Guyana PMTCT TrainingModule 5, Slide 1 Module 5 HIV Testing and Counselling for PMTCT.

Guyana PMTCT Training Module 5, Slide 1

Module 5

HIV Testing and Counselling for PMTCT

Guyana PMTCT Training Module 5, Slide 2Module 5, Slide 2

Module Objectives

Discuss the integration of HIV testing and counselling in settings where MCH services are provided

Discuss the three guiding principles for testing and counselling

Explain the difference between provider- and client- initiated approaches to HIV testing


Module Objectives (Continued)

Describe the importance of effective communication and counselling skills when working in settings where PMTCT services are provided

Describe the ways to deliver pre-test information & counselling

Provide pre-test information

Provide an overview of HIV testing of women with unknown status in labour and delivery (L&D) settings


Module Objectives (Continued)

Describe HIV Testing Processes

Explain the meaning of positive (reactive) and negative (non-reactive) HIV test results

Describe the steps involved in post-test counselling

Discuss the disclosure process for women who are HIV-infected


Session 1

Overview of HIV Testing and Counselling for

PMTCT


Session 1 Objectives

Discuss the integration of HIV testing and counselling in settings where MCH services are provided

Discuss the three guiding principles for testing and counselling

Explain the difference between provider- and client- initiated approaches to HIV testing


HIV Testing and Counselling

HIV testing provides:

Information about HIV status

Opportunity to identify women with HIV and empower them to make decisions to prevent MTCT

Opportunity to identify women who are HIV negative and empower them to remain negative


Provider- and Client-Initiated Approaches to HIV Testing

Two basic approaches to HIV testing:

1. Provider-initiated

2. Client-initiated

Both approaches include

Basic information about providing HIV testing

Risks and benefits of testing


Provider-Initiated Approach

HIV testing is a routine, expected part of standard care

Also referred to as “opt-out”

All women provided with pre-test information

All women are tested for HIV and provided with post-test counselling unless they decline testing

Testing is still voluntary under the provider-initiated approach


Client-Initiated Approach

Client specifically requests HIV test Also referred to as “opt-in”

Clients provided with pre-test counselling

Only clients who specifically request to be tested are provided with HIV testing

Client gives verbal or written consent


Preferred Testing Strategy: Provider-Initiated

Recommended for HIV testing and counselling in ANC, L&D, post-delivery settings

Helps normalize HIV testing

Likely to increase the number of women who get tested for HIV


HIV Testing and Counselling (continued)

WHO recommends provider-initiated HIV testing and counselling as a standard part of antenatal care (ANC), labour and delivery and

post-delivery care


Provider Initiated or Opt-Out Approach HIV testing is offered as a routine part of care

Women are provided with information and tested for HIV unless they decline to be tested or “opt-out”

Testing is still voluntary under “opt-out” since the client has a right to decline testing

Confidential post-test counselling is provided

Guyana’s HIV Testing Policy


Definitions

HIV testing: process of determining if a client is infected with HIV. Blood or body fluids are tested for the presence of antibodies or antigens associated with HIV infection

HIV counselling: confidential dialogue between an individual or a couple and a healthcare worker (HCW) to help clients examine their risk of acquiring or transmitting HIV

HIV counselling is tailored to the risk behaviour, circumstances and special needs of the client


Advantages of Testing and Counselling for All Clients

1. HIV testing and counselling provides clients with an opportunity to learn their HIV status

2. Discuss partner testing and prevention (discordance, disclosure)

3. Receive information on treatment, care, nutrition, family planning and support services

4. Learn about importance of continuous health care

5. Make informed decisions about their pregnancy


Advantages of Testing and Counselling continued

For HIV-negative women, advantages include:

Information and support to remain uninfected

Information and support to exclusively breastfeed


Advantages of Testing and Counselling (Continued)

For HIV-infected women, advantages include:

PMTCT interventions (ARVs, safer delivery, infant feeding, referrals)

Learn about the needs of HIV-exposed children (HIV testing, cotrimoxazole)


Guiding Principles for HIV Testing

1. Confidentiality

2. Informed consent

3. Post-test support and services


Guiding Principles (Continued)

1. Confidentiality Important responsibility of all HCWs

Essential to establishing and maintaining client trust

Information shared between HCWs and clients must be kept private



1. Confidentiality, continued

Personal and medical information may be disclosed to other HCWs only to ensure client receives appropriate medical care

Only those directly involved in client's care will have access to medical records - and only on “need-to-know” basis

Anyone not directly involved in a client’s care (e.g., receptionist at ANC clinic), should not have access to client medical records



1. Confidentiality, continued

All medical records and registers, whether or not they include HIV-related information, should be kept private and stored in a safe, secure place



2. Informed Consent

Process during which clients receive clear and accurate information about HIV testing to make an informed decision about whether to accept or decline testing



Elements of informed consent:

An understanding of the purpose and benefits of testing, counselling and PMTCT services

An understanding of the testing and counselling process

Respect for the client’s testing decision



Informed consent:

Since HIV testing in Guyana during ANC is offered as part of routine care services (Opt-Out), written informed consent is not required

The client has the right to decline testing and can do so verbally



3. Post-test counselling support and services

HIV test result should be offered in person as part of an individual (or couple) post-test counselling session

Provide both HIV-negative and HIV-positive women with test results and counselling



3. Post-test counselling support and services

Ensure privacy when providing HIV test results

Reassure client you will keep the conversation and test results confidential

Inform client that follow-up treatment, care, support are available, including support for disclosure when needed


Exercise 5.1

Confidentiality Role Play: Large Group Discussion


Session 2

Counselling Skills



Describe the importance of effective communication and counselling skills when working in settings where PMTCT services are provided


Basic counselling Skills

Empathising

Active listening

Open questioning and probing

Focusing

Correcting inaccurate information

Module 5, Slide 30


Characteristics of a Good Counsellor

Establishes good rapport with client

Has a good understanding of the issue (HIV/AIDS, Infant Feeding, Testing, etc.)

Understands the cultural and psychological factors that may affect a client’s decision

Uses non-judgmental approach

Presents information in a sensitive way

Recognizes when they cannot sufficiently assist a client, and refers him/her to an appropriate provider

Observes and responds to non-verbal communication (body language)

Module 5, Slide 31


Role of the HCW in Counselling

Role of HCW during counselling: support and assist client’s decision-making process by:

Listening to client

Understanding the choices client needs to make

Helping client explore her/his circumstances and options

Helping client develop self-confidence to carry out her/his decision about testing


Role of the HCW in Counselling(Continued)

HCW is not responsible for:

Solving all of the client’s problems

The client’s decisions


Counselling Skills: Active Listening

It involves:

Listening to and understanding the client

Taking note of client’s non-verbal behaviour

Listening for client’s social and cultural context

Listening to client’s negative comments or feelings—make note of things that may have to be clarified

Active listening helps establish a trusting relationship with the client


Counselling Skills: Self-Awareness

HCWs needs to be aware of their:

Strengths and weaknesses

Fears or anxiety about HIV


Counselling Skills: Self-Awareness (Continued)

Consider your responses to these questions:

What are my expectations of my clients?

How do I feel about discussing HIV infection and AIDS?

What are my feelings about people with HIV infection or AIDS?

What are my feelings about people whose behaviour has placed them at risk?


Counselling Skills: Self-Awareness (Continued)

Consider your responses to these questions:

Which sexual practices would I find most difficult to talk about?

Will I be judgemental of clients whose values, beliefs, attitudes, fears and views differ from mine?

Am I ready to let clients make their own decisions?


Listening and Learning Skills

Skill 1: Use helpful non-verbal communication

Includes all aspects of the message not conveyed by words

It includes the impact of gestures, gaze, posture and expressions that convey information

Reflects attitude

Helpful non-verbal communication encourages client to feel HCW is interested in him/her


Non-Verbal Communication

R A relaxed and natural attitude with clients

O Open posture should be adopted—it shows that you are open to the client and to what client is saying

L Leaning forward toward the client is a sign of involvement

E Maintain culturally appropriate eye contact

S Sit squarely facing client to show involvement


Listening and Learning Skills

Skill 1: Use helpful non-verbal communication

Demonstration


Listening and Learning Skills (Continued)

Skill 2: Ask open-ended questions

Open-ended questions begin with “how?” “what?” “when?” “where?” or “why?”

Encourages responses that lead to further discussion

Try to avoid questions with a “yes” or “no” answer



Closed-ended Open-endedYou know what HIV is, don’t you?

What is HIV?

Do you have any other questions about MTCT?

What other questions do you have about MTCT?

Are you going to tell your partner about your HIV test result?

Who are you going to tell about your HIV test result?

Is your husband your only partner?

How many partners have you had in the last 3 months?

Do you plan to replacement feed?

How do you plan to feed your baby?



Skill 2: Ask open-ended questions

Demonstration



Skill 3: Use gestures and responses that show interest

Gestures: nodding and smiling

Responses: “Mmm,” “Aha”

Attending skills: clarifying and summarizing - invite client to relax, talk about herself and her problems



Clarifying

Prevents misunderstanding

Helps sort out what has been said

Summarizing

Helps ensure client and HCW understand each other

Summarizing can offer support and encouragement to clients to help them carry out decisions they have made



Skill 3: Use gestures and responses that show interest

Demonstration



Skill 4: Reflect back what the client says

Encourages person to say more

Shows HCW is actively listening, encourages dialogue, gives HCW opportunity to better understand client’s feelings

Say what client said in a slightly different way

If client says, “I don’t know what to give she to eat, she ain’t want nothing” HCW might reflect back by saying: “You sure she not eating anything at all?”



Skill 4: Reflect back what the mother says

Demonstration



Skill 5: Empathize - show you understand how client feels

Used in response to an emotional statement

Encourages client to discuss the issue further

If client says, “I don’t know how to tell he I got the virus,” HCW could respond with “Wha you mean, you don’t know how to tell he?”

HCW is not empathizing if she responds with a question that has a factual answer



Skill 5: Empathize—show you understand how client feels

Demonstration



Skill 6: Avoid words that sound judging

Words like: right, wrong, well, badly, good, enough, properly

Using these words may make client feels she is wrong, or that there is something wrong with her baby

BUT, sometimes HCW needs to use “good” judging words to build a mother's confidence



Skill 6: Avoid words that sound judging

Demonstration


Exercise 5.2

Listening and learning skills: demonstration (in the large group)

and practice (in small groups)


Common Mistakes

Controlling the discussion

Judging the client

Preaching to a client

Labelling a client instead of finding out their individual motivations, fears or anxieties

Reassuring a client without knowing what the outcome could be


Common Mistakes (Continued)

Not accepting the client’s feelings

Advising before client has arrived at a personal solution

Interrogating

Encouraging dependence

Persuading or coaxing


Session 3

HIV Pre-test Information, Counselling and Testing



Describe the ways to deliver pre-test information

Provide pre-test information

Provide an overview of HIV testing of women with unknown status in labour and delivery (L&D) settings

Describe HIV Testing Processes

Explain the meaning of positive (reactive) and negative (non-reactive) HIV test results


Pre-test Information

The purpose of the pre-test session in PMTCT settings is to provide the woman or couple with adequate information to make an informed decision about HIV testing


Pre-test Information (Continued)

Objectives and components of the pre-test session:

Help client understand HIV

Explain importance and benefits of HIV testing

Explain HIV testing procedures

Explain importance of partner testing, discordance, disclosure

Explain risk reduction and available services (condoms, MTCT) and provide referrals

Encourage continuous healthcare attendance (ANC and post-delivery)


Delivery of Pre-test Information

Pre-test delivery model should: Optimize the staff available

Not disrupt client flow

Maximize the number of women tested during their first visit

Pre-test session models: Group information

Individual information

Couple counselling


Group Pre-test Information

Group information: Optimize human resources

Allow for interaction among participants

Can be easily integrated into the clinic flow

Group information sessions: Are recommended for ANC settings

Not practical or recommended for the L&D setting


Group Pre-test Information (Continued)

Key considerations for group sessions:

Adjust information to fit group's level of knowledge

Emphasize behaviour change, including safer sex practices

Set aside time for questions and answers

Have enough knowledge and skills to answer questions

Refer for individual counselling, when requested



Key information for group sessions:

Definitions of HIV & AIDS

Modes of HIV transmission

How to prevent HIV & other STIs

Safer sex practices

Confidentiality

HIV Testing Process

Interventions to prevent MTCT (e.g., ARVs, etc)



Support and encourage women to be tested at their first ANC visit

Accommodate the need for family support and return visits where requested

Welcome family members; provide them with the same HIV pre-test information given to the client


Exercise 5.3

Providing pre-test information: demonstration (in the large group)

and practice (in small groups)


Individual Pre-test Session

The individual session is used either to:

1. Provide pre-test information OR

2. Provide information that complements group session to:

Reinforce pre-test information and answer questions

Address barriers to testing

Provide risk assessment, risk reduction counselling


Individual Pre-test Session (Continued)

When testing and counselling is part of ANC services, clients must be reassured that declining an HIV test will NOT affect access to services.

Emphasize that if the client changes his/her mind and wants to be tested, an HIV test can be

provided during a later visit.


Testing and Counselling in L&D

L&D presents unique challenges for HIV testing:

It is busy and the patient has very little privacy

Women are often anxious and in pain

Women of unknown/undocumented HIV status at time of labour may be tested in L&D

Make the woman comfortable, ensure testing is as confidential as possible


Testing and Counselling in L&D (Continued)

Scenario Possible solution

Woman presents to L&D in early labour

Provide pre-test information, rapid testing and result

Woman presents to L&D in advanced labour with just enough time for pre-test session

Provide pre-test information and testing if possible.

Woman presents to L&D late in labour or is unable to test during labour

Offer pre-test information, testing and result after delivery


Testing and Counselling in L&D (Continued)

Content of the pre-test session in L&D

1. Introduce yourself

2. Explain MTCT

3. Discuss importance of testing

4. Explain testing process


Conducting the Pre-Test Session in L&D

Agree on a signal for contractions; wait until the contraction is over

If no record of HIV testing, inform mother she will receive information and testing for HIV

HIV testing is done, unless woman declines

Speak in soft tones, but make sure she can hear

Use a temporary screen or curtain for privacy or conduct session in another quiet area


Overview of HIV Testing

HIV tests detect antibodies or antigens associated with HIV in whole blood, saliva, or urine

Blood sampling is the most common method of testing

HIV tests are very accurate


HIV Tests

Antibody tests

After infection with HIV, the body makes antibodies to fight the virus

It may take 4 to 6 weeks, but occasionally up to 3 months for antibodies to become detectable in the blood During this time, a person can still transmit the virus to

others

Rapid HIV tests and the ELISA are the most common antibody tests in PMTCT settings


HIV Tests (Continued)

Rapid HIV tests Accurate results within 20-40 minutes

Can be done in the clinic setting

Accurate when performed correctly

Usually performed on serum or whole blood (by fingerprick or venous sample); some rapid HIV tests use saliva

No batching required

HCWs can be trained to perform the tests

Usually do not require special equipment, electricity or refrigeration


HIV Tests (Continued)

Benefits of rapid HIV testing include:

On-site testing and same day results

Lower risk of administrative error

Accepted by clients

Fewer resources required:

Human resources

Resources at the facility

Financial resources

Lower risk of occupational exposure


Guyana’s Rapid HIV Testing Algorithm

Parallel testing

Two HIV tests are performed on same sample at the same time, e.g., in parallel

If both are non-reactive, client reported HIV-negative

If both are reactive, client reported HIV-positive

If one is reactive and the other non-reactive, a “tiebreaker test” is performed


Guyana’s Rapid HIV Testing Algorithm(Parallel Testing)


ELISA

The ELISA is also an HIV antibody test

Accuracy of the ELISA and rapid testing are comparable

Limitations of the ELISA: Tests must be done in batches of 4090

Positive results must be confirmed with another ELISA or Western blot

Specimens sent to a laboratory for testing—results may take days to weeks

Test requires refrigeration and specific reagents


Interpreting HIV Antibody Tests

A positive HIV test means that antibodies to HIV are present. It does not mean that the client has AIDS

A negative HIV test can mean:

The person is not infected with HIV, or

The person is infected with the virus but is in the “window period”

A negative test does not mean that person cannot become infected. There is no such thing as

immunity to HIV infection


HIV Viral Tests

Viral tests detect the presence of HIV in blood

Viral tests must be done by trained personnel in the laboratory


HIV Viral Tests (Continued)

There are two types of viral tests:

p24 antigen test: measures one of the HIV proteins used for screening blood and for infant diagnosis

PCR (polymerase chain reaction) tests:

DNA PCR detects presence of HIV inblood and is used for infant diagnosis

RNA PCR detects and measures amount of virus in blood (viral load)


Steps to HIV Testing

1. Information is provided to client

2. Consent obtained

3. Blood specimen taken

4. The specimen is processed

5. Test is conducted by a HCW or laboratory technician

6. The client is told their result

7. HCW provides post-test counselling, support and appropriate referrals


Session 4

HIV Post-test Counselling



Describe the steps involved in post-test counselling

Discuss the disclosure process for women who are HIV-infected


Post-test Counselling – All Clients

All HIV test results, whether positive or negative, must be given in person, privately (as a single client or couple)

Put the client or couple at ease

Where possible, provide a quietand private room for the discussion

Ideally, the same HCW who conducted the pre-test session will also conduct the post-test session


Post-test Counselling HIV-negative Client

Post-test counselling provides an opportunity for the woman to:

Review the meaning of the test result and discuss the “window period”

Learn how to protect herself and her infant from HIV infection

Learn that if infected during pregnancy or breastfeeding, risk of MTCT is increased


Post-test Counselling HIV-negative Client (Continued)

Objectives of the post-test session:1. Provide HIV test result and assess understanding of result

2. Identify and address client questions

3. Discuss: Partner HIV testing and disclosure

Safer sex and risk reduction

Exclusive breastfeeding

Antenatal care, post-delivery care

Importance of delivering in a healthcare facility

Infant care

4. Provide referrals, take-home information


Post-test Counselling HIV-positive Client

Inform the client of the result simply & clearly and give time to consider it

Client reactions to results can range from acceptance to disbelief; help client cope with these emotions

Discuss what “HIV-positive” result means

Remain non-judgemental, supportive and confident throughout the counselling process


Post-test Counselling HIV-positive Client (Continued)

Discuss any immediate concerns, including personal safety and issues of domestic violence

Assist the client to determine who in social/family network can provide support

Arrange a specific date & time for a follow-up visit

Provide the client with a contact person’s name and phone number

Encourage client to return for her ANC visits and follow-up HIV post-test counselling


Post-test Counselling HIV-positive Client (Continued)

Other topics for post-test sessions: Coping strategies

Issues of Domestic Violence

ARV therapy or prophylaxis

Infant feeding options

Maternal nutrition including iron & folic acid supplementation

Safer sex, including provision of male and female condoms and guidance on their use

Treatment and support services for client and family


Disclosure of HIV Status

Disclosure is informing others of a test result

Clients who disclose are in a better position to:

Encourage partner(s) to be tested

Prevent transmission of HIV to partner(s)

Access PMTCT interventions

Receive support from partner(s) and family

It is important to respect client's choice regarding timing and process of disclosure


Exercise 5.4

Post-test Counselling:demonstration (in the large group) and

practice (in small groups)


Subsequent ANC Visits

Discuss, or reinforce, the following during subsequent visits:

ARV Interventions for PMTCT

Infant feeding options

Follow-up care and treatment for the woman and her infant

Family planning options

These topics should be discussed beginning during the first ANC visit


Key Points

Guyana utilizes the provider-initiated approach to HIV testing and counselling in ANC, labour and delivery and post-delivery settings.

With the provider-initiated approach, the client has the right to decline the test. Testing will be done, unless the client declines

Partner testing and couple’s counselling are encouraged


Key Points (Continued)

Pre-test information, HIV testing and post-test counselling should be available to all pregnant women

There are three guiding principles for testing and counselling in PMTCT settings: confidentiality, informed consent and post-test support and services



There are two processes for rapid HIV testing: parallel and serial testing

Guyana uses parallel HIV testing. Two HIV tests are performed on the same sample at the same time. If both are non-reactive, client is reported as negative, while if they are both reactive, client is reported as positive. If the two results are different a “tiebreaker” test is performed.



Post-test counselling is important for all women: For women who are HIV-negative, to emphasize

prevention of HIV infection

For women infected with HIV, to give information on PMTCT and referrals for HIV care, treatment and social services, where available

An important component of the post-test session is the offer of subsequent healthcare visits and referrals for HIV prevention, treatment, care and support services.

All women should be encouraged and assisted to return for subsequent healthcare visits, particularly those who test HIV-positive

Guyana PMTCT TrainingModule 5, Slide 1 Module 5 HIV Testing and Counselling for PMTCT.

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