.
           respect-2/counseling.htm.                                   70.   ibid.
     34.   WHO, 2003, op. cit.                                         71.   WHO, 1999, op. cit.
     35.   WHO, 2003, op. cit.                                         72.   WHO, 2003, op. cit.
     36.   MOH of Ukraine, 2001, op. cit.                              73.   Burnout in HIV/AIDS Health Care and Support,
     37.   UNAIDS, 2000, op. cit.                                            H. van Dis and E. van Dongen, eds. (Amsterdam Univer-
     38.   WHO, 2003, op. cit.                                               sity Press, 1993).
     39.   ibid.                                                       74.   WHO, 1999, op. cit.
     40.   ibid                                                        75.   UNAIDS, 2000, op. cit.
     41.   SPIDInfosvyaz, Counseling Before and After HIV Testing:     76.   WHO, 1999, op. cit.
           A Guide [Руководство «Консультирование до и после           77.   UNAIDS, 2000, op. cit.
           теста на ВИЧ-инфекцию»], Moscow, 2000.                      78.   WHO, 2003, op. cit.
     42.   WHO, Voluntary Counseling and Testing for HIV Infection     79.   UNAIDS, 2000, op. cit.
           in Antenatal Care: Practical Considerations for Implemen-   80.   WHO, 2003, op. cit.
           tation, 1999.                                               81.   UNAIDS, Prevention of HIV Transmission from Mother to
     43.   WHO, 2003, op. cit.                                               Child: Strategic Options. UNAIDS Best Practice Collection,
     44.   UNFPA, op. cit.                                                   2001; www.unaids.org/publications/documents/
     45.   WHO, 2003, op. cit.                                               mtct/una9940e.pdf.
     46.   ibid.                                                       82.   UNAIDS, 2000, op. cit.
     47.   UNAIDS, Gateway to Prevention, June 2002, op. cit.          83.   MOH of Ukrainian and UNICEF, 2003, op. cit.
     48.   Ministry of Health of Ukraine assisted by UNICEF,
           Preventing HIV Transmission from Mother to Child: A
           Textbook [Предупреждение трансмиссии ВИЧ от
           матери ребенку. Учебное пособие], 2003.
     49.   FHI, 2001, op. cit.
     50.   MOH of Ukraine, 2001, op. cit.




50            Preventing Mother-to-Child Transmission of HIV           Counseling and Testing Procedures                                  51
                                             Additional Reading



     ADDITIONAL READING
     Family Planning Guide [Руководство по планированию
     семьи], I.B. Vovk and N.N. Nizova, eds. (Kiev, 1998).

     A Guide to the Clinical Care of Women with HIV [Руководство
     по медицинской помощи ВИЧ-инфици-ро-ван-ным                      Appendix 1: Counseling
     женщинам], J.R. Anderson, ed., 2001 edition (published by
     AIHA in Russian), 2003.                                          and Testing Protocol
     M. Moore, “A Behavior Change Perspective on Integrating
     PMTCT and Safe Motherhood Programs: A Discussion Paper,”
     The CHANGE Project, March 2003.
                                                                                                COUNSELING AND TESTING PROTOCOL
     K. Meursing, A World of Silence: Living with HIV in Matabele-
     land, Zimbabwe [Слово молчания. Жизнь с ВИЧ в Мета-              Activity                    Description
     беле-ланде, Зимбабве] (Royal Tropical Institute, Netherlands,    Pre-test group              Address the following issues
     1997).                                                           counseling—                 • Behavior associated with high risk of infection; arguments in favor
                                                                      adaptable to condi-           of HIV testing
     PAHO, UNAIDS, IAPAC, Building Blocks: Proceedings of the
                                                                      tions at institutions       •   HIV transmission routes, preventive measures, description of testing
     Consultations on Standards of Care for Persons Living with
                                                                      where C&T will be               procedure
     HIV/AIDS in the Americas, June 2000.
                                                                      carried out in:
                                                                                                  •   Consequences of learning HIV status for future life
     R. Baggaley et al., “HIV Counselors’ Knowledge and Attitudes     • women’s clinics
                                                                                                  •   Testing is voluntary and free
     and Vulnerabilities to HI,” [Знания и установки                  •   tuberculosis, drug,
     консультантов по ВИЧ и уязвимость к ВИЧ], AIDS Care 8,               or STD clinics          •   Test results are confidential
     pp. 155-166 (1996).                                              •   prison hospitals        •   Procedures for obtaining informed consent and receiving test results
                                                                      •   as part of              •   Active prevention of HIV transmission
     E. Israel and M. Kroeger, “Integrating Prevention of Mother-
     To-Child HIV Transmission into Existing Maternal, Child, and         various initiatives     •   Use of condoms to prevent transmission to partner(s)
     Productive Health Programs,” Pathfinder International 3, Janu-                               •   Harm reduction programs for IDUs
     ary 2003.                                                                                        (for example, needle exchange)
                                                                                                  •   Possibilities for HIV-positive persons to obtain medical care and
     S. Kalibala, Research, Interventions and Current Issues in                                       psychosocial support
     Burnout and Response in Health Workers and AIDS [Исследова-                                  •   Where to find more detailed information and possibilities for
     ния, программы и текущие вопросы по проблеме «сгорания»,                                         obtaining individual counseling on matters related to HIV
     возможности решения], L. Bennett et al., eds. (Hardwood
     Academic Publishers, Switzerland, 1995).                         Individual pre-test         Address the following issues
                                                                      counseling                  • Behavior associated with high risk of infection; arguments in favor
                                                                                                    of HIV testing
                                                                                                  •   HIV transmission routes, preventive measures, description of testing
                                                                                                      procedure, meaning of positive and negative test results, “window”
                                                                                                      period, etc.
                                                                                                  •   Consequences of learning HIV status for patient’s future life, practical
                                                                                                      conclusions; patient’s ability to cope with news of a positive result
                                                                                                  •   Assessment of risk of adverse consequences of a positive test result
                                                                                                      (suicide, violence inflicted by others on self or friends/family), past
                                                                                                      autoaggressive acts, psychiatric history




52            Preventing Mother-to-Child Transmission of HIV          Counseling and Testing Procedures                                                                         53
                                                                                             Appendix 1         Counseling and Testing Protocol


Individual pre-test         •   Testing is voluntary and free                                                   their HIV status. This      •   Discuss immediate plans, intentions, and actions with the patient; take
counseling                  •   Test results are confidential                                                   topic should be given           necessary steps if signs are unfavorable.
continued                                                                                                       special attention and       •   Schedule a follow-up counseling session with a specific counselor in 3
                            •   Explanation of the test
                                                                                                                be the subject of a             days (or sooner if indicated).
                            •   Procedures for obtaining informed consent and receiving test results            second post-testing
                            •   Active prevention of HIV transmission
                                                                                                                                            •   Where possible, help the patient implement a risk-reduction plan
                                                                                                                counseling session if
                                                                                                                                                (dispense condoms, needles, etc.).
                            •   Use of condoms to prevent transmitting HIV to partner(s)                        possible.
                            •   Harm reduction programs for IDUs (for example, needle exchange)
                                                                                                                Post-test counseling:       •   Communicate the test result in simple and understandable language.
                            •   Possibilities for HIV-positive persons to obtain medical care and               NEGATIVE test result
                                psychosocial support
                                                                                                                                            •   Wait for the patient to acknowledge the test result.

                            •                                                                                                               •   Make sure the patient has understood the test result.
                                Referral to STI or tuberculosis clinic, if needed                               Note: With a negative
                            •   Where to find more detailed information and possibilities for obtain-           test result, it is impor-   •   Help the patient cope with his/her emotional reaction (see “Risk
                                                                                                                tant to discuss steps           assessment and warning of negative consequences”).
                                ing individual counseling on matters related to HIV infection
                                                                                                                for reducing the risk of    •   Discuss the meaning of the test result for the patient.
Obtaining informed          •   Give the patient time to think through issues addressed in counseling.          infection. This may re-     •   Discuss the consequences for personal life and family and social
consent                     •   Check how well the patient understands the information provided and             quire further counsel-          relationships.
                                correct any misunderstandings.                                                  ing about safe behav-       •   Discuss whom the patient can tell of his/her status and when.
                            •   Ask the patient whether he/she consents to undergo testing.                     iors or referral to
                                                                                                                                            •   Chart an individual risk-reduction plan, stress the importance of
                                                                                                                other services that
                            •   Have patient complete and sign informed consent form.                                                           prevention, including steps to reduce harm (needle or hypodermic
                                                                                                                help individuals
                                                                                                                                                exchange, substitute drug treatment), and the need for safe sex and the
Referral for testing        Perform testing in accordance with the algorithm shown in Append. 3, p.58.          change their lifestyles
                                                                                                                                                use of condoms.
                                                                                                                and lower risk
Post-test counseling:       •   Communicate the test result in simple and understandable language.                                          •   Discuss the patient’s future medical care and psychosocial assistance,
POSITIVE test result                                                                                                                            including referrals to appropriate institutions (based on relative or
                            •   Wait for the patient to acknowledge the test result.
                                                                                                                                                absolute indications), especially aimed at reducing the future risk of
                            •   Make sure the patient has understood the test result.                                                           infection.
Note: The list of topics
that should be dis-         •   Help the patient cope with his/her emotional reaction (see “Risk                                            •   Chart a plan of actions for the immediate future.
cussed with patients            assessment and warning of negative consequences”).
                                                                                                                                            •   If indicated, schedule a follow-up counseling session and/or retesting
with positive and           •   Discuss the meaning of the test result for the patient.                                                         for HIV in 3 months.
negative test results is    •   Discuss the consequences for personal life and family and social                                            •   Where possible, help the patient implement a risk-reduction plan
practically identical,          relationships.                                                                                                  (dispense condoms, needles, etc.).
but patients with posi-     •   Discuss whom and when the patient can tell about his/her HIV status;
tive test results usually
                                                                                                                                            •   If necessary, refer the patient to an STI or TB clinic.
                                advise the patient not to tell anyone immediately except those closest
require more detailed           to him/her (spouse or other very close person).                                 Risk assessment and         •   During post-test counseling and beginning with communication of
discussion of the                                                                                               warning of negative
                            •   Chart an individual risk reduction plan, stress the importance of                                               the test result, the counselor must assess the risk of adverse conse-
situation and additional                                                                                        consequences                    quences occurring when the patient learns their HIV status. This in-
                                prevention, including steps to reduce harm (needle or hypodermic
support and counseling                                                                                                                          cludes the danger of suicide (cf. Appendix 2, “Suicide Risk Factors”
                                exchange, substitute drug treatment), and the need for safe sex and the
in the future, especially                                                                                                                       pg.57), depression, and aggression. The goal is to help the patient
                                use of condoms.
in the first days after                                                                                                                         minimize any negative consequences between themselves and their
receiving the test          •   Determine whether the patient has the necessary support during the
                                period immediately after leaving the institution: Does he/she have                                              partner and/or family.
results.
                                anyone close at home or nearby?                                                                             •   Explore which members of the patient’s family or social group can
                            •   Discuss procedure for obtaining medical care and psychosocial assis-                                            provide support.
HIV-positive
individuals are                 tance, give referrals to appropriate institutions (all patients with positive                               •   Explain that the patient needs help to cope with the adverse conse-
especially concerned            test results should be sent for medical screening, and where indicated, to                                      quences of learning his/her HIV status, and offer the assistance of a
about disclosure of             an STI or TB clinic, family planning service, polyclinic, etc.).                                                psychologist or psychiatrist.




54                                                Preventing Mother-to-Child Transmission of HIV                Counseling and Testing Procedures                                                                   55
                                                                                             Appendix 1


Referral for further           •   All patients with positive test results must be referred to a doctor
screening, treatment,              for further screening and treatment.
and psycho-social              •   All patients with positive test results must be referred to organiza-
support                            tions that provide psychosocial support; for example, NGOs, social
                                   services, etc.
                               •   The patient must be given further counseling at the same or
                                   another institution, depending on the circumstances.
                                                                                                             Appendix 2: Sucide Risk
                               •   If the patient is unable to cope with the news of his/her HIV
                                   status, the patient should be referred for appropriate services
                                                                                                             Factors
                                   (for example, a psychiatrist or a social worker).
Source: WHO HIV/AIDS Treatment and Care Protocols for Countries of the Commonwealth of Independent States,
Aug. 2003.

                                                                                                                 Individual and Social Factors
                                                                                                                 • Age: women under 35, men under 40            • Living alone and/or social isolation
                                                                                                                 • Threat of loss of someone close              • Financial troubles or poverty
                                                                                                                 • Recently diagnosed with a serious illness or poor health
                                                                                                                 • Recent breakup with spouse, divorce, or severe loss
                                                                                                                 • Living in a poor city neighborhood or resort/seasonal area

                                                                                                                 Occupational Factors
                                                                                                                 • Recent job loss or retirement                           • High social status (doctor, dentist, lawyer)
                                                                                                                 • Student

                                                                                                                 Events
                                                                                                                 • Severe loss or recent major falling out/breakup with family or friends
                                                                                                                 • Job loss
                                                                                                                 • Inability to continue familiar life because of diagnosis of fatal disease or terminal stage of
                                                                                                                    illness
                                                                                                                 • Family and social consequence of alcohol or drug dependence

                                                                                                                 Mental Health
                                                                                                                 • Depression (especially endogenous, prolonged, and recurrent) or mania
                                                                                                                 • Alcohol or drug dependence
                                                                                                                 • Mental disorders or organic injuries to the brain (especially in epilepsy and craniocerebral
                                                                                                                    trauma), early dementia, and senility

                                                                                                                 History
                                                                                                                 • Past suicide attempts (especially using active violent methods and/or in the past 12
                                                                                                                    months)
                                                                                                                 • History of affective disorders
                                                                                                                 • Family history of affective disorders, suicide attempts, or alcoholism

                                                                                                                 Suicidal Behavior
                                                                                                                 • Hinting at or discussing the possibility of suicide
                                                                                                                 • Preparations for suicide (selecting a method and preparing to implement it, writing a will
                                                                                                                    or suicide note, life insurance)



                                                                                                                 Source: WHO HIV/AIDS Treatment and Care Protocols for Countries of the Commonwealth of Independent States, Aug. 2003.




56                                                Preventing Mother-to-Child Transmission of HIV             Counseling and Testing Procedures                                                                                           57
Appendix 3: HIV
Screening Procedures

See chart on following page.




Counseling and Testing Procedures   59
                                                                                                                Appendix 3



                               HIV SCREENING PROCEDURE AND
                                 INTERPRETATION OF RESULTS
                             (including additional or diagnosis-confirming tests)


        First Test (screening)                                                     Negative Result                           Appendix 4: Informed
       High sensitivity and specificity
                                                                                                                             Consent Form
                                                                       ❙   Release test result

              Positive Result                                          ❙   Perform post-test counseling,
                                                                           including explanation of the
                                                                           possibility of a “window” period,
                                                                           and suggest repeating the test in 3                                                   CONSENT TO HIV TESTING
                                                                           months.
     Second (Additional) Test                                          ❙   Discuss steps to prevent HIV infection
                                                                                                                                   I hereby certify that I, the undersigned, am _______ years of age.
    High sensitivity and specificity.Test
   must be performed either by another                                                                                              I contacted this institution for HIV testing and counseling voluntarily, in order to
    method or with another specimen                                                                                              undergo HIV testing. By this statement I affirm my wish and I direct the Center to take
                                                                                     Positive Result
   (a second rapid test can be done).                                                                                            a specimen of my blood (urine, saliva) and study it for HIV.
                                                                                                                                    I confirm that the numbers of my blood (urine, saliva) specimens taken agree with
                                                                                                                                 the numbers listed on my registration card.
                                                                       ❙   Release test result
                                                                                                                                   I confirm that I have also received information about:
                                                                       ❙   Perform post-test counseling,
                                                                                                                                       •    the goals and procedure of HIV testing; and
             Negative Result                                               including discussion of preventive
                                                                                                                                       •    steps to prevent HIV infection and transmission.
                                                                           measures and ways of obtaining
                                                                           medical care and other forms of                          I have also received counseling regarding additional steps I should take depend-
                                                                           assistance and support                                ing on whether my test result is positive or negative.
                   Third Test
   (to confirm diagnosis when prior                                    ❙   Give referrals to appropriate                           I have been advised of my right to refuse to receive the test results.
         test results disagree)                                            institutions and organizations for
                                                                                                                                    I hereby declare that I will not make any claims directly or indirectly related to
 When results disagree, the express                                        assistance and support
                                                                                                                                 the test results against the institution performing the test, against its personnel or
 test can be repeated, or a blood
                                                                                                                                 representatives, or against other parties participating in the provision of HIV testing
 specimen can be sent to a control
 laboratory.                                                                                                                     and counseling, including charges for reporting false-positive or false-negative test
                                                                                   Negative Result                               results.
                                                                                                                                   I permit the Center to perform retesting for verification of my HIV status; the
                                                                                                                                 decision as to the necessity for retesting shall remain at the Center’s discretion.
                                                                       If the first test result is positive, and
                                                                       the second and third are negative,
                                                                       the result of the HIV examination is                        Signature of patient                               Date
                                                                       considered negative.

                                                                                                                                   Signature of witness                               Date
Source: WHO HIV/AIDS Treatment and Care Protocols for Countries of the Commonwealth of Independent States, Aug. 2003.




60                                                          Preventing Mother-to-Child Transmission of HIV                   Counseling and Testing Procedures                                                             61
American International Health Alliance
           aiha@aiha.com
           www.aiha.com

				
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