Reimagining HIV counselling and testing in an …...Reimagining HIV counselling and testing in an...
Transcript of Reimagining HIV counselling and testing in an …...Reimagining HIV counselling and testing in an...
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Reimagining HIV counselling and testing in an evolving
epidemic
Heidi van Rooyen, PhD Human Sciences Research Council
2nd Serial NDOH/PEPFAR Dissemination Workshop
Reaching 90-90-90 Part I: Best Practices and Innovations in HCT and Linkage Innovations
30 November 2015, Southern Sun, Pretoria
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Outline
• Looking back
• The limits of our assumptions
• Lost in translation
• Treatment tilts the axis
• Reimagining
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LOOKING BACK
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Looking back
• Model evolved in the US and Europe – Morally conservative time; gay
plague – Fear, stigma, mortality and
clinical powerlessness
• Measures commonly used for other diseases questioned: – With no effective treatment,
HIV a “death sentence” – Limited health benefits to
knowing – Widespread screening not
promoted
Bayer, 1991; de Cock et al, 2002; de Cock, 2005
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The first counselling and testing policy
• Focus on protection, autonomy, privacy and human rights of PLHA or those at risk
• “AIDS exceptionalism”
• Emphasis on voluntary counselling and testing,
the 3Cs:
–Counselling before and after a test
– Informed consent
–Confidentiality
Bayer, 1991; de Cock et al, 2002; de Cock, 2005; CDC, 1990; 1994
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Looking back HIV and AIDS does warrant ‘special treatment’
“ the psychological effects of the disease are felt by individuals, families and health care staff; this together with the nature of the illness – a potentially fatal, incurable, transmissible disease – elevates the need for counselling in HIV infection to that of a major priority”
Keeling, 1993
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THE LIMITS OF OUR
ASSUMPTIONS
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Behaviour change assumptions of HIV testing
• VCT is an individual-level, behavior change intervention
• People are rational, responsible, motivated and have agency to adopt protective actions – Individuals have not changed their behavior
because they are uncertain about their status – Testing by itself will effect standard behavioral
changes – Testing information will cause people to behave
differently • We’ve come to learn, if not fully appreciate, that
human behavior is more complex than that
Yeatman, 2007
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LOST IN TRANSLATION
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Simple cultural transfers rarely work
• Simply transferred to Africa
• Low income, poverty, at scale in communities
• In a context of families and reproduction
• In cultures with emphasis on “we” and obligations to others
Angotti, 2007; 2012
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Global 3 Cs lost in translation: Confidentiality Examples
• Malawi counsellors struggle to enforce strict confidentiality when: – someone they knew will be infected – they felt those who provide care should be
informed • Confidentiality was never meant to mean
secrecy. But, in South Africa direct translation for confidentiality is “Imfihlo”: – known by few privileged people – something that is hidden from the public domain – HIV is a secret
Angotti, 2007; 2012
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A dilemma of simultaneous orientation
Public Health Approach
• Directive with clear public health outcomes
• Identify, alter, and address desirable behaviour
Client-centred Counselling
• Non-directive
• Clients experience starting point
• Clients ‘empowered’, their self-directedness increased
van Rooyen et al 2009; van Rooyen, 2011
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TREATMENT TILTS THE AXIS
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REIMAGINING
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Create Demand for HIV Testing
Link to HIV Testing
Deliver Pre-Test
Information
HIV Diagnosis
Deliver Post-Test
Counselling
Refer and Link to Other Health
Services
The HIV Prevention Continuum
WHO HIV Testing Services Guidelines, 2015
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HIV
neg
ativ
e
HIV
Po
siti
ve Link to Care
Link to Prevention
Link to Art
Adherence and Viral Suppression
Link to Prevention Services
ART as Prevention/Test and Treat
WHO HIV Testing Services Guidelines, 2015
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How would HIV have developed if borne out of an African experience?
UNAIDS MDG Report, 2015
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Innovate, expand the essential HCT mix
“ HIV testing should remain voluntary, but counselling remains mandatory; it
has not evolved”
Marum et al, 2013
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Community-based HCT shift’s service delivery: “takes services to people through active providers”
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Community HBCT as a platform for integrated response
Sustainable East Africa Research for Community Health
SEARCH: Cluster randomized trial of universal vs. standard ART
16 villages; n = 10,000 each
Universal ART
(all CD4 counts)
Country-guided
ART)
Community Health • HIV incidence
• HIV population viral metrics
• AIDS
• Maternal and child health
• TB
Outcomes
Community
Productivity • Workforce participation
• Child labor prevalence
• Agricultural output
• Household income
• Educational attainment
• Healthcare utilization
SEARCH
Partners NIH
WHO
PEPFAR
World Bank
Gilead
Sciences
Uganda MOH
Kenya MOH
UGANDA KENYA
Mbarara
Tororo
Nyanza
Control Communities:
Intervention
Communities:
HIV Screening/Diagnosis
Malaria testing & care
HTN and Diabetes testing
Maternal/child health
Annual Community
Health Campaigns 16 villages; n = 10,000 each
Slide: Connie Celum
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Sexual behavior is shaped through social interactions between partners within a couple and through pressure and
influence from family and the community (Parker 2001).
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Community-based HCT provides an opportunity for a comprehensive responses to HIV
Counselling and Education
Clinical Interventions
Long lasting
Protective Interventions
Changing the Context Healthy Default Decisions
Socio-economic Factors
Increasing individual
effort needed
Increasing population
impact
Health Impact Pyramid Frieden, 2010
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UNAIDS MDG Report, 2015