HCT Policy Guideline Orientation

Policy Vision, Mission and Aims of HCT

Short description: This document discusses the new HCT policy, covering diffirent topics such as Policy Vision, Mission and Aims. It gives guidelines on HCT.  The objectives of this policy guideline are to:

Find this document attached below (PPT)

National Guidelines for HIV Counseling and Testing in Clinical Settings

Subtitle: Provider initiated counseling and testing.

Abstract: This document discusses PICT. PICT Objectives includes to assist HCP to expand quality HCT services in clinical settings to reduce the impact of HIV among individuals, families and communities by reducing HIV transmission. People intended to use these guidelines include:

National Guidelines for Implementation of Home-based HIV Counselling and Testing (HBHCT) in South Africa

Department of Health of the Republic of South Africa

September 2010

This guideline provides guidance on the implementation of HBHCT and all implementers are urged to adhere to them in order to facilitate common understanding, effective implementation and support for all implementers.

The purpose of these guidelines is to provide national standards that will guide all institutions, organizations and individuals in the provision of high quality home-based HCT

See this document attached below (Doc, 31pg)

National Implementation Guidelines on Provider Initiated Counselling and Testing (PICT)

Department of Health of the Republic of South Africa

September 2010

In order to guide the national response to HIV and AIDS pandemic, the South African Government develops the HIV & AIDS and STI National Strategic Plan (NSP). The two main targets in the latest NSP (2007 – 2011) are:

This guideline provides guidance on the implementation of Provider Initiated Counselling and Testing in all province

See this document attached below (Doc, 43pg)

Policy Statement on HIV Testing and Counselling in Health Facilities for Refugees

This policy statement examines the role of HIV testing and counselling in health facilities in increasing access to HIV prevention, treatment, care and support services for refugees, internally displaced persons (IDPs) and other persons of concern to UNHCR. It also identifies specific issues regarding HIV testing and counselling amongst these populations as well as makes recommendations for future action.

© UNHCR, 2009. All rights reserved.

To download this document, click here (pdf, 805.89 KB, 21 pg)

Quality Assurance Guidelines

Simple HIV tests present unique challenges

Subtitle: Q.A on Rapid HIV Testing

Abstract: These simple HIV tests present unique challenges – testing is often performed by persons without formal laboratory training, there is no residual sample that can be checked or re-tested, conventional quality control methods cannot be used, and there are special problems associated with efforts to provide conventional external quality assessments (e.g. proficiency testing)

Please find the document attached below (PPT)

Regional Minimum Standards for Harmonised Guidance on HIV Testing and Counselling (HTC) in the SADC Region

The review notes modest achievements in priority areas

Published by SADC August 2009

The SADC region bears the brunt of the HIV and AIDS epidemic, which is diverse with varying levels of adult HIV prevalence fuelled by behavioural, social, cultural, biomedical and economic factors. HIV remains the leading cause of morbidity and mortality in the region.

SADC Heads of State and government made several commitments to fight the HIV and AIDS epidemic and other communicable diseases through the Maseru Declaration and other global commitments such as the Abuja Declaration, Maputo Declaration 2005, Brazzaville Commitment 2006 and Millenium Development Goals. Additionally, in order to implement some of the commitments, the SADC region developed the SADC Regional Prevention Strategy and Action plan to support Member States’ efforts to significantly reduce the incidence of new HIV infections with the ultimate aim of declining prevalence.

The review notes modest achievements in priority areas of prevention of mother-to-child transmission of HIV (PMTCT), condom use, management of sexually transmitted infections (STI), HIV testing and behaviour change which have not been sufficient to reduce the incidence enough to turn back the epidemic.

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The VCT experience: The psychology of HIV testing in sub-Saharan Africa. 16/2/11

Among the interventions which play a pivotal role both in treatment and in prevention, HIV testing and counselling stands out as paramount.

CAI - Consultancy Africa Intelligence

HIV & AIDS have ravaged the African continent. Worldwide, approximately 68% of individuals infected with HIV have been identified as originating within sub-Saharan Africa.(2) Above this, current estimates suggest that 72% of the 1.8 million deaths occurring due to HIV & AIDS-related causes in 2009 were Africans.(3)

Among the key interventions identified internationally for curbing the spread of HIV & AIDS is voluntary counselling and testing (VCT). A Policy Statement on HIV Testing released by the Joint United Nations Programme on HIV & AIDS (UNAIDS) and the World Health Organisation (WHO) states: “Without effective HIV prevention, there will be an ever-increasing number of people who will require HIV treatment. Among the interventions which play a pivotal role both in treatment and in prevention, HIV testing and counselling stands out as paramount.”(4) In fact, VCT has been consistently promoted by both organisations as a routine and essential part of HIV testing in developing countries.(5)

Any individual who seeks to know their HIV serostatus will ideally undergo this process, expanded upon in the paper which follows. The experience of learning one’s serostatus is widely accepted to be psychologically taxing, with possible implications for the mental health of the presenting client. Conversely, and of equal importance, is the ability of the counsellor to provide a psychologically supportive environment in which the diagnosis may be received. This paper therefore serves to explore the tenuous nature of the HIV testing process. Despite its touted importance and effectiveness as a means to combat the spread of HIV & AIDS, it remains a psychologically threatening process for many, and this may continue to hamper the potential efficacy of this critical point of intervention.

VCT in sub-Saharan Africa

According to a 2010 progress report released by the United Nations Children’s Fund (UNICEF), UNAIDS and the WHO, the median percentage of people in sub-Saharan African living with HIV who are aware of their serostatus is below 40%.(6) Further, the report suggests that at present, “considerable gaps remain between testing and counselling needs and existing practices.”(7) These ‘gaps’ highlight deficiencies in the capacity for care in this region, and call attention to the need for policy and practice to be revised accordingly.

Examining the availability of testing services of approximately 40 countries in sub-Saharan Africa, the median number of facilities per 100,000 members of the population improved from 5.9 in 2008 to 8.4 in 2009, while the median number of tests per 1,000 members of the adult population improved from 58 to 66.(8) These figures suggest an increasing availability and uptake of testing services throughout the region.

Despite these improvements, however, the number of people who have never been tested for or know their serostatus continues to outweigh those who do. There are a number of possible reasons why these figures are low, ranging from socio-culturally based motivations to individual anxieties and concerns around the testing process. It is also likely that it is a combination of these factors that presents barriers to an individual’s willingness to test. It is therefore important to consider the nature of the counselling and testing experience as experienced by the client.

Voluntary counselling and testing

Voluntary counselling and testing represents, as mentioned, a core intervention against the spread of HIV. Procedurally, it is composed of three key segments: pre-test counselling, the HIV test, and post-test counselling. The review which follows is based on WHO regulations and guidelines, as they appear in the Voluntary HIV counselling and testing: Manual for training of trainers,(9) as well as the manual titled Guidance on provider-initiated HIV testing and counselling in health facilities.(10)

The initial intake session aims to assess the client’s motivation for finding out his or her serostatus. The counsellor will assess the client’s current risk behaviour profile and advise him or her accordingly. This establishes the basis from which the client must now decide whether to seek testing or not. Ethically, one of the central tenets of this process is that the client must elect to undergo the HIV test. After being given appropriate time to consider, should the client decide to undergo the test, the pre-test counselling session will also entail talking with the client about the potential outcomes of the test, and appropriate coping strategies to apply in these instances.

Most testing centres employ a rapid HIV test. Once the results of the test have been obtained, the presenting client will enter into a post-test counselling session –with his or her consent– to receive the results of the test. The content of this session will be determined by the serostatus diagnosis of the client. Should the client obtain a diagnosis of being HIV-negative, the counsellor will discuss with the client his or her feelings, as well as the importance of appropriate lifestyle choices to maintain this state. Additionally clients will be reminded of the window period, during which one may be infected but testing will not yet be able to detect the presence of the virus.

Should the test return an HIV-positive diagnosis, the counselling session will involve a number of aspects. Primarily, the counselling session will focus on the emotional content of the diagnostic experience. It is the responsibility of the counsellor to ensure that the news is received in a safe and sensitive environment. The client’s coping skills and support systems will be assessed as it is crucial to ensure that he or she is equipped with the necessary resources to adjust to the diagnosis. Counsellors will also focus on how to make appropriate and reasonable plans for the client’s now altered future. These discussions will include the necessity to seek and establish an appropriate treatment regime based on the client’s particular profile. Also of crucial importance is encouraging the client to share his or her diagnosis with present as well as past sexual partners. In some instances the opportunity for ongoing counselling will be made available to clients.

Implicit in this discussion is the fact that both pre- and post-test counselling sessions must proceed with sensitivity and caution, and require some therapeutic micro-skills on the part of the counsellor. If one examines training materials and VCT guidelines, these skills are often identified to include verbal and non-verbal behaviour. The former is composed of types of questions, appropriate phrasing, and language sensitivity, as well as active listening to allow for thoughtful and insightful reflection. The latter is characterised by appropriate body language (including body orientation, eye-contact, gestures and facial expressions) and paralinguistic cues (including voice pitch, volume and fluency). These skills are employed by the counsellor to put the client at ease, and to optimise the efficiency of any session. Additionally, counsellors must be contextually sensitive–particularly in a region characterised by its crucible of cultures, each with its own specific dictates surrounding the norms and dynamics of interpersonal and therapeutic interactions.

The counselling and testing experience

Having acknowledged the importance of VCT in encouraging individuals to test for HIV as well as its potential to facilitate the process of discovery, one must acknowledge that in order to initiate this process an individual needs to make the conscious decision to find out his or her diagnosis. In order to do this, a supportive environment must exist which would allow for the individual to feel safe and comfortable in the decision to test.

Research has shown that the diagnostic testing procedure and receiving the test results are associated with moderate to intense levels of anxiety and distress for the client.(11) One prominent issue here is that of stigma. Stigma represents a considerable threat both to people who are concerned about their statuses and to those living with HIV & AIDS.(12) A study conducted at a South African university revealed that while the main benefit of VCT was seen to be ‘knowing your status’ the main barriers were described as a fear of being stigmatised and a fear of being diagnosed HIV positive.(13) Further, the study showed that AIDS-related stigma was attributed to three main factors–a lack of HIV & AIDS related knowledge, the life-threatening character of the disease, and blaming those who have contracted the virus for their infection.(14) Despite the considerable advances which have been achieved in the options available for care for those living with the virus, interpersonal, communal, and societal-based discrimination remains rife. At a psychological level (as well as social and communal levels) this stigma represents a considerable barrier even before the process has begun.(15)

Another important factor to consider in terms of the psychological components of the testing experience is the fact that although HIV has come to be conceptualised as a chronic illness, at a more intimate level, as well as within certain culture-bound settings, a diagnosis as HIV positive is still strongly associated with a death sentence.(16) Of concern is the fact that it has been suggested that even certain health care professionals continue to view the diagnosis in this way.(17) The notion of an HIV diagnosis as a ‘death sentence’ can have adverse implications for healthcare. Firstly, the possibility of receiving such a decree may act as a deterrent from presentation for testing. Fear of psycho-social abandonment as a result of one’s diagnosis presents a significant barrier in such instances. Secondly, should one receive a diagnosis of a positive serostatus, the experience can be regarded as emotionally traumatic. On receiving a positive diagnosis, the client will likely undergo a paradigm shift in terms of their self-concept and experience concern and fear regarding their future and prognosis.

Addressing this shift, Stevens and Doerr, in their exploration of the narratives of women who had been diagnosed with HIV, described how each participant referred to the traumatic nature of the diagnosis.(18) Their report highlighted the sense of ‘imminent demise’ and helplessness with which these individuals reported being faced.

Notably, Olley, Zeier, Seedat and Stein have described how recently-diagnosed patients may present with symptoms indicative of Post-traumatic Stress Disorder as a result of the acutely traumatic event of being diagnosed as HIV& AIDS positive.(19) They note how when infected individuals receive their serostatus diagnosis they may experience intrusive and recurrent thoughts or dreams of illness and death, and in addition may also avoid people, activities and places that serve as reminders of the illness.(20) The capacity of the event to affect the psyche in this way highlights the potential influence on the mental health of any presenting client.

Post-test counselling, as well as long-term counselling or support-group meetings must be sure to take cognisance of this inherent trauma, and the emotional consequences of the diagnostic experience. Counsellors are charged with the responsibility of imparting appropriate information and skills to clients to ensure that they are able to cope, both physically and psychologically, with the consequences of diagnosis.(21) Coping skills, available support networks and services are therefore core components of HIV-specific counselling sessions.

Concluding remarks

It is clear that at each stage of the VCT process the adoption of a psychological lens adds depth to an understanding of the efficacy of the intervention. Whether it is the micro-skills necessary to facilitate the session on the part of the counsellor, or the fears, concerns and emotional complexities of the decision to test and the diagnosis of the client’s serostatus, sensitivity to these aspects must be shown at all times. To present for testing suggests that one is already intimately associated with the nature of infection with HIV & AIDS. The psychological journey undertaken when choosing to test is by its nature complex and extremely sensitive.  This paper therefore contends that it is imperative that an empathetic and psychologically supportive environment be established as core components of the VCT experience.

With the incidence of HIV & AIDS rife in sub-Saharan Africa, it is critical the VCT service be seen to be a psychologically safe and supportive one, in order to ensure an optimal opportunity to effective intervention. Willingness to test is impacted by such factors as a fear of stigmatisation, discrimination and blame for the need to test, let alone a positive diagnosis. Thus by adopting the lens described, and allowing it to inform the process of intervention, as well as advocacy and information dissemination around this important topic, this service will be increasingly able to reach its maximum potential.

Why Test?

HIV testing, or VCT (Voluntary Counselling and Testing), is something we often hear and read about. The reactions you hear from people about VCT differ widely.

Some of the reactions are:

How should we look at all these different viewpoints? Not one of these statements are scientifically accurate, or the most healthy way to look at the matter.

HIV and AIDS affect us all. If you are sexually active, your partner may place you at risk. This may also happen if you are faithful. More than 70% of HIV+ women in Africa are in a relationship where they are faithful to one partner. You may even be at risk through contact with blood of a HIV+ person. If you are not at risk, being tested may help others. If testing becomes routine and commonplace, it will help break down the stigma of HIV.

If you are HIV positive, practising safe sex will protect present and future partners from HIV. If you are pregnant and HIV positive, you can take measures that may help protect your unborn baby from being infected. If you are HIV negative, you can protect yourself and stay that way.

Although the HI-virus can not be destroyed, being HIV positive is not the end of your life. By living a healthy lifestyle you can strengthen your immune system. This includes diet, exercise, good sleeping patterns, stress management, getting emotional support and avoiding other infections. If your immune system becomes weaker, antiretroviral medication is available to suppress the virus. You may also qualify for certain government grants to help you financially. If treatment is unsuccessful, knowing this may give you and your family the opportunity to make important arrangements about your children and your belongings.

Some persons (especially women) do not have the power to say no to husbands or partners, or may even be raped. In this situation, knowing your status means that you can do everything possible to keep yourself healthy, and to protect others.

We do not like to think about unpleasant things such as HIV and getting ill, maybe even dying. If you live in an ethical and responsible manner, it is your responsibility to think about, and make a decision about, testing for HIV.

Written for The Communicator, Staff Newsletter of the Trans 50 organisation, by Lyn van Rooyen on 20/04/2005

HIV Testing and Counseling: New Guidance. 30 May 2007.

WHO and UNAIDS issued new guidance on informed, voluntary HIV testing and counselling in health facilities on Wednesday 30 May, with a view to increase access to needed HIV treatment, care, support and HIV prevention services. The new guidance focuses on provider-initiated HIV testing and counselling (PICT). The complete document is large (2.78MB) and can be downloaded here or you can the executive summary.

HIV Counseling and Testing for Youth: A Manual for Providers. 2005

Family Health International. This manual is designed for service providers and counselors working with youth. Approximately one-third of clients who seek HIV testing are youth, and these young people often have different needs than do adults. With this easy-to-use, spiral-bound booklet, service providers and counselors can improve their skills and assist youth with the difficult issue of HIV counseling and testing. The tool emphasizes integrated services with handy references and charts on contraceptives, other STIs, youth-friendly services, and other information. Download full manual or in sections( 88p, 559 KB)

Horizons Report, Examine HIV Testing From Different Angles.

This issue of Horizons Report, the biannual newsletter of the Horizons Program, examines HIV testing from different angles, drawing from relevant studies in several countries. These include the readiness of health workers in Kenya to provide routine HIV testing, and the effectiveness of workplace VCT programs in Kenya and Zambia to reach health workers and teachers. The issue also describes strategies for increasing uptake of testing by truckers in Brazil and the role of families in youths' decision-making to get tested for HIV in Zambia. Download

Let's Talk About HIV Counselling and Testing - Facilitators' Guide.

Tools to build NGO/CBO capacity to mobilise communities for HIV counselling and testing. (International HIV/AIDS Alliance International HIV/AIDS Alliance) This toolkit is designed to help NGOs, CBOs and other civil society organisations responding to HIV/AIDS in developing countries increase their knowledge and improve the quality of their work onHIV counselling and testing. It has eight sections covering different aspects of HIV counselling and testing. Each section begins by providing essential information comprising key definitions, concepts and messages after which participatory activities are presented for carrying out with NGO/CBO staff. Download PDF (428KB).

Let’s Talk About Voluntary HIV Counselling and Testing.

International HIV/AIDS Alliance. Has ten sections covering different aspects of voluntary HIV counselling and testing. Each section begins by providing essential information comprising key definitions, concepts and messages after which participatory activities are presented for carrying out with NGO/CBO staff. Download (337kb).

Models for HIV Testing.

The traditional focus internationally was on VCT - voluntary testing.

* The South African Guidelines on operating a VCT service is available here (Document incomplete) (100KB)

The move in many circles now seems to be towards Routine opt-out testing; a model of HIV testing and counselling that makes the HIV test a routine part of medical care in countries. A number of article on this topic can be found:

* One of the strong South African advocates is Judge Cameron. An article from PlusNews is available here (35KB)

* Read a news article about "Testing stigma" from AEGIS

* A more scientific article on "Changing the Paradigm for HIV Testing" can be found here.(76KB)

* The newest recommendations from the CDC can be downloaded (251 KB)

* A comprehensive article with a note of caution about some of the challenges of this model can be found in this article (85.0 KB) reporting on the 2006 PEPFAR Meeting

* An individual living with HIV shares his concern in the PositvelyAware Journal.

* "WHO/UNAIDS endorse opt-out HIV testing" -read this AIDSMAP article published on 30 May 2007. The complete guidelines are available here.

The last option is compulsory testing. Other than in selected cases (eg " to protect victims of crime, emergency service workers and persons who provide emergency first aid") this is mostly frowned on in Human Rights circles, although it is legal in countries like Hungary and suggested by people like Bill Clinton as a solution. Read more about Mr Clinton's view here.

Routine Opt-Out Testing.

A model of HIV testing and counselling that makes the HIV test a routine part of medical care in countries. A number of article on this topic can be found:

A comprehensive article with a note of caution about some of the challenges of this model can be found in this article(85.0 KB) reporting on the 2006 PEPFAR Meeting.

A more scientific article on "Changing the Paradigm for HIV Testing" can be found here.(76KB)

An individual living with HIV shares his concern in the PositvelyAware Journal.

The recommendations from the CDC can be downloaded (251 KB).

One of the strong South African advocates is Judge Cameron. An article from PlusNews is available here (35KB).

Read a news article about "Testing stigma" from AEGIS.

"WHO/UNAIDS endorse opt-out HIV testing" - read this AIDSMAP article published on 30 May 2007. The complete guidelines are available here.

South African Guidelines on operating a VCT.

The South African Guidelines on operating a VCT service is available here (Document incomplete) (100KB).

Call for Home Testing for HIV. 1/11/10

Home HIV testing kits should be made widely available in South Africa

Home HIV testing kits should be made widely available in South Africa, three Aids experts have urged in the latest issue of the SA Medical Journal.

Laws and policies should be changed to pave the way for the kits' distribution, said Wits University academics Marlise Richter and Dr Francois Venter, and Andy Gray, a senior lecturer at the University of KwaZulu-Natal's medical school.

"South Africa has reached a point in its Aids epidemic where individuals should be able to decide when and where they would like to test for HIV, and do so without having to involve anyone else," they said.

They said the SA Medical Association (Sama) earlier this year warned the public against HIV self-testing kits.

Sama had said it was risky for patients to test themselves "unmonitored", and warned this could lead to patients committing suicide. The warning had been echoed by the national department of health and the Treatment Action Campaign.

The three experts said however the same objections would apply to any medical self test, including the existing test for type 1 diabetes, which had been a certain death sentence before there was widespread access to insulin.

"The arguments against self-testing are largely based on vague fears with little or no evidence to support them," they said.

"It would seem sensible to provide increased access to HIV testing in a facilitatory way, encouraging people to access care in a way that suits them, rather than based on a model that encourages unnecessary 'Aids exceptionalism' and fear-mongering."

They said it seemed that at present there was no legal impediment to supermarkets selling HIV testing kits, but that pharmacists were prevented by their code of practice from stocking them. There was no mechanism to regulate the quality and reliability of any self-tests, a matter which should be addressed urgently.

Centre for HIV/AIDS Networking Monthly HCT Campaign Media Round-up

HIVAN’s monthly update series tracks media coverage of South Africa’s HIV Counselling and Testing (HCT) campaign.

September 2010

Our fifth edition reflects two important concerns about the campaign’s reach and efficacy: the urgent need for a mass-media communications drive to boost uptake, and the ethical issues involved in conducting HCT at schools. Related topics include the effects of the recent health sector strike on drug resistance, the ongoing debate about virginity testing, the momentum of national medical male circumcision, commentary on task-shifting, and news on provincial and sectoral efforts to strengthen AIDS responses.

What can you tell us about the HCT roll-out within and beyond your community?

Claim your power to mobilise action by sharing relevant news, views and solutions from where you are.

Email us: info@hiv911.org.za

Falling short, but not failing

The Health Department has acknowledged in mainstream media reports that the HCT campaign is behind schedule in terms of reaching its targets. An August progress report showed that 1,5 million people – half the desired number – had been tested since the launch.

The 2010 FIFA World Cup and the public health strike were cited as two factors that had hampered HCT over the past three months, and SANAC Deputy Chairperson Mark Heywood highlighted other shortcomings under the components of funding, monitoring and implementation.

There is evidence of inadequate links between testing and care, poor referral to health services (especially ARV treatment), low quality control of national counselling and testing protocols, coercive testing in some provinces, and no clear mandates for co-ordination.

Heywood has frequently lamented the lack of budget for a mass communications strategy to promote the campaign, but has also explained that “adverse events” create negative perceptions on the ground. Certainly, if health workers do not administer the tests properly, or insist that clients undergo testing in order to receive health services, no amount of PR around the campaign will persuade the public to join it.

Nonetheless, the campaign has generated the adoption of task-shifting to strengthen implementation, with lay counsellors being empowered to conduct testing. There are reservations about this policy: some contest that less trained community health workers are usurping professional health workers’ jobs, and that the policy might lower the quality of healthcare. However, studies show that in a country burdened with a severe AIDS epidemic and a drastic shortage of health staff, task-shifting can contribute to more efficient use of resources, better working conditions and higher retention of scarce skills in the health sector. An article published in The Lancet on 25 September cites research findings that in South Africa, Malawi and Ethiopia, task-shifting has achieved higher levels of ART coverage, and services by nurses are not inferior to those offered by doctors. In fact, the authors recommend that to address unmet needs in ART access, further task-shifting to lay providers, the community and trained AIDS patients should be considered.

The HCT campaign has normalised HIV testing, as is shown in the unprecedented numbers of people coming forward for HCT – despite the absence of concerted mass-media promotion. For example, the North West reported that just over 365 000 people had been tested since the April launch: if these levels can be sustained or increased, the province can achieve its target of testing one million people by June 2011.

Moreover, the degree of openness displayed by health leadership in relaying and confronting the campaign’s impediments continues to inspire. We as citizens are not off the hook in terms of owning and demonstrating our own responsibility for health-seeking behaviour. This is the key message of the HCT campaign, and one that each one of us has a duty to espouse.

Take HCT out of schools

To advance progress towards 15-million people being tested by mid-2011, the Health Ministry plans to re-launch the HCT campaign and extend its reach to workplaces and schools. However, the risk of “adverse events” for youth in HCT is exemplified in warnings issued by child rights advocates, who advise that learners in the 12 to 18-year age group are unable to exercise choice in the midst of a mass campaign, that educators and health workers are not properly supported to implement schools-based testing, and that confidentiality can be easily breached in this setting.

Clearly, such challenges require special contextualised responses, so that children can be afforded safe and easy access to HCT and health services. Heywood agrees that this motive is sound, but the means to achieve it need careful attention. Whilst logic directs the roll-out to target people where they are, child-focused organisations recommend that HCT should not take place in schools, but rather in child- and youth-friendly clinics. Cati Vawda of the Children’s Rights Centre urges the Health Department to gear its health facilities towards attracting children and youth with the assurance of proper monitoring and support as well as dealing with related discrimination. This tack would also enable the distribution of condoms to young people, which is not possible at schools in terms of the Education Department’s policy.

Efforts on the ground

-In the Eastern Cape, the Health Department and the Men’s Christian Guild of the Presbyterian Church in Southern Africa partnered to run HCT and a TB survey during the MCG’s four-day annual conference, held early in September in Port Elizabeth. The event gathered men from 15 regions in Southern Africa, and the MCG is piloting health promotion and HIV prevention initiatives at Empilweni Hospital in New Brighton, PE, with the vision of rolling out nationally.

-At the Tehillah Community Centre in Soweto, Gauteng, Collin Williams is a gay HIV-positive health activist who runs an outreach campaign for HIV prevention, treatment and support. His experiences with youth in the community offer a portrayal that differs from recent data showing that condom usage is highest among the 15-24 age group; he says condoms are often used by youngsters to polish shoes and should not be cited in statistics as being used for safe sex. In his view, government has a detached stance towards prevention, while his Centre practices an interactive approach, with five on-duty nurses available for counseling and separate sex-education discussion groups for young girls and boys. Williams says these practices contributed significantly to the drop in teenage pregnancy and HIV infection rates among youth in the area since the Centre’s opening in 2008. This narrative, among others contained in an online article in The Famuan, reflects on the efficacy of national mass-media HIV awareness campaigns as opposed to local, community-orientated efforts. Proactive, direct approaches that “get in with the people” are regarded as more engaging, allowing volunteers to connect experientially with target audiences around self-responsibility.

-In the Western Cape, medicine delivery services have been boosted by a “Mr Delivery” model spearheaded by the provincial Department of Health. The Chronic Dispensing Unit is being used at 43 community health centres, eight local authority clinics, two district hospitals and 19 homes for the elderly in an effort to reduce long queues at health care facilities and pharmacies. ARVs, urinary bags, linen savers and chronic medication is packaged at Tygerberg Hospital and the service has helped patients who would otherwise have to travel long distances and take a day’s leave to receive their medical supplies.

-The launch edition of Hlasela News, official newspaper of the Free State provincial government, reports that a comprehensive turnaround strategy for health has improved basic healthcare services. Aligned with government’s 10-point plan for health, implementation of the strategy was adopted in July 2009 and has seen a record numbers of people testing for HIV, receiving and adhering to HIV and TB treatment, with 73% of HIV-positive pregnant women receiving dual therapy for PMTCT. Provision of basic essential equipment to all clinics and district hospitals, the appointment of 1038 new staff (including 105 permanent cleaning and security staff at Bongani Hospital), and a well-functioning medical depot are among the other achievements described.

-In an effort to improve provision of health services, more than R10-billion has been allocated to rebuild and rehabilitate five major hospitals across the country. Health Minister Dr Aaron Motsoaledi announced that this project is scheduled for completion within five years. The hospitals earmarked for redevelopment are King Edward VIII in Durban, Chris Hani Baragwanath and Dr George Mukhari in Gauteng, Nelson Mandela Academic in the Eastern Cape, and the Limpopo Academic Hospital.

-Staying pure staves off STDs – this was the thread of one article covering the annual Royal Reed Dance that celebrated the virginal status of 26 000 young Zulu women. Speaking of virgins, the maiden edition of The New Age, the ANC’s new national newspaper, featured a piece headlined “Persistently, controversially, Ngobese continues virginity testing”. It describes Dr Nomagugu Ngobese (who holds a PhD in Theology from the University of KwaZulu-Natal) as having defied the views of feminists, children’s rights activists and even the Gender and SA Human Rights Commissions for 12 years in her quest to administer “the ultimate abstinence test among young girls in KZN”. It also presents the arguments against virginity testing as proffered by the Treatment Action Campaign. 

Professor Pumla Dineo Gqola, writing in City Press, added her compelling voice to this fray, asking whose culture this was and whose purposes it serves: “Practices that render women’s bodies hyper-visible are dangerous and need to be questioned. Linking and equating a young woman’s value to her virginity makes virginity her duty. The man, on the other hand, has no similar responsibility, so this isn’t an equal partnership … we need to face the possibility that some inheritances do more harm than good, and either adapt them or abolish them … we need to enhance human life and value, not endanger some of our most vulnerable.”

-Also featured in The New Age was a full-page article on South Africa’s medical male circumcision that comprehensively addressed the benefits of this prevention strategy along with drawbacks in its implementation. It offered a well-balanced range of expert perspectives on the social dynamics surrounding the procedure, such as the meanings associated with sexuality and gender sensitivity, as well as cautions about the need for consistent condom use. It also highlighted the dangers of marketing the services before they were ready, and without massively publicising key awareness messages that circumcision does not obviate the need for safe sex practices.

While it was gratifying to see this level of journalism being purveyed in The New Age, the launch of which has been dogged by criticism in a political vein, the editorial board either ditched, or failed to recognise, a golden opportunity to elevate perceptions of both the party and the publication by sponsoring a “first”: HCT campaign promotion.

Reflections on resistance

During a truce between government and public sector strikers brought welcome relief to health services and patients after three weeks of turmoil in August, health ethicist Professor Ames Dhai of Wits University’s Faculty of Health Sciences contends that government must finalise a Minimum (Level) Service Agreement with unions to prevent recurrences of paralysis in service delivery. In a Health-e News report, she also criticised striking nurses, saying that whilst their right to a work environment that would support fulfilment of their oath to serve was infringed, violence and intimidation cannot be condoned, and that they too betrayed patients’ rights, with tragic consequences.

The effects of this dual betrayal constitute deadly resistance in another form: in one instance, with the virtual closure of King George V Hospital – a specialised TB treatment referral facility in Durban – during the strike, most patients with multi-drug-resistant (MDR) and extremely drug-resistant (XDR)-TB were sent home. They, along with thousands of the nation’s patients infected or co-infected with HIV, will have experienced interruptions of their medication, leading to increased drug resistance, and endangering their lives and those in their households and communities.

With drug-resistance testing being unavailable in Africa, and many of South Africa’s treatment programmes for HIV and TB being under-regulated, there is a horrifying prospect of patients with these infections being untreatable in time to come. "Imagine if one out of four [HIV-positive] people … were infected with [drug] resistant viruses, and needed to start second- and third-line treatment immediately," says Prof Tobias Rinke de Wit, programme director of PASER (PharmAccess African Studies to Evaluate Resistance).

Second-line ARVs cost at least five times more than first-line drugs, and funding for AIDS treatment is already diminishing; according to a report in Health-e News, South Africa needs an extra R2-billion a year to monitor and treat the estimated four million people needing ARVs. With the spread of drug-resistant viruses, not only would expansion of treatment access be impossible, but extremely drug-resistant HIV strains would make our existing ARVs obsolete. 

PASER is piloting ART-A, a cheap, easy-to-use drug-resistance test, in South Africa and Uganda, but even if it works well in the field, it would only be available for wider use in another two years. This threat is yet another motivation to step up prevention efforts. As health economist Professor Alan Whiteside said to Health-e News: “HIV treatment without prevention is like mopping the floor while the tap is running.”

As we look back on September as Heritage Month, perhaps we should reflect on what we as a nation must resist if we are to bequeath anything worthwhile as a legacy for future generations. Pumla Dineo Gqola reminds us that we are tomorrow’s ancestors. Surely, then, we should resist attitudes and actions that manifest as “we don’t care” and “we won’t care”. The HCT campaign message must be propagated to saturate our collective consciousness: take responsibility – for HIV prevention, testing and treating, and for respecting the rights of all.

The contents of this publication reflect the opinion of the author only and are intended purely for informational purposes. HIVAN accepts no liability for the content of this document, or for the consequences of any actions taken on the basis of the information it provides.  If you wish to copy or distribute part or the whole of this document, please acknowledge HIVAN as its source.

See the full document attached below

Deadly Consequences of Inadequate HIV Counselling. 28/10/10

I apologized to her but all she says is I betrayed her; I didn't know it would end like this

Gulu - Carol Apiyo* is struggling to cope with bitterness and anger towards her husband, whom she blames for infecting her with HIV; a few months ago, she tried to kill him by poisoning his food.

Fortunately her husband recovered after treatment at Gulu Hospital in northern Uganda. "I can't forgive him for what he has done to me – he is the only man I have known in my life," she told IRIN/PlusNews. "I [still] feel like killing him."

Her husband, Richard Okello*, told IRIN/PlusNews he had no idea he was HIV positive. "I [only] knew the result when my wife told me that I was required to undergo HIV testing with her at the antenatal clinic," he said. "The result was shocking because I have been using condoms with my other partners.

"I apologized to her but all she says is I betrayed her; I didn't know it would end like this," he added.

According to health workers in Gulu district, the counselling given to people such as Otto and Adiyo is insufficient to deal with the complicated feelings and issues they face following a positive diagnosis.

"Counselling lasts less than 15 minutes when patients are given their results; they are later left on their own without follow-up counselling," said William Odur, senior psychiatrist at Gulu Hospital. "After they are given their HIV status, a number develop mental disorders, are depressed, commit suicide or kill their partners."

Deadly consequences

The country has had several cases of murder following HIV-positive diagnoses, including a man in the southwestern district of Rukungiri murdering his wife in 2008, the lynching of a woman in Gulu suspected of infecting a man and, in September, a 20-year-old woman in the eastern district of Soroti being sentenced to death for killing her soldier husband after she tested positive and he was negative.

"One session is rarely sufficient, especially with discordant couples," said Goretti Nakabugo from Strengthening HIV/AIDS Counsellor Training in Uganda (SCOT), part of the national NGO, The AIDS Support Organization (TASO). "Counsellors need to put couples in touch with peer support networks or arrange for follow-up home visits."

She noted that over and above dealing with the fear, suspicion and anxiety when one partner is found to be HIV-positive, counselling was needed to support both the negative partner - now at high risk of contracting HIV - and the positive partner, who needed to know how to live a healthy life.

Under Ministry of Health guidelines on HIV counselling and testing, only trained counsellors should provide HIV pre- and post-test information or counselling; training for counsellors is at least one-month long and must be conducted by a government-approved institution.

Need for more counsellors

However, Zainab Akol, head of the HIV programme in the Ministry of Health, told IRIN/PlusNews the government had no register of all the HIV counsellors operating in the country; she added that many professionally trained counsellors worked in fields other than HIV.

A counsellor at Gulu Hospital told IRIN/PlusNews that counsellors often conducted their work hurriedly due to the high volume of people turning up for VCT after public campaigns encouraging widespread testing.

Paul Olobo said he was counselled for just 10 minutes at Gulu Hospital.

"Your test result shows that you are HIV positive, it's not the end of the world and you should accept it - that is what I was told at the hospital and the health worker sat quietly waiting to see the next patient in the line as I walked out of the counselling room," he said. "It's up to the patient to decide what next; it's not easy."

Uganda is also in the process of rolling out provider-initiated counselling and testing - where health workers routinely offer HIV counselling and testing to all patients visiting health facilities - and couples counselling and testing, which will require even more health workers.

Quality over quantity

"Counsellors need to look beyond targets and numbers and try to provide a quality service to their clients," SCOT's Nakabugo said. "The 45 minutes or one hour allocated for each client is often not enough to ease their anxiety; shock is a natural reaction so both pre-test and post-test counselling must be provided.

"Counsellors should also make use of the wealth of the communities they work in - use their referral networks to put people in touch with people who can support them," she added. "Guidance on disclosure is also important - for example, if telling your family that your partner is HIV-positive and you are not will cause trouble, perhaps it's better not to do so."

EU Drugs Agency Launches New Guidelines for HIV Testing in Injecting Drug Users. 30/11/10

The new guidelines recommend a strategy to increase testing uptake

More injecting drug users should undergo tests for HIV, viral hepatitis and other infections such as tuberculosis, says the EU drugs agency (EMCDDA). In new guidelines published today on the eve of World AIDS Day, the agency describes how, in this group, the uptake of testing is still low in many European countries (¹).

Infectious diseases are among the most serious health consequences of injecting drug use and can lead to significant healthcare costs. The new guidelines recommend a strategy to increase testing uptake, both in Europe and beyond, that would ensure earlier treatment for injecting drug users (IDUs) and would lower the risk of infection spreading to the wider population.

IDUs are vulnerable to a range of infectious diseases due to a variety of risk behaviours and underlying conditions, such as poor hygiene, homelessness and poverty. The EMCDDA estimates that 30–50% of HIV positive IDUs in Europe are unaware of being infected. It also estimates that around 50% of IDUs (varying between countries from 10% to 90%) are infected with viral hepatitis (notably hepatitis C), which can lead to severe liver disease and premature death.

Commenting today, EMCDDA Director Wolfgang Götz said: ‘It is crucial that those infected are aware of their condition so that they can protect their partners and access the appropriate care and treatment. We encourage service providers and healthcare professionals to take a more proactive approach and ensure that clients at the highest risk of contracting drug-related infections are offered testing on a regular basis. Until now, timely diagnosis and treatment of infectious diseases has often been too low a priority among professionals in contact with drug users’.

Today’s manual provides guidance at a practical level, proposing a series of standard tests to be undertaken regularly on a voluntary and informed basis. Among these are serology tests for HIV, hepatitis (A, B, C, D) and other sexually transmitted infections; general blood tests; and tests for tuberculosis. For high-risk IDUs, these tests should be considered annually, or even bi-annually. The guidelines also offer a package of prevention, primary care and referral routines in relation to IDUs and infections.

The guidelines recommend that health providers initiate examination, testing and counselling in IDUs in a variety of healthcare settings (e.g. primary healthcare; special health services for IDUs; low-threshold service centres visited by IDUs; rehabilitation centres; dedicated sexually transmitted infections clinics and prison healthcare facilities). Developed in collaboration with European experts on drug-related infectious diseases, the guidelines are now being distributed across the European Union and globally. They are intended to be of use to thousands of service providers, and may potentially benefit hundreds of thousands of IDUs.

FDA Approves Abbott’s New HIV Test. 6/10

Current antibody-only tests miss up to 10% of HIV infections in some high-risk populations because they do not detect antigens.

On June 21, Abbott Laboratories announced that the U.S. Food and Drug Administration (FDA) has approved “an innovative new diagnostic tool, which will allow patients to be diagnosed earlier than ever before.” This marks the fastest approval by the FDA of an automated HIV test to date.

According to the release, “Abbott's ARCHITECT HIV Ag/Ab Combo assay is the first test approved in the United States that can simultaneously detect both HIV antigen and antibodies. HIV antigen is a protein produced by the virus immediately after infection, whereas antibodies are developed days later as the body works to fight off the infection. Studies have demonstrated that Abbott’s new test may detect HIV days earlier than antibody-only tests, which is important in controlling the spread of the virus.”

“Since individuals are most infectious to others shortly after infection, detecting HIV earlier is critical and life-saving,” said Peter Leone, M.D., medical director, North Carolina HIV/STD Prevention and Control Branch, University of North Carolina, Chapel Hill. “A significant percentage of new HIV infections are transmitted by someone with an undetected acute infection, so identifying more people earlier offers a significant opportunity for counseling, which can reduce high-risk behaviors and also initiate antiretroviral treatment for early-stage infection, if appropriate.”

Studies conducted by the Centers for Disease Control and Prevention (CDC) show that current antibody-only tests miss up to 10% of HIV infections in some high-risk populations because they do not detect antigens. However, Abbott’s new assay detects the HIV p24 antigen, or the direct presence of HIV, allowing for diagnosis of early infections days before antibodies emerge.

The Abbott ARCHITECT HIV Ag/Ab Combo assay will be available to consumers in the U.S. later this year.

Firm Develops Early HIV Diagnosis System for Infants. 16/12/10

Infants infected with HIV/Aids will now be able to access diagnosis within two days after testing

AllAfrica

Kenyan infants infected with HIV/Aids will now be able to access diagnosis within two days after testing, drastically reducing the high infant death rate linked to late data delivery.

This follows the ongoing installation of a technology that can link remote medical institutions across the country.

With the help of Strathmore University students, Hewlett Packard has developed a custom database application that uses cloud computing to capture, manage and return infant HIV test results in one to two days, a significant improvement from the previous paper-based system that took over one month.

"Parents of the infant were required to travel to take blood samples to the nearest health facility from where it was brought to Nairobi via courier service. Results of the test were then taken back via courier service, taking a lot of time and resources," said Mr Matilu Mwau, the director and principal investigator of early infant diagnosis at the Kenya Medical Research Institute (Kemri) in Busia.

The technology will now make test results available online, as well as via SMS and GSM in real time, thereby drastically reducing the time taken to inform parents of the test results.

The turn-around time for test results is especially critical, as infants diagnosed with HIV must begin anti-retroviral treatment (ART) as quickly as possible to ensure survival.

Without immediate treatment, half of HIV-positive infants are unlikely to survive past age two.

Cloud computing refers to accessing computing resources that are typically owned and operated by a third-party provider.

"Currently, we are working with HP and they are in the process of setting up the system from which we expect to speed up delivery of the test results," said Mr Mwau.

The initial phase of the project that cost Sh88 million comprises the installation of two data centres at the Kenya Medical Research Institute (Kemri) and the National Aids/STI Control Programme (Nascop) headquarters in Nairobi.

The initiative will provide structural and systemic improvements in testing and treatment of more than 120,000 infants exposed to HIV in Kenya each year.

Out of every 10,000 infants, 300 are HIV positive while 45 per cent die due to delayed medication arising from late diagnosis.

Healthy life

Without treatment, an infant infected with HIV in Kenya has a 35 per cent chance of dying by his first birthday and a 53 per cent chance of dying before the age of two, according to a study by Pathfinder International Kenya.

But if the baby receives prophylactic antibiotics soon after birth and anti-retroviral therapy (ART) early enough, he has a good chance of surviving childhood and living a long and healthy life.

Three additional sites are expected to be online next year at Kemri centres in Busia, Kisumu and the ministry of Health headquarters at Afya House.

The investment also includes servers, storage, PCs, networking equipment, SMS-enabled printers, and personnel training and support.

The system will also scale up to support the Ministry of Public Health and Sanitation as it expands prevention of mother-to-child transmission services to more than 3,000 facilities during the next two years.

"We believe these efforts will facilitate our ability to provide long-term health interventions that truly make a difference in keeping our population healthy and productive," said Public Health Services minister Beth Mugo.

Additionally, the results will be made available via an online database to communicate with rural health centres and through SMS.

The HP technology provisioning also includes five data centres connected with four existing laboratories.

Within the first year in operation, about 70,000 infants will be reached.

In Kenya, about one in every 10 pregnant women is HIV-positive.

That means that of the 1.3 million children born in Kenya each year, more than 120,000 have HIV-positive mothers.

Without intervention, there is up to a 45 per cent chance that an infant born to a mother with HIV will become infected.

Due to the high rate of HIV in Kenya, infants are required to be tested for the disease before they are six weeks old.

However, the current testing procedure is paper-based and results can take up to three months to arrive in rural areas.

This delay reduces the efficacy of life-saving anti-retroviral treatment, which needs to be started immediately following a diagnosis.

For example, an HIV-positive infant who does not receive ART has less than a 50 per cent chance of living to see his or her second birthday.

The Clinton Health Access Initiative (CHAI), which is supporting HP financially, is a global health organisation committed to strengthening integrated health systems in the developing world and expanding access to care and treatment for HIV/Aids, malaria, and tuberculosis.

CHAI's solution-oriented approach focuses on improving market dynamics for medicines and diagnostics, lowering prices for treatment, accelerating access to life-saving technologies, and helping governments build the capacity required for high-quality care and treatment programmes.

Frequent Testing for HIV Results in Better Prognosis for Those who do get HIV. 23/2/11

People who tested regularly for HIV but subsequently contracted the infection had half the risk of death when compared to people diagnosed at their first HIV test, the researchers found.

AIDSMap

Frequent testing for HIV is associated with improved outcomes after diagnosis, Dutch investigators report in the online edition of AIDS. People who tested regularly for HIV but subsequently contracted the infection had half the risk of death when compared to people diagnosed at their first HIV test, the researchers found.

Patients who tested for HIV at least annually had higher CD4 cell counts at the time HIV therapy was started and lower mortality rates compared to individuals who tested for HIV less frequently. The worst outcomes were seen in patients who were diagnosed at their first HIV test, and a high proportion of these individuals already had a CD4 cell count below 200 cells/mm³ at the time of diagnosis.

“Patients repeatedly tested for HIV antibodies…had higher CD4 cell counts at cART [combination antiretroviral therapy] initiation and a lower rate compared to those initially tested positive,” comment the authors.

Thanks to antiretroviral therapy, many HIV-positive individuals can look forward to a long and healthy life.

However, even with HIV therapy mortality rates are still higher among HIV-positive individuals than the general population, and this is largely because many people have their HIV diagnosed late.

Guidelines in the Netherlands and many other countries recommend that individuals at high risk of HIV, such as gay men, should test for HIV at least annually.

“Although seemingly obvious, it has never before been demonstrated that patients who were repeatedly tested for HIV before testing positive have a better clinical prognosis than patients who initially tested positive,” write the investigators.

They therefore designed a study involving 5494 patients who were newly diagnosed with HIV in the Netherlands between 2004 and 2008.

On the basis of their HIV testing history prior to diagnosis, these patients were divided into three groups:

The investigators then conducted analyses to see if frequency of testing was associated with two outcomes:

The vast majority of patients were diagnosed with HIV at their first HIV test (4067 individuals vs 561 infrequent testers vs 866 frequent testers)

There were important demographic differences between these three groups, most notably, 23% of individuals diagnosed at their first test were sub-Saharan Africans, but just 4% of those diagnosed with HIV after frequent screening came from this group.

The median CD4 cell count at the time of diagnosis was associated with testing history, and was lowest for those whose HIV was diagnosed at a first test (350 cells/mm³ vs 470 cells/mm³ for infrequent testers, and 550 cells/mm³ for patients who tested frequently).

Frequency of testing was also associated with the presence of an AIDS diagnosis at the time of diagnosis (16% first test vs 2% infrequent testing vs 3% frequent testing).

Overall, 186 patients died. The mortality rate was highest for patients diagnosed at a first HIV test (1.33 per 100 person years), and was significantly lower for individuals who had tested previously (infrequent test = 0.58 per 100 person years, p = 0.02; frequent testing = 0.54 per 100 person years, p = 0.003).

After taking into consideration differences in baseline characteristics, the investigators calculated that individuals with a history of HIV testing had a 50% reduction in their risk of death compared to patients whose HIV was detected the first time they had an HIV test.

Median CD4 cell count at the time HIV therapy was started was 190 cells/mm³ among patients diagnosed the first time they had an HIV test, compared to 250 cells/mm³ (difference, p < 0.0007) for patients with a history of infrequent testing, and 260 cells/mm³ (difference, p < 0.0007) for patients who tested for HIV at least once a year.

Patients diagnosed the first time they had an HIV test were also the group most likely to have an AIDS diagnosis and CD4 cell count below 200 cells/mm³ at the time antiretroviral therapy was initiated.

“Our findings illustrate the benefit of repeated testing for HIV,” write the investigators, “it shortens the time between infection and diagnosis and improves the likelihood of timely treatment, with the prevention of clinical progression to AIDS and death.”

The researchers also believe that “increasing testing to annually may greatly impact on transmission rates at a population level.” They quote a modelling study that suggested that transmission rates in the Netherlands could be reduced by 40% over a decade “if the average time between infection and diagnosis was reduced to 1 year.”

HIV Home Test Kits in South Africa

Lyn's Comment: Late in 2009 it was reported that home testing kits for HIV will be piloted in South Africa.  The initial response to this was quite positive.  However, as organisations and the government reflected on this, more concerns were raised. Some of the issues to consider include:

HIV Home Testing - Should we or Shouldn’t we? 30/11/10

Should HIV testing be left to individuals - under little or no supervision?

Health-e

As the government seeks to make HIV testing the norm, some in the health field are suggesting that HIV home testing kits should be promoted as part of the strategy. But should HIV testing be left to individuals - under little or no supervision? Ayanda Yeni, of Health-e News Service, takes up the story.

In a recent open letter to the public, three HIV/AIDS specialists suggest that HIV home testing should be made readily available to the public. The letter argues that South Africans should be able to take an HIV test in the comfort of their homes. One of the authors of the letter is Deputy Executive Director of the Wits Institute for Sexual Health and Related Diseases at Wits University, Professor Francois Venter. He says the country is in crisis and innovations like the HIV home testing kit will help us understand and deal with the extent of HIV infection.

“I think this country is in denial about HIV. I think the problem is that our government, the churches, unions and so on... everybody is able to say they are doing their bit for World Aids Day, then they pack up for the rest of the year. This country is in absolute crisis at the moment. Almost half of all deaths are related to HIV. We have a massive orphan population, we see huge impacts on our working population, and it has implications on our grants systems. The healthcare system is under a huge amount of pressure from people falling ill, yet we can mobilise the whole country behind the World Cup, the Gautrain but we cannot mobilise ourselves around HIV”.

Professor Venter argues that home testing is also about convenience. He says it needs to be taken into account that some people may not want to be put through the whole process of waiting in queues or being counselled when taking an HIV test.

“Personally, I sometimes would like to know my HIV status and I don’t want to go to the clinic. I don’t want to go through the rigmarole of counselling. I don’t want to repeatedly go through the same process again. I want to do it when it suits me, to be honest. And at the moment I don’t think our HIV services suit most of us”, says Professor Venter.

However, not everyone is in agreement. The South African Medical Association, SAMA, has spoken out against HIV home testing, saying it has the potential of damaging many peoples’ lives. It says key to HIV testing is the pre and post- counselling and that that component should not be taken for granted. SAMA Chairperson Poppie Ramathuvha explains why.

“When you do your pre-test counselling, you counsel an individual in such a way that he or she is sure that she is positive before you even do the test. So, when you do the test and find that they are negative, it’s a bonus. When you counsel a person you have to be sure that even if they are positive they’ll still go home knowing it’s okay. Without such a process it’s going to be a problem”.

Dr Ramathuvha added that there could be severe repercussions to testing yourself without a professional at hand.  

“When you are alone you say to yourself: ‘Am I going to die? I know there are ARV’s, but how do I access them?’ You don’t know which regimen you are supposed to be on. Many tests need to be done on you, but you then go and find means to get ARV’s, and then you access wrong ones that further complicate things. Or, immediately when you test and it comes back positive you commit suicide. Many of us when we go for an HIV test it’s very stressful, including myself, knowing everything I do about HIV. But when I go for that test I need somebody with me, otherwise I become scared”.

The Treatment Action Campaign, TAC, has also added its voice to the debate. It has reinforced the importance of pre and post-counselling when taking an HIV test. TAC’s Ekurhuleni Branch Representative, Luckyboy Mkhondwane, says an HIV test is more complicated than a pregnancy test.

“In order for one to do an HIV test you have to be in your right mind, that’s why we prefer someone to go for counselling. But if you go and buy your own home test and do it, it will have many implications that are bad because you won’t have the coping mechanism that someone who has been to a clinic has. You need to be prepared; you can act brave and think you are ready to know your HIV status, but when you do it’s different”, he says.

With the focus being on World Aids Day this week, many South Africans still don’t know their HIV status and government has embarked on a massive effort to encourage the public to get tested with the launch of the HIV Counselling and Testing (HCT) campaign in April. But Professor Francois Venter argues that the country’s current HIV testing system is not yet up to scratch, hence the need for the home kit.

“The process of testing by counsellors, in particular and the pricking of patients by nurses... there have been lots of quality over-sight problems. People haven’t been waiting long enough to get the test read, the counselling has been very poor quality and the post-counselling hasn’t referred people into the system. What we’re seeing now at the clinics is that instead of people waiting for 15 minutes they take 8 minutes to read the test, and that’s not good. So, I do worry about the HIV testing system in our country and if we don’t focus on the quality of that test, particularly of reading the test result, we run the risk of undermining what is a very important programme. South Africans need to know their status and to trust the systems that give them that”, says Professor Venter.

HIV Testing 'Not a Once-off Thing'. 14/2/11

South African health minister, Motsoaledi, hopes the programme would be an annual feature of the orientation week at various universities.

Johannesburg - Testing for HIV/Aids has to be done regularly and is not just a "once-off thing", Health Minister Aaron Motsoaledi said on Monday.

"... It would be a grave mistake for South Africans to think it's a once-off thing... It's a lifelong thing... You have to just keep on testing," Motsoaledi said in Johannesburg at the launch of a testing campaign targeting first-year university students.

Motsoaledi said the widespread testing and counselling programme launched last year was "progressing well".

"We have now reached close to six million people," he said.

The campaign was launched with President Jacob Zuma getting tested last year, and runs through to June 2011.

Heightened awareness

Motsoaledi said in the duration of the campaign, there was heightened awareness of the necessity for all South Africans to get tested.

But, it was important for South Africans to continue getting tested throughout their lifetime - long after the campaign concluded.

South Africa is the worst affected in the world, with about 5.7m people living with the virus that causes Aids.

The campaign - a public, private partnership - will target first year students at 18 universities across the country.

Motsoaledi said he hoped the programme would be an annual feature of the orientation week at various universities.

Getting tested is only one of nine HIV preventative measures, but is arguably one of the most important, he said.

HIV Testing should be Promoted in School Sex Education Classes and on Facebook. 26/1/11

In order to reach those Australian gay and bisexual men who have never tested for HIV, innovative methods needed

AIDSMap

In order to reach those Australian gay and bisexual men who have never tested for HIV, innovative methods will have to be developed, Martin Holt and colleagues write in the online edition of AIDS and Behavior. Health messages delivered through gay community outreach and by clinicians will tend to reach men who have already tested.

The researchers’ analysis of the demographic and behavioural characteristics of men who have never tested suggests school and college sex education classes could play an important role. Moreover internet interventions, especially on social networking sites, can reach men with fewer ties to metropolitan gay communities.

In order to have an up to date understanding of men who have never tested or not done so recently, the researchers included relevant questions in a national, online survey of gay and bisexual men in Australia in 2008. The e-male survey was promoted through a wide variety of methods (adverts and links on relevant websites; promotion by gay and HIV organisations; flyers in gay venues; adverts in the gay media; adverts in the personal, adult or classified sections of local newspapers).

A total of 3457 men took part in e-male. However the analysis that is reported here excludes men who have ever tested HIV-positive. Moreover as only half the participants were asked the full set of questions on testing (the other half were given questions on other topics), the data here is of 1770 participants.

How many men have tested?

HIV testing is generally considered to be far more common among Australian gay and bisexual men than among men in other countries, including the UK. However this understanding comes from surveys conducted at gay community events and gay venues. For example, in the 2009 Gay Community Periodic Surveys, 87% had ever been tested and 60% had done so in the past year.

Such surveys are likely to under-represent younger men, non-gay identified men and men living in rural or remote areas, whereas online surveys tend to recruit more of these men. Indeed, one in five e-male respondents identified as bisexual or heterosexual.

In this sample, 72% of the participants had ever been tested for HIV and 28% had never been tested. Around half the men (48%) had tested in the last twelve months.

To put this in context, back in 2001-2002, a representative survey of Australian adults had found that 77% of gay men and 71% of bisexual men had ever tested. Furthermore, the Gay Community Periodic Surveys have found testing rates to be stable over the past decade.

The rest of the analysis considered the profiles of the men who had never tested and recently tested in the e-male study.

Never tested

Men who had never tested, compared to men who had tested more than twelve months ago, tended to be younger and have lower levels of education.

Moreover, they had fewer gay male friends and were less likely to seek sexual health advice from a gay community or HIV organisation. This confirms previous findings which suggest that men who are more attached to the gay community are more likely to test.

Untested men were also much less likely to seek sexual health advice from a doctor or nurse.

The researchers believe that these findings suggest that the promotion of HIV testing through gay venues, gay social networks and clinicians will fail to reach men who have never tested. They argue for school and college based sex education as an alternative.

Untested men tended to spend more time using Facebook and other social networking websites. The researchers note that “The internet is particularly good at reaching those men who have not been tested for HIV and who may be geographically or socially distant from metropolitan centres of gay community activity.” They recommend that health promotion messages about testing should be placed on social networking sites, especially those which allow advertisers to target male and same-sex-attracted users.

Men who had had unprotected anal intercourse with a regular male partner in the past six months were more likely to have tested. The researchers consider that this is probably due to HIV testing being used to inform decisions about condom use in relationships.

Men who had never tested were more likely to agree with the idea that HIV-negative men should disclose their HIV status before sex. While more men expected HIV-positive men to disclose their status, this belief did not distinguish non-testers from testers.

Moreover other factors such as unprotected anal sex with casual partners or use of particular venues were not significantly associated with having been tested or not.

Recently tested

Men who had tested in the past year, compared to men who had tested more than a year ago, were more likely to have a larger numbers of gay male friends and to have attended a pool, beach or gym used by gay men in the past year, reinforcing the association of HIV testing and gay community attachment. On average, they also had more sexual partners.

Men testing in the past year were younger (mean age 35) than men who had tested more than a year ago (mean age 39). On the other hand, men who had never tested were younger still (mean age 30).

Recent testers were more likely to have ever sought advice or information on sexual health from a doctor or nurse.

Moreover these men were more likely to expect that HIV-negative men should disclose their status before sex. They were also more likely to report HIV disclosure to or from some of their casual male partners in the last six months. The researchers comment: “This appears to indicate that as HIV disclosure becomes more common between casual male partners in Australia, MSM who engage in HIV disclosure (or rely upon it as a way to assess HIV transmission risk) may be increasing the frequency with which they get tested for HIV”.

Other factors did not distinguish recent testers from other men in the multivariate analysis.

Comparison with the UK

In the 2008 United Kingdom Gay Men’s Sex Survey, 68% of respondents had ever tested, and 44% had tested in the past year. (These figures exclude men with diagnosed HIV).

Although there are important differences between the two samples, it remains possible that the numbers who have ever tested in the UK and Australia are not as dissimilar as is often thought.

In the UK survey, a number of the same factors are also associated with ever testing for HIV or having done so recently - older age, more education and more sexual partners.

In addition, the UK study found that men who had sex with both men and women were less likely to test. While a similar finding was initially found in the Australian study (and large numbers of bisexual men took part), this did not remain a significant factor in the multivariate analysis - which provides the most reliable results.

Moreover in the 2006 UK survey, men who had never tested were more likely to expect HIV-positive men to disclose their status before sex. Again, this was found in the Australian raw data, but not in the multivariate analysis.

Home HIV Testing Helps Early Diagnosis of High-risk Children. 21/9/10

It took some convincing to get parents to allow their children to be tested

Nairobi - Home-based voluntary counselling and testing (HCT) can help to diagnose HIV early among high-risk children, new research in western Kenya has found.

"Through home-based counselling and testing, you are able to get children and parents who might not go to health facilities for these services," said Samson Ndege, one of the authors of the study and HCT project coordinator with the USAID-supported Academic Model Providing Access to Healthcare (AMPATH), which cares for more than 100,000 HIV-positive adults and children in the region. "HCT provides an opportunity to... link children and parents to treatment."

The study, published in the Journal of Acquired Immune Deficiency Syndromes, looked at the uptake of HIV testing and HIV prevalence among children given HCT and aged between 18 months and 13 years, whose mothers were either dead, HIV-infected or of unknown HIV status.

Ndege noted that it took some convincing to get parents to allow their children to be tested. "One reason many parents did not want their children tested was fear of disclosing their HIV status, but through counselling, many parents now know the children can access treatment and therefore there is an increase of those willing to have children tested," he said.

Diagnosis and treatment of HIV-positive children remains very low in much of sub-Saharan Africa; the UN Children's Fund (UNICEF) estimates that without treatment, about half of HIV-infected children will die before their second birthday.

Limitations

Kenya's 2008 national HIV testing guidelines single out diagnosis of children as a benefit of HCT.

Of the 2,289 children offered HCT in the Kenyan study, 57 percent participated and of these nearly 5 percent were found to be HIV-positive.

"In every place where we carried out the research... there are AMPATH clinics where the HIV-positive children and their parents are referred to for treatment," Ndege said. "Community health workers are employed to make follow up visits and ensure that those enrolled in treatment do not default."

Some limitations of the study included the fact that it was restricted to "high-risk" children, it did not test children younger than 18 months - who would have required more complex tests than the rapid one administered in the home - and the limited geographical and cultural scope of the study, which means the results cannot be generalized.

The authors concluded that while HCT did provide an opportunity to diagnose HIV among high-risk children, further investigation was needed to identify and overcome barriers to testing uptake.

How to Build a Lab in a Shipping Container. 1/2/11

Tiny laboratory capable of handle 100 sputum samples a day (using four technicians) to test for TB in Zambia

Lusaka - A tiny laboratory capable of doing big things is what Barry Kosloff, working with the London School of Hygiene and Tropical medicine, has created - a new type of high-tech, low-cost, tuberculosis (TB) lab in a shipping container. He walked IRIN/PlusNews through what it takes to build one.

“I don’t know if this is normal but it’s almost like I had a photograph of it in my head,” said Kosloff, who designed such a lab for the national reference laboratory in the capital, Lusaka. It is part of efforts by the Zambia AIDS-Related TB Project, a local NGO, to expand the country’s diagnostic capacity.

The facility is the first in Zambia to be equipped with infection controls that make it safe for staff to grow the TB cultures needed to diagnose HIV-positive patients, and to determine whether TB patients have successfully completed treatment.

Communicate with your suppliers

Based on his experience in designing container labs, Kosloff said it was important to get suppliers talking and listening.

“[Suppliers] didn’t really understand what we were trying to do, and we didn’t understand what the capabilities were,” he told IRIN/PlusNews. “It came with very small sinks, and it used US-style air conditioners - the ones where you have to make a big hole in the wall [to mount it], and that brought in a lot of dust.”

This time Kosloff made sure that suppliers installed bigger sinks and mounted air conditioners internally to avoid letting in dust that could damage equipment and contaminate TB cultures.

“We wanted bigger sinks because in TB labs you make smears or stain slides, so we needed sinks you could actually work in,” he said.

The space race

The lab can handle 100 sputum samples a day, using four technicians.
Kosloff said many people were surprised that a lab this small could be so efficient. He said a container lab’s size could improve efficiency if you utilized the space to best advantage.

“In most container labs I’ve seen they tend to just have counters and equipment along one wall - they don’t make use of both sides …[like] I did,” he told IRIN/PlusNews.

“It’s like a [ship’s] galley kitchen, where you have equipment on both sides and all you have to do is turn around and there’s more equipment,” he said. “The layout is very efficient - when you sit down everything is close by. You’re not having to get up every five minutes and get something from down the hall.”

The efficient use of space also allows more room for storing supplies, which is important because the lab could be stationed in a remote location for a period of time.

Go with the flow

The possibility of spilled specimens that could send a spray of infectious TB bacteria into the air and into a technician’s respiratory tract makes working in a TB lab dangerous. Well-designed ventilation and exhaust systems are critical.

In Kosloff’s lab, air is drawn into the container and filtered, then moves in a one-directional flow from the least dangerous part of the lab to the room where cultures and sputum are handled, which has negative pressure. If an accident occurred, the direction of the air flow would prevent dangerous bacteria from being carried out of the negative pressure zone and reaching technicians in other rooms.

“This also works better when you have a long, narrow room. If you have a big room, the air is getting stirred around in all different directions, and that doesn’t protect you very well,” Kosloff commented.

The doors are self-closing but the air flow also helps make sure they stay shut - a standard infection-control measure. In more expensive labs the doors are also fitted with electromagnetic locks to ensure that they do not stay open, and that no two doors are open at the same time. In the space-constrained container, Kosloff placed doors between rooms close together, which makes opening any two at the same time very awkward.

The ventilation and air filtration systems also help keep the lab clean. In Zambia’s dusty climate, the filters in lab equipment typically have to be replaced every year but Kosloff estimated that those in the container lab could last up to four years, making maintenance cheaper and easier.

Think local

Kosloff looked for regional expertise to fit out the lab and used Air Filtration Maintenance Services (AFMS), a South African company, to design and install the ventilation and exhaust systems. Although AFMS had not worked on a container before, their knowledge of resource-poor settings like Zambia meant the company used as many locally obtainable parts as possible, making it easier to find replacements and do small repairs in Lusaka.

“In the US, when you have a problem you call someone and they’re there in an hour. Here, if something breaks we have to fly people in from South Africa because there’s no one in the country that can do the work,” Kosloff told IRIN/PlusNews. “The fancier the system, the more you need highly skilled people to fix it.”

Lessons from HCT Campaign. Living with AIDS # 481. 21/7/11

Never has any country in the world targeted such a huge population – 15 million citizens to test for HIV – and had 10.2 million people accepting the HIV test

Health-e

About 15 million South Africans were targeted for HIV testing in the government’s HIV Counselling and Testing (HCT) campaign, but the effort got slightly over 10 million people to test. The campaign has challenged South Africans and the health system in significant ways.

The campaign has been described as ambitious. Never has any country in the world targeted such a huge population – 15 million citizens to test for HIV – and had 10.2 million people accepting the HIV test. But the campaign was not without any flaws. There are reports that some of the tests were obtained in a manner that violated the human rights of people.   

“We are hearing stories of people being tested without their consent. We are hearing stories of people being told: ‘If you don’t have an HIV test, we’re not going to give you the treatment that you need’. We are hearing stories of people saying: ‘Look, I already know that I’ve got HIV. Why do I need to test again’?”, says Mark Heywood is the deputy chairperson of the South African National AIDS Council (SANAC), which is responsible for co-ordinating the HIV Counselling and Testing (HCT) campaign.

Heywood says that in carrying the campaign forward there needs to be systems to identify human rights violations as they occur and there also needs to be better education of health workers and the public around issues relating to human rights. 

“If we are having a big campaign amongst rural people, what do we do to make sure that those people who test positive have support, that they are not isolated and victimised within their community? If we’re targeting men who have sex with men we can’t just test men who have sex with men for HIV. We also have to be educating health care workers to make sure that clinics and hospitals are friendly – not discriminating against, not stigmatizing men who have sex with men. I don’t want to discover my HIV status and, then, find that if I go into a clinic that I’m going to be humiliated and made fun of because I’m gay”, he says.

From April last year, the Health Department aimed to test 15 million South Africans for HIV by this June. So far, the campaign has tested 10.2 million people. This is out of 12 million citizens who were counseled for HIV testing since the start of the campaign. The enormity of the effort, which came into an already over-burdened health sector, has “tested the totality of the health system”, says Dr Thobile Mbengashe, the Chief Director of the HIV and AIDS and STIs unit in the national Health Department.   

“It has always been unknown to what extent can you stretch the system to actually achieve high output, high qualities and reach many people within a short time. That’s the first thing. I think the second one is that you can learn more by doing and fix the things that need to be fixed as you do. And you actually become very effective. Let me give you an example. When we started the campaign, there were only about 490 facilities that were providing ART services out of the 4 300. Between the time when the HCT campaign was launched and now, over 2 000 facilities are able to provide ART.

We learned that it is possible to provide ART services and provide quality using nurse practitioners who are actually trained to provide this. We had about 290 nurses who were actually qualified to provide ART. We trained and we have now 1 700. Those are actually providing services in those health facilities which were not there. And all that was done during this time”, Mbengashe says.

“This is learning as we go, it’s about doing things differently”, says SANAC’s Mark Heywood.

“Some people might argue that you should not undertake a campaign like this at all until you are absolutely sure that the system can support that sort of campaign. But I think in a country like ours to do that would be irresponsible because part of this campaign is about: How can we get ahead of the HIV epidemic? One way to get ahead of the epidemic is to normalise HIV testing, is to use HIV testing as a way to try to begin to break down the stigma around HIV, and it’s to use HIV testing to try to get much larger numbers of people onto treatment. There are certain risks in that. But I think it is more irresponsible to sit back and wait until we have the perfect system before we embark on something like this”, he adds.

Of the 10.2 million people who tested for HIV in the campaign, about 1.7 million were found to be HIV-positive. About 1.4 million people have been put onto the government’s AIDS treatment programme since April last year. But it’s not clear as to how many are receiving treatment as a result of testing in this campaign.

“One of the lessons we have learned”, says Dr Thobile Mbengashe of the Health Department, “is that the biggest need is that once people have been identified positive, they must not be lost from the system. If you lost from the system… you might have done something extraordinary in terms of coming up early, but you might not get the good benefit of starting treatment early. So, this is one of the components that we are really strengthening in our system”.

The formal run of the HCT campaign officially ended in June. The Health Department is yet to communicate the final achievements of the campaign, which it says will continue being offered to encourage as many South Africans as possible to know their HIV status.

Mobile Testing Units Show Success in Linking People to HIV Care, Treatment. 23/9/11

Linkage to facility-based HIV care from a mobile testing unit is feasible

AIDSMap

More Men Getting HIV Tests. 25/01/10

Johannesburg - HIV testing among men has increased considerably over the last 12 months, rising from 24% to 60%, a nationwide survey has found.

"The figures show a dramatic increase in HIV testing, particularly among males," said Dr Saul Johnson, managing director for Health and Development Africa, at a media briefing in Johannesburg on Monday.

He attributed the increase to awareness campaigns and programmes having reached people, who acted on the information and got tested.

He was releasing the findings of the Second National HIV/Aids 2009 survey, which was conducted in all nine provinces between June and August last year. A total of 9 728 people aged between 16 and 55 took part in the survey.

Of those in the 15 to 24 age group in 2006, 17% of men and 38% of women were tested. In 2009 this increased to 31.8% of men and 71.2% of women.

About 75% of young men and 78% of women between 16 and 19 were tested in the last year.

Faithfulness
In 2006, the study found 26% of respondents believed faithfulness was a way to prevent the spread of the virus, compared to 39.1% in 2009.

People in stable, long-term relationships were less likely to use condoms.

Half the women interviewed, who were involved in one-night stands, did not use condoms. Most men and women believed cheating was a norm and pervasive.

While there is evidence that the message around the risks of multiple partners is getting through, the message needs to be sustained in the future to further increase knowledge levels and bring about behaviour change," Johnson said.

The survey found stable relationships were uncommon for younger men.

"It takes a long time for people to enter into stable relationships, especially for men. Young men have multiple partners, and have more casual relationships," he said.

Both men and women were more likely to settle into stable relationships in their late 30s.

Alcohol
Alcohol was found to be a big problem, as when people got drunk, they didn't worry about HIV. There was also a perception that alcohol consumption would lower the risk of contracting HIV.

Johnson said their HIV/Aids campaigns were working and that knowledge of condom use, ARV treatment and tuberculosis was very high.

About one in 10 people start having sex before the age of 15, which puts young women at high risk of HIV infection.

Condom use was high among young people and those in "casual" relationships, particularly among males.

Johnson estimated that Aids communication programmes reached about 90% of the population - younger people more than older ones.

The survey concluded that information on mother-to-child-transmission was still fairly poor, and male circumcision was not a "top-of-mind" issue. Only a few men knew that male circumcision reduced the risk of contracting HIV.

The campaign still had a long way to go to help reduce multiple partners.

- SAPA

Newly Approved HIV Test Can Spot Infection Earlier. 21/6/10

Abbott's Architect HIV Ag/Ab Combo assay has been approved by the U.S. Food and Drug Administration.

Abbott's Architect HIV Ag/Ab Combo assay has been approved by the U.S. Food and Drug Administration.

Traditional HIV diagnostics have detected HIV antibodies, which are developed days after an infection as a sign that the body is working to fight the invading virus. The Architect assay also detects the HIV p24 antigen, which is a protein produced by the virus immediately after infection, Abbott said in a news release.

The risk of HIV transmission is highest just after infection with the AIDS-causing virus, the company said.

Since the new test could detect HIV infection days earlier than antibody-only diagnostics, people could be alerted before unknowingly spreading the infection and be treated earlier, Abbott said.

Some 56,000 new cases of HIV infection are diagnosed each year in the United States, the Illinois-based company said, citing the U.S. Centers for Disease Control and Prevention.

Physician: HIV Test Guidelines not being Followed. 5/10/10

"Physicians still haven't given up the old 'I can tell by looking,' risk-based" testing

The Wichita Eagle

Wichita physician Donna Sweet says neither patients nor physicians are following HIV screening guidelines unveiled four years ago by the federal Centers for Disease Control and Prevention.

In 2006, she said, the CDC recommended "with very good reasoning" that every sexually active American, age 13 and older, be tested for HIV.

"That was four years ago. It is one of the most widely undone (tests) and disregarded guidelines in medicine," she said. "Physicians still haven't given up the old 'I can tell by looking,' risk-based" testing.

The case of an Air Force sergeant accused of having unprotected sex without disclosing his HIV-positive status "points out that people have forgotten about this disease," she said.

Sweet, an internal medicine practitioner and professor at the University of Kansas School of Medicine-Wichita, has a large patient base of people who are infected with HIV or have AIDS.

An estimated 1.1 million people in the United States are HIV-positive and about 250,000 of them don't know they are infected, she said.

"They're not going to be able to say to you, 'Hey, let's use a condom because I could give you something.' It's back to the day of buyer beware."

Sweet said it's easy for a physician to offer an HIV test along with any other age- or risk-appropriate screening tests. An HIV test used to require a signed consent form, similar to the ones used for surgery, but no longer does.

If a patient declines the offer to be tested, that can be noted in his or her file.

But if a patient sees two or three doctors and never gets the offer for a test, then turns out to be infected, "It's just like a failed diagnosis for cancer, and you've got a lawsuit there," she said.

"It's really about the fact that this disease carries so much stigma and always has," she said.

Her practice normally gets about 100 to 110 new patients a year. "We're going to beat that record this year."

Early detection and treatment work, she said, and someone diagnosed at age 20 can expect to live to about 70 "if they take care of themselves and do things right."

Sandra Springer, HIV and AIDS director for the Kansas Department of Health and Environment, said people who are high risk for HIV and other STDs should get tested every three to six months.

Because people are living with HIV and AIDS and not seeing the devastating effects that were common early in the disease, "there are a fair amount of folks that have kind of a prevention burnout. It's not as on the forefront of people's minds as it was."

But knowing your status and being treated is important to the health of a community, Springer said, because "if someone is in care, they are less likely to transmit the disease to their partner because of their decreased viral load. It's still possible but not as likely if on treatment."

In addition, after people find out they're infected, "they do tend to change behavior," Sweet said. Medications can lower the presence of the virus to an undetectable level in the blood, at which point "they're much less likely to infect anyone," Sweet said.

South Africa: Counsellors to Give "The Prick". 9/7/10

Lay counsellors in South Africa can now legally perform HIV tests

Johannesburg- Lay counsellors in South Africa can now legally perform HIV tests, but delays in paying them and shortages of test kits are threatening a national campaign to scale up voluntary HIV testing and counselling (VCT).

Before new regulations came into effect in May 2010 only nurses were allowed to administer finger-prick HIV tests, but AIDS activists had long argued that this not only added to an already heavy work load, but could also hamstring the VCT campaign aiming to test 15 million South Africans by 2011.

"The way it used to work, if I wanted an HIV test, a counsellor would have to sit down and do all the pre-test counselling ... and then that counsellor would have to go hunt down a nurse to do something that takes 10 minutes to teach a diabetic [how to do]," said Dr Francois Venter, president of the Southern African HIV Clinicians Society and head of the HIV management cluster at Johannesburg's Reproductive Health and HIV Research Unit (RHRU).

"It was ridiculous that one of our most important diagnostic tools be held hostage to our human resources crises," he told IRIN/PlusNews.

Task-shifting the prick

South Africa's public health system is struggling to cope with one of the world's worst HIV epidemics, as well as a shortage of doctors and nurses. The South African Nursing Council estimates that the country has about one registered nurse for every 440 patients, but according to the Human Sciences Research Council, up to 20 percent of nurses are not practicing.

Malawi and Zambia, faced with even worse health worker shortages, have put HIV testing in the hands of trained lay counsellors, a strategy known as "task-shifting".

South Africa's new legislation requires counsellors to undergo three hours of training before being added to a database of healthcare providers allowed to perform "the prick". Dr Thobile Mbengashe, chief director of HIV and AIDS in the Department of Health, said they would not be allowed to perform other tasks, such as drawing blood.

The departments of health and social development are partnering with organizations funded by the US President's Emergency Plan for AIDS Relief (PEPFAR) to conduct the training. Venter said a handful of organizations, including RHRU, had started training their lay counsellors, but most clinics had not yet begun.

Civil society groups, including the Southern African HIV Clinicians Society, the Treatment Action Campaign (TAC), a local AIDS lobby group, and the Democratic Nursing Organisation of South Africa, have welcomed the new legislation.

"This is really the second extremely important task-shifting move we've seen this year," said Catherine Tomlinson, a senior researcher at the TAC. The first was the announcement in the new guidelines released in April 2010 of government's goal to trains nurses to initiate and manage antiretroviral (ARV) treatment. "With the new [VCT] campaign, we needed another level of task-shifting and that’s what we’re seeing with this second move."

Challenges remain

Tomlinson cautioned that despite the strides made in task-shifting, challenges remain for the VCT campaign. The TAC has documented shortages of HIV testing materials, and counsellors going unpaid in Eastern Cape and Limpopo provinces.

"People are coming in numbers to do HIV testing, but ... we don't have lancets [a pricking needle used to obtain blood for testing], so we are using needles to do the tests," said Noloyiso Ntamehlo, a TAC coordinator in the Eastern Cape district of Lusikisiki.

The payment of monthly stipends for counsellors had also been delayed, and the off-road utility vehicles to take VCT to the district's largely rural population have not arrived.

Mbengashe said the health department was aware of the stipend delays and was working with the South African National AIDS Council to prioritise payment.

South Africa: HIV Testing and Mental Illness. 17/03/10

People suffering from HIV-related mental disorders is growing, but mental health remains an ethical, legal and clinical minefield, where many doctors and nurses fear to tread - and fear to test.

Johannesburg — As more HIV-positive people access treatment and live longer, the number of people suffering from HIV-related mental disorders is growing, but mental health remains an ethical, legal and clinical minefield, where many doctors and nurses fear to tread - and fear to test.

"We're moving away from seeing patients on their death beds towards patients who are living longer, and are being affected by mental disorders that have real impacts on their life and work," said Dr Greg Jonsson, a psychiatrist at the Luthando Psychiatric HIV Clinic at the Chris Hani Baragwanath Hospital, in Johannesburg.

Various studies have shown a higher than average prevalence of mental illness among people living with HIV. A 2005 study by South Africa's Human Sciences Research Council found that about 44 percent of the 900 HIV-positive individuals surveyed suffered from a mental disorder.

The links between HIV and mental illness are complex, but factors include the effects of the virus on the central nervous system, as well as difficulties in dealing with HIV-related stigma and discrimination.

South Africa has the world's largest ARV programme to counter an HIV prevalence rate of about 18 percent, according to UNAIDS, and about 920,000 people are on ARV treatment.

No easy choices

Doctors and nurses in clinics often find it daunting to test mental health patients for HIV. "People who are not trained in psychiatric disorders are scared of getting consent from patients with mental disorders," Jonsson told IRIN/PlusNews. "People should not assume that mentally ill or even psychotic patients are incapable of understanding [testing] and consenting."

But Jonsson added that there would be times where doctors would need to make tough calls about testing severely mentally ill patients who could not consent to HIV testing and whose families may not be approachable to consent on their behalf.

Psych is hard because the 'three ticks equal this' approach doesn't really work, and that's why people are so scared of it.

"If you can't obtain informed consent, you need to weigh up the potential harm and benefit to the patient - ask yourself whether this test is going to change your diagnoses or your treatment," he suggested to health workers at an annual symposium held by the Aurum Institute, a non-profit medical research organization.

"I think if the answer is 'yes' to either, then go for it. It is really the right of the patient to be offered effective HIV treatment," said Jonsson, who pointed out that doctors should be aware of possible interactions between mental health medications and antiretroviral (ARV) drugs.

He advised doctors to document the process and counsel patients throughout, especially about how to reduce risk, given the prevalence of substance abuse among mental health as well as HIV patients.

"Psych is hard because the 'three ticks equal this' approach doesn't really work, and that's why people are so scared of it," Jonsson told IRIN/PlusNews.

No right answers

Once a mental health patient started taking ARVs, healthcare providers would have to evaluate whether mandating a "treatment supporter" - a friend or family member to help the patient adhere to treatment - would be appropriate. Again, there may not be a right answer.

"We need to draw up protocols and put them in primary healthcare, but the problem with protocol-based system is that people don't think outside the box - with mental health patients it really is on a case-by-case basis," Jonsson told the symposium audience.

"I tell most of my patients, 'If you can get treatment support, go for it', but I don't insist on it - disclosing to a patient's family is difficult and ... at my clinic, our patients on treatment are already so stigmatized and victimized."

The Luthando Psychiatric HIV Clinic has a treatment default rate - patients who discontinue ARVs - that is the same as institutions in Johannesburg that mandate treatment supporters, Jonsson added.

Text Message Reminders Double HIV Re-testing Rates in Gay Men. 22/2/11

Text reminder allowes large numbers of messages to be sent simultaneously and automatically, reminders are direct, immediate and cheap to send and demanded minimal labour

AIDSMap

Text message reminders significantly increase re-testing rates in gay men for HIV and other sexually transmitted infections (STIs), Australian investigators report in the online edition of Sexually Transmitted Infections. 

Testing rates were twice as high among men who received the reminders than in men who did not.

“To our knowledge, this is the first published study to demonstrate improved HIV/STI re-testing in MSM [men who have sex with men] through SMS [short message service] reminders,” comment the investigators.

Gay and other men who have sex with men in Australia are recommended to have an annual HIV test. More frequent tests, at intervals of every three to six months, are recommended for individuals with riskier sex lives. Mathematical modelling has suggested that increasing the proportion of individuals who are aware of their HIV status could help reduce HIV incidence.

However, only a quarter of high-risk gay men have two or more HIV tests and sexual health screens each year.

Investigators from the Sydney Sexual Health Centre wished to see if sending text or SMS reminders to gay men increased testing rates.

To test this, they designed a study involving 714 HIV-negative gay men who had an HIV test and sexual health screen between January and August 2009. Every four months, reminders to re-test were sent to these individuals.

Testing frequency in these individuals was compared to those of two other groups. The first included 1084 men who had an initial HIV test or sexual health screen in the same period, but did not receive text reminders.  The second comparison group included 1753 men who were tested at the clinic in 2008, and therefore before the introduction of the text reminder service.

Results of the study showed that re-testing rates were significantly higher in the group who received text reminders (64%) than the comparison group (30%, p < 0.001), and the pre-text population (31%, p < 0.001).

After taking into account some differences in the study groups, the investigators found that receiving a text reminder was associated with a four-fold increase in the chances of re-testing (odds ratio [OR] = 4.4; 95% CI, 3.5 – 5.5, p < 0.001).

“The HIV/STI re-testing rate was more than double among MSM who received SMS reminders compared to those who did not,” write the investigators, adding “after adjusting for differences in baseline characteristics, HIV/STI re-testing was three to four times more likely in the SMS group than the comparison group.”

The investigators believe that the text reminder service has a number of attractive features: “it allowed large numbers of messages to be sent simultaneously and automatically, reminders were direct, immediate and cheap to send and demanded minimal labour.”

They believe that if adopted more widely, text reminder to attend for repeat HIV tests and sexual health screens, “have great potential to reduce HIV/STI infection rates in the MSM community. More randomised trials at other sexual health clinics and primary care settings are needed.”

Tragic Mix Up over HIV Test at Royal Berks. 21/4/11

Positive HIV tests were routinely rechecked but negatives were not; Double-checking of negative HIV tests as well as positive ones introduced to prevent false negatives

A 56-year-old Calcot woman would have had a 70 per cent chance of survival if an HIV test 11 months before her death had been correct.

But coroner Peter Bedford heard at an inquest yesterday the test made at Royal Berkshire Hospital in June 2009 produced a false negative and Karen Goodridge, of Corsham Road, was not re-tested for HIV until three days before her death on May 17 last year.

The final result of the second test came on the day she died.

He also heard that another HIV test made on a different patient on the same fateful day had also produced a false negative because the machine used to make the tests had been incorrectly loaded.

The other HIV patient, according to the hospital chief medical officer Dr Jonathan Fielden, is now receiving “the appropriate treatment”.

The inquest heard how Mrs Goodridge’s doctor at the hospital Dr Ann McGown was concerned at her patient’s failure to respond to treatment but was consistently told by the hospital’s haematologists her condition called myelodysplasia  – or failure to make red and white blood cells – had been caused by the chemotherapy treatment she received for breast cancer in 2005.

During the months before her death she was in and out of hospital, treated for TB and other microbiological infections with antibiotics and at times her condition rallied.

Dr McGown told the inquest she had questioned the diagnosis but had not questioned whether the HIV test was incorrect.

She told the inquest she could have ordered another test at any time but in 20 years as a doctor she had never heard of a negative HIV test being wrong.

The inquest heard that positive HIV tests were routinely rechecked but negatives were not.

She also told the coroner at a meeting with Mrs Goodridge’s family after her death she was “close to tears” when describing how she had asked the haematologists to check their diagnosis and they had come up with the same conclusion.

She also described how it had been “difficult to talk to” a haematologist called Dr Hassan and  get a “face-to-face” meeting with him to review Mrs Goodridge’s case.

The coroner had been unable to trace Dr Hassan to call him as a witness. Dr Bedford put it to Dr McGown one of the family’s concerns that the hospital believed her condition was psychological, that she was “attention–seeking” and that she was treated “with a lack of respect and negativity”.

“Hopefully not by me,” Dr McGown replied.

She told the inquest “she could well have survived” had the first HIV test been correct.

Dr Fielden said an independent review after Mrs Goodridge’s death found she would have had a 70 per cent chance of survival if the test had been right.

He also acknowledged that pressure of work in the pathology lab and a possible design problem with the machine used to make the test contributed to the “system failure”.

He said the hospital has made a number of changes since Mrs Goodridge’s death. He said there had been additional training, the introduction of double-checking of negative HIV tests as well as positive ones and additional supervision of tests by a consultant.

He said the hospital had not yet replaced the equipment used.

The coroner gave a lengthy narrative verdict saying Mrs Goodridge had died of pnuemocystiscarinii pneu-monia or PCP due to hospital-acq-uired pneu-monia and from the human imm-unodeficiency virus HIV.

He said if she had received a diagnosis of HIV in June 2009 she would have had a “good chance of survival”, in excess of 70 per cent.

He said the design of the blood testing machine and reduced staffing increased the risk of the false negative test. However he did not make any further order to the hospital under coroner rule 43.

Mr Bedford said the false negative was a very rare occurrence and he commended the efforts the hospital had made and for the “candid nature of its evidence”.

After the hearing Mrs Goodridge’s family declined to comment. They were represented by counsel at the inquest.

WHO Recommends New Early HIV Detection Ways. 9/6/10

The World Health Organisation has come up with new ways to enhance early detection of HIV and ensure quick access to anti-retroviral therapy.

Harare — The World Health Organisation has come up with new ways to enhance early detection of HIV and ensure quick access to anti-retroviral therapy.

WHO team leader for HIV and Aids programmes Dr Bryan Pazvakavambwa said this at a recent stakeholders’ workshop in Harare. He said the new recommendations followed extensive research accumulated over the years.

"The updated recommendations are aimed at promoting earlier diagnosis of HIV and earlier anti-retroviral treatment initiation, use of less toxic and more patient-friendly regimens, and early initiation of prophylaxis or treatment as medically indicated for prevention of mother-to-child transmission," he said.

WHO also revised paediatric HIV care and treatment guidelines.

However, Dr Pazvakavambwa said the new recommendations presented challenges to country interventions.

"As more people will now be eligible for treatment and the role of the laboratory in patient management expanded, the financial implications could be huge for low income countries.

"Early ARV for treatment and PMTCT initiation will prolong the duration of ART use and ensuring adherence may be a challenge.

"Increased ART care and the need for close follow-up with counselling, family and community support for breastfeeding HIV-infected mothers may challenge the health systems," he said.

ZAMBIA: HIV Testing Services Missing the Mark. 5/01/10

Service missing prevention opportunitiy.

Most clients did not receive counselling on partner reduction
Photo: Kristy Siegfried/IRIN

  LUSAKA, 5 January 2010 (PlusNews) - New research has found that Voluntary Counselling and Testing (VCT) services in Zambia are squandering the opportunity to reach clients with information about how to reduce their HIV risk.

The study, conducted by Private Sector Partnerships–One, (PSP-ONE), a USAID project aimed at increasing the private sector's capacity to provide quality health services in developing countries, looked at VCT services offered by the private, non-governmental, government and faith-based sectors in one urban and one rural province of the country - Copperbelt and Luapula.

In a report compiling the study findings, the researchers emphasise that VCT services form a critical opportunity to provide risk reduction counselling and HIV prevention information and to act as a gateway to HIV/AIDS services for clients who test positive.

Zambia has an adult HIV prevalence of 14.3 percent, but the infection rate is as high as 20 percent in some urban areas. New HIV infections rose from an estimated 70,000 in 2007 to 82,000 in 2008 - the majority of them through heterosexual sexual contact.

"In a generalized HIV epidemic where multiple concurrent sexual partnerships are a significant driver of new infections, discussion of risk-reduction methods should be a main focus of pre-test and post-test counselling," comment the researchers.

However, the study found that across all sectors, while condom use was emphasized, only one in three clients received counselling on reducing their number of sexual partners and even fewer were advised on how to disclose their HIV test results to partners.

Pre-test counselling tended to over-emphasise the risk of contracting HIV through blood exchange, which is not a major driver of Zambia's HIV epidemic, and of living positively with HIV, even before a client's status was known.

The research also found that VCT services across all sectors were mainly accessed by the most educated segments of the population, and were largely failing to reach the 65 percent of women and 51 percent of men in Zambia who have no or only primary school education.

The study found the quality of VCT services provided by private sector clinics was on a par with or better than those provided by public and NGO clinics, despite the lack of HIV prevention training opportunities offered to private providers. This raised the question of how beneficial those trainings were and whether their cost was justified.

One positive finding that emerged from the study was that most people sought VCT services close to their homes indicating they did not fear being stigmatized by their communities. This is in contrast to other studies from the region in which clients reported choosing VCT and treatment sites far from home to avoid detection and stigma from neighbours.

Although most of the clients reported being satisfied with the qualify of VCT services they received, this often had more to do with the friendliness of counsellors than their technical competence at emphasizing risk reduction and behaviour change.

The researchers conclude: "A renewed focus on adapting counselling topics to the realities of Zambia’s HIV epidemic will improve the efficacy of VCT across all sectors."

Call to Join World AIDS Day “Testing Millions” Campaign. 2009

Dear friends and colleagues,

Today 33 million people are estimated to be living with HIV. We know that the majority do not know their status. We can change that.

If you have not yet joined in support of the World AIDS Day “Testing Millions” Campaign we ask you to do so today. And we thank those of you that have.  A global coalition is working hard to make HIV testing free and accessible with linkages to antiretroviral treatment (ART).  We urge you to be a part of this worldwide movement to stop HIV/AIDS.

Around the world people are lining up to get tested ~ overcoming stigma and fear. To support their courageous steps to take control of their own health, we commit to making HIV testing faster, easier and more convenient.

From the Asia Pacific region, AIDS Healthcare Foundation’s country leadership has sent you a video message. Please take a moment and hear what they have to say by clicking here. They are on the front lines and are determined to transform HIV testing in their countries. They are fighting to save lives and we ask you to sign on with them.

Last year’s ONE MILLION Tests campaign resulted in 1,603,272 people being tested.  61,399 worldwide were identified as positive as a result of the campaign. This year we are hoping to more than double that.

We need your help. We ask for your endorsement and support in making Testing Millions a reality this World AIDS Day.

Be a part of this wordwide effort.

Many Thanks,

Terri M. Ford
Senior Director of Policy/Advocacy
AIDS Healthcare Foundation

Push For Routine Offers of HIV Tests. 11/11/09

CAPE TOWN — Health Minister Aaron Motsoaledi is pushing for a radical change in SA’s approach to HIV testing, proposing that doctors and nurses routinely offer screening to all their patients instead of waiting for them to volunteer or get AIDS- related illnesses.

People would still be able to decline the offer of an HIV test.

At the same time, Motsoaledi is leading a government charge to get more people to take voluntary tests. Both measures are meant to increase acceptance of testing and raise the proportion of HIV-positive people who know their status, in the hope that they will take precautions to protect others from infection and seek help if they fall ill.

SA has an estimated 5,3-million people infected with HIV, according to the Department of Health. Yet few of them know their status; last year only a quarter of South Africans had taken a test in the previous 12 months, according to the Human Sciences Research Council.

Motsoaledi said he expected the Cabinet and other leaders to be at the forefront of a huge public HIV testing campaign, possibly on World AIDS Day on December 1 — yet another mark of the current administration’s clear break with the Mbeki era’s lacklustre efforts .

“I will ask him (Zuma) to be in front of the queue, and indications are that he will agree,” Motsoaledi told reporters yesterday. “And I told the bishops to lead their flocks,” he said, referring to a recent meeting with religious leaders.

While prominent South Africans have on occasion taken public HIV tests there has not yet been a co- ordinated campaign involving high- profile figures. Public HIV tests for senior politicians became a contentious issue under the previous administration as neither former president Thabo Mbeki nor his health minister Manto Tshabalala- Msimang would take a such a step, defending their position as a personal matter. Tshabalala-Msimang was so irritated by Business Day’s questions at a press conference two years ago that she broke into Russian, which she had learnt during her time in exile. Tshabalala-Msimang did take a blood pressure test at a public event in a Cape Town township several years ago, in order to encourage people to follow suit.

By contrast, Zuma took a public HIV test in rural KwaZulu-Natal in March 2007, and the then deputy health minister Nozizwe Madlala- Routledge, in no less deliberate fashion, did so too.

The progression of the pan demic could be reversed with appropriate leadership, Motsoaledi said, citing the example of the Western Cape which broke ranks with national government. The province provided HIV-positive mothers with two drugs instead of one to reduce the risk of mother-to-child transmission of HIV. Dual therapy enabled the Western Cape to significantly cut its AIDS- related infant mortality rate.

Motsoaledi said he had asked the South African National AIDS Council to review SA’s capacity to conduct a huge voluntary HIV testing campaign and to determine whether the facilities existed to provide care to the people identified as infected.

Francois Venter, President of the Southern African HIV Clinicians Society, welcomed Motsoaledi’s suggestion of introducing provider- initiated HIV testing, saying such tests should be routinely offered.

kahnt@bdfm.co.za

Nearly One In Three People With HIV Do Not Know: EU. 27/10/09

(AFP)

 BRUSSELS — Almost one in three people infected with the virus that causes AIDS do not know they have the disease, increasing the risk of infection, the European Commission warned Monday.

In a document on combatting AIDS more than a quarter century after it surfaced, the EU's executive arm said now was not the time for Europe to drop its guard, noting that the figure was up to double in some neighbour nations.

And while efficient treatments exist to slow the evolution of the human immunodeficiency virus (HIV), no vaccine or cure has been found.

"We need to continue the political momentum in the fight against HIV/AIDS," EU Health Commissioner Androulla Vassiliou said in a statement.

"We need to encourage people to take responsibility for themselves and their partners by talking about and practicing safe sex and going for HIV testing," she said.

According to commission figures, the number of people living with HIV or AIDS in the 27 EU countries and its neighbours rose from 1.5 million in 2001 to 2.2 million in 2007, around 730,000 of whom live in the bloc.

Some 50,000 new cases of HIV were diagnosed in the EU and its neighbours in 2007.

The percentage of adults, ranging in age from 15 to 49, infected with HIV vary widely, from less than 0.1 percent in some countries to more than 1.0 percent in others.

France, Italy, Spain and Portugal have relatively high infection rates -- ranging from 0.4 percent to 0.5 percent -- but the number roughly triples in Estonia, which has a rate of 1.3 percent.

In Russia, around 1.1 percent of the population is HIV positive, while the figure climbs to 1.6 percent in Ukraine.

Copyright © 2009 AFP. All rights reserved

Screening Tool for HIV in Children Not Being Used Effectively. 15/10/09

 Incorrect use in routine practice of a World Health Organization (WHO)/UNICEF HIV screening tool for children at primary health care clinics in Limpopo and KwaZulu Natal provinces, South Africa leads to the failure of life saving interventions, Christiane Horwood and colleagues reported in a study in the September 22 2009 edition of BMC Pediatrics.
Forty per cent of trained health workers failed to identify HIV in any child and not one was able to classify every child correctly for HIV.

In South Africa where HIV prevalence rates among pregnant women remain at 29% the burden of paediatric HIV disease continues to grow. Limpopo with a mostly rural population of 5.5 million has high rates of poverty and poor access to basic services. While KwaZulu Natal has less poverty, half of the 10 million population lives in rural areas and antenatal HIV prevalence in 2006 was close to 40%.

Insufficient testing and follow-up of HIV-exposed children leads to high mortality rates with over half of untreated children dying within the first two years of life. Few children who need antiretroviral treatment receive it in spite of it being free. Improved follow-up of HIV exposed children, increased early identification of children with symptomatic HIV and improved access to ART for children are urgently needed.

New guidelines from WHO recommend that where virological testing is unavailable children should be started on antiretroviral treatment based on clinical diagnosis alone followed by quick confirmation of HIV status.

WHO and UNICEF developed the Integrated Management of Childhood Illnesses (IMCI) strategy to improve child survival in resource-poor settings. Focusing on the well-being of the whole child, the aim is to reduce death, illness, disability, and to promote improved growth and development among children under five years of age. South Africa adopted these guidelines as the standard of care for children at the primary level in 1997.

Multi-country evaluations of the IMCI strategy indicate, when used correctly, improved health worker performance and quality of care as well as a reduction in under-five mortality and improved nutritional status.

The guidelines have been adapted to incorporate a validated HIV component (including an algorithm) to identify and manage HIV infected (at risk for early death) and exposed (symptomatic) children. The IMCI course includes comprehensive training on this component.

For effective use of the algorithm, health care workers are expected to ask every mother bringing a sick child to a health care facility whether she has been tested for HIV, so that children may be classified as HIV-exposed, and all children should be assessed for clinical symptoms suggestive of HIV. The presence of three or more symptoms should trigger further investigation and the carer should be advised of the need for the child to be tested for HIV.

In this first known evaluation of the IMCI/HIV guidelines the study was designed to show how the guidelines are used by IMCI trained health workers, the validity of the HIV algorithm when used by expert IMCI practitioners in routine practice and the burden of HIV disease among under-fives attending primary health care facilities in Limpopo and KwaZulu Natal provinces.

Between May 2006 and January 2007 seventy-seven randomly selected IMCI trained health workers were observed by IMCI experts in 74 primary health care facilities in Limpopo and KwaZulu Natal provinces.

All sick children between the ages of two months and five years were eligible. Consultations with a total of 1357 sick children were observed. A different IMCI expert reassessed each child to confirm correct findings.

Consent for HIV testing for all children who attended was requested from parents or legal guardians with them. Positive rapid tests were confirmed with HIV polymerase chain reaction (PCR) in children under 18 months of age. HIV-positive children had CD4 counts and HIV clinical staging done.

Each health worker was observed for a mean of 2.2 days and 17.7 consultations. The average age of the observed children was 19.6 months of which 40.7% (552) were under one year of age. A third of all consultations were observed in Limpopo and the remaining two-thirds in KwaZulu Natal.

Of the 1064 children with available HIV test results 76 tested positive giving an HIV prevalence rate of 7.1% (CI: 5.7%-8.9%) among children in primary health care clinics. Of these 76, one was on antiretroviral treatment. Following CD4 counts or if unavailable WHO clinical staging, ART was indicated for 84% (63/75) of the remaining.

When compared to the HIV test results IMCI experts skilled at using the HIV algorithm correctly identified 90.8% (69/76) of HIV-infected children as either suspected symptomatic HIV or HIV-exposed and therefore in need of further investigation. This shows that when used correctly the HIV algorithm is an effective screening tool and can lead to improved access to life-saving treatment for HIV infected and exposed children.

In comparison over 40% of IMCI-trained health workers failed to identify HIV in any child because of poor or incomplete use of the HIV component. And, nine did not classify the disease stage of any child with HIV correctly.

Even when health workers classified children with suspected symptomatic HIV the need for testing, cotrimoxazole prophylaxis and feeding advice was only communicated to 64%, 31% and 43% of carers, respectively.

The authors suggest several reasons for poor use of the algorithm:

The authors recommend the strengthening of PMTCT and linkage with IMCI as well as improved access to HIV PCR for exposed children. This may reduce the need for the algorithm to identify symptomatic HIV. However, it will remain important for children whose mothers do not disclose their status, become infected during pregnancy and breastfeeding, and in settings where virological testing is not available.

The authors note that these findings show that undiagnosed HIV infection is common in primary health care clinics among under-five year olds and most have advanced disease. Current recommendations suggest that antiretroviral treatment is begun in children under one year of age as soon as HIV status is confirmed. They also note that their findings support the IMCI recommendation to check all children for possible HIV infection.

The authors highlight the study’s strengths. The IMCI experts were all highly experienced and pr0vided a “reliable gold standard”; observation of large numbers of children and health workers made it possible to describe performance using the health worker as the unit of analysis. Health workers had no notice of the observation and observation of large numbers over several days reduced bias.

The authors note several limitations. The observer’s presence may have influenced performance and led to bias. For example, health workers may have worked out what to do during the observation. Evaluation of individual ability to identify specific signs did not take place to avoid interference during the consultation. Evaluation of the sensitivity of HIV rapid tests in children under 18 months of age remains incomplete. They did not get CD4 results for all HIV infected children.

The authors conclude that IMCI and the correct use of the current guidelines can identify HIV-infected and exposed children and provide increased and earlier access to care in South Africa to reduce under-five mortality.

However, poor use of the guidelines limits its potential. The authors suggest further study to understand poor health worker performance “to provide evidence-based interventions to address poor IMCI implementation”.

Reference
Horwood C et al. Paediatric HIV management at primary care level: an evaluation of the integrated management of childhood illness (IMCI) guidelines for HIV. BMC Pediatrics 9:59, 2009.

Governments and Civil Society Expand Access to HIV Testing and Counselling. 30/9/09

HIV Testing More Than Doubles Worldwide in 2008. 30/9/09

HIV testing more than doubled in dozens of countries last year, leading to an upswing in HIV reporting and an increase in people getting treated, according to UNAIDS as reported by The New York Times.

 The agency’s 2009 progress report showed that the number of people on antiretroviral medication increased by more than a million people in 2008, raising the total number of people on treatment to more than 4 million. The number of HIV-positive children receiving medication increased from 198,000 to 275,7000 during that same period. More than half of HIV-positive mothers in Africa who need medication to prevent transmission of the virus to their infant received it.

“In the space of one year, you’re seeing a huge ramping up of AIDS services,” said Mark Stirling, regional director for UNAIDS in eastern and southern Africa. “It’s unprecedented. In the acceleration and intensification of reach, 2008 was an extraordinary year.”

However, the report also showed that while more than 1 million positive people were put on treatment in the past year, 2.7 million were newly infected in 2007, the last year data were available.

In Their Minds, Those Boys Do Not Have HIV. 31/7/09

JOHANNESBURG, 31 July (PLUSNEWS) - Jessica Standish-White is a senior student at St Mary's, a prestigious girls' school in one of Johannesburg's more affluent suburbs, where she organized an HIV testing drive. Standish-White, who is going to the University of Cape Town next year, told IRIN/PlusNews that some of her peers still think HIV can't happen to them.

South Africa: Time To Rethink Testing. 26/6/09

 PlusNews

Is HIV Self-Testing The Future? Living with AIDS # 391. 28/5/09

Health-e

Only 2% of SA Citizens have been Tested for HIV. 28/03/08

The billions spent on failed biological tools to stop HIV infection, such as microbicides, should rather have been spent on "human behavioural stuff", according to the president of the Southern African HIV Clinicians Society, Francois Venter.

"We have to fix human behaviour. The solution to the HIV crisis is probably in our social values," Venter said in a hard-hitting talk in Cape Town on Wednesday night.

It was estimated that half of all South Africans will eventually be infected with HIV and this showed how the prevention policy had failed.

The failure was due to healthcare workers not offering patients what they needed, but preaching "a moral message" of stopping smoking, better nutrition and "believing in Jesus".

Consequently, three-quarters of those who tested positive were lost to follow-up, until their white blood cell counts dropped to a critical point and they returned desperately ill. "When are we going to start offering something that patients value?"

Since anti-retroviral therapy (Art) rollout, there had been 1.8 million new infections. There were four new infections for every one person starting on Art.

"What is going on that we will be treating in 10 years someone who is infected tonight? We need an emergency approach to prevention. There is not a single hint at the moment that the HIV rate is going down, except maybe in teenagers," he said.

In South Africa, half of all deaths a year were Aids-related. By 2025, the best forecast for life expectancy would be 59 years and the worst 50 years.

The fact that there would be two million Aids orphans by 2010 was an "absolute national catastrophe and crisis by itself" - especially considering there was no social welfare system in place to deal with it.

While promoting the use of condoms was the major thrust of the HIV prevention campaign in South Africa, people were still not registering that they had to use them every time they had sex.

And there was no focus on the high risk groups: married women and widows.

"We do not understand the sexual dynamics of this country," Venter said.

Only two percent of the population have tested for HIV.

"Everybody thinks they're immune," he added. Four-fifths of those with HIV in the world lived in southern Africa and one-fifth in South Africa.

A World Health Organisation report recently warned that the world "must be scared" if South Africa does not get its HIV problem right, he said.

Another future problem was that while medicine took care of tuberculosis, pneumonia and gastroenteritis - the top three killers in South Africa apart from Aids - there would be "a flood" of cardiovascular diseases from the fourth and fifth top killers - the lifestyle diseases, hypertension and diabetes.

People who Stigmatise HIV are Less Likely to Take an HIV Test. 30/10/10

People who tested were significantly less likely to hold negative attitudes and beliefs about people living with HIV

AIDSMap

Individuals with stigmatising beliefs about HIV are less likely to test for the virus, an international team of investigators report in the online edition of the Journal of Acquired Immune Deficiency Syndromes. The research involved 5249 individuals in the South African townships of Soweto and Vulindlela. Only 41% had ever tested for HIV.

 “Compared to those who had never tested, people who tested were significantly less likely to hold negative attitudes and beliefs about people living with HIV, more likely to believe people with HIV face discrimination, more likely to hold beliefs that people living with HIV should be treated equally, and more likely to believe that most people have previously tested for HIV”, write the investigators.

Stigma must be addressed in future studies looking at improving HIV testing rates in South Africa, the authors stress.

Many patients with HIV die needlessly because their HIV is diagnosed late. There is also good evidence that many new HIV transmissions originate in undiagnosed individuals. Therefore increasing rates of HIV testing is a public health priority, especially in South Africa, where there is a high prevalence of undiagnosed infections.

Investigators from Project Accept wanted to examine the associations between HIV testing and perceptions of stigma and social norms in South Africa.

A total of 5259 individuals aged between 18 and 32 were therefore asked to complete a questionnaire. This enquired about the individuals’ HIV testing history. 

Questions were also included on HIV-related stigma. These were designed to see if the participants had negative attitudes towards people with HIV. For example, they were asked to agree or disagree with statements such as “people who have HIV/AIDS are cursed”, and “people with AIDS are disgusting.”

Participants were also asked if they thought people with HIV were discriminated against, and if they believed people with HIV should be treated equally.

Finally, a question was included to see if testing for HIV was perceived to be the social norm, and participants were also asked to indicate if they believed “most people have been tested for HIV.”

Overall, 41% of individuals reported that they had had an HIV test. These individuals were older (25 vs. 22) and better educated than those who had never tested (13+ years of education: 11% vs. 7%).

The investigators’ first set of analyses showed that the following factors were associated with an increased likelihood of testing:

Further analysis showed that women (p = 0.0078), older individuals (p = 0.0141), and those with 13 or more years of education (p = 0.0016) were significantly more likely to have tested.

However, the relationship between two of these measures (sex and education) and an increased likelihood of testing, weakened with age.

In contrast, the relationship between testing and a belief that people with HIV experienced discrimination increased with age (p = 0.001). Women who believed that people with HIV should be treated equally were more likely to have tested than men who had this belief (p = 0.009).

‘The present study suggests a link between HIV testing, stigma, and social norms such that decreasing HIV-related stigma may help to increase testing”, comment the investigators.

They continue, “interventions that culturally and demographically tailored toward populations of interest might prove to be more effective in decreasing stigma and increasing testing.”

Use of self-reported testing history, and gathering information on stigma via a questionnaire was, the investigators acknowledge, a potential limitation of their study. They comment, “it is possible that participants were motivated to underreport negative attitudes related to HIV because of social desirability.

However, the researchers are confident that their study “builds on results of previous research on stigma and testing and suggests that stigma is associated with people’s HIV testing behaviour.”

They conclude that it is “imperative” that future studies looking at ways of increasing HIV testing in South Africa address stigma.