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Program Areas

5 Voluntary counseling and testing
Description:  
Goals: Voluntary counselling and HIV testing (VCT) is becoming an increasingly important area of HIV prevention and care programming. People who have chosen to be counselled and then have gone on to have an HIV test have, in limited studies, registered some behaviour change that should contribute to lower rates of HIV spread. The ready availability of VCT services is also thought to be a factor in reducing stigma surrounding HIV and in encouraging community support and care for those affected. Perhaps most importantly, VCT services are an essential early entry point to social support services and medical and associated care for those infected with HIV, where these services exist.

Many national AIDS programmes are trying to increase the availability and quality of counselling and of testing services by supporting the training of counsellors and providing necessary inputs such as test kits.

In countries where efforts are being made to reduce transmission of HIV from mother to child, there is a special interest in the counselling and voluntary testing of pregnant women. This area of VCT programming is dealt with in the section on mother to child transmission. 

Key Questions: Is there a national policy to provide HIV testing and counseling in all districts?
Are voluntary HIV counselling and testing services widely available?
Do they have the resources needed (staff, space, systems) to function as planned?
Are they providing quality services? 
Challenges: In counselling--perhaps more than in any other area of service provision--service quality determines the outcome. Poor quality counselling can result in misunderstanding and even resistance to change, and circumstantial evidence suggests that poor counselling is not uncommon. But measuring quality of counselling is exceptionally difficult. Because confidentiality is a critical element of VCT, observational studies are difficult, though by no means impossible.

Mystery patient studies and exit interviews with clients are possibilities for assessing the quality of counselling; mystery clients in particular could help avoid some inherent problems of observation. For example, providers/counsellors may not provide the same level or type of counselling when being observed as they do in a normal routine. When using mystery clients to assess quality of counselling, mystery clients should undergo training and have ongoing support and feedback. In addition, mystery clients should be used according to the same guidelines used in sexually transmitted infection evaluation, e.g., the clinic is notified and agrees to having mystery clients over a certain defined time period. Finally, observations of the mystery clients should be used for improving counsellor work, but not for punitive measures and this should be stressed to the participating sites, managers and providers.

Issues of confidentiality also complicate other outcome and impact measures, such as the proportion of those testing positive who are adequately referred to care and support service, and who receive such care and support.

Special studies have followed up former clients to determine the extent of behaviour change. These studies are prone to bias introduced by loss to follow-up and are complex to carry out. They are unlikely to form part of a regular monitoring and evaluation system.

Demand for HIV testing is hard to measure. Survey questions asking about willingness to be tested typically get very high positive response rates. Yet when free counselling and testing is offered in the same populations, uptake is typically very low. The only reliable measures of demand are those based on uptake, and these will of course be biased by supply, by perceptions about confidentiality and the quality of counselling, and by services available to (or, conversely, the degree of stigma likely to be encountered by) those testing positive.

Another difficulty in evaluating progress in the provision of quality VCT is deciding which service providers should be included in an assessment. While an increasing number of countries have special centres dedicated exclusively to counselling and testing for HIV, a high proportion of tests take place in private clinics or doctors' surgeries. The fact that tests are proposed for diagnostic purposes does not diminish the need for pre- and post-test counselling, confidentiality and other elements of quality service provision. 


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