The working group recommends that the offer of an HIV test should be encountered in all health care settings, in order to increase the proportion of people who know their HIV status and to identify those who need immediate treatment. How practical is this, given that only 12% of individuals who might need VCT currently have access to it, and what issues does it raise?
Chris Green, a HATIP panel member who works as a treatment educator in Indonesia, is particularly concerned about the potential for prevention and care opportunities to be lost if the process of voluntary counselling and testing is slimmed down in order to offer the test to more people.
Until HIV infection is normalised, the test must always be accompanied by pre- and post-test counselling, provided by trained counsellors. I prefer to talk about CVCT Counselling and Voluntary Confidential Testing to reflect the process and the need for confidentiality. Note that WHO now refers not to VCT but to T&C.
The WHO/UNAIDS approach is to focus on those who are symptomatic and in treatment, and to adapt pre-test counselling in these situations to that necessary 'to simply ensure informed consent, without a full education and counselling session.' [UNAIDS/WHO Policy Statement on HIV Testing (June 2004)]
Chris Green at least takes issue with this approach. "In my experience, pre-test counselling is more important than post-test counselling. After the fateful word 'positive', little of what follows is heard. While post-test counselling should be an on-going process, we cannot be sure that the person concerned will take this up. Thus the main lessons must be provided during pre-test counselling."
However, while pre-test counselling does require training, counsellors do not have to come from a health care background. This is a role that can (and must) be played by the community, a fact which is accepted by the WHO. Naturally, counsellors must be provided with training, must be reimbursed for their time, and must be provided with psychological support for their very stressful task.
But he concedes that introduction of rapid tests that allow diagnosis on the same day or within minutes could change patterns of practice.
Many countries are now debating how to make HIV testing routine, arguing that `opt in` voluntary counselling and testing allows people to avoid confronting their risk of HIV infection as well as contributing to stigma.
Current practices are also labour intensive. Molly Tumisiime, a nurse at the Mildmay Centre in Kampala points out: The patient health worker ratio is still high making it relatively unrealistic to add a service such as pre and post test counselling to the already overworked health care worker.
Increasing access to voluntary counseling and testing is essential for reaching ambitious treatment goals - WHOs 3 x 5 target and PEPFARs target of 2 million on treatment by the end of 2008. The availability of treatment is likely to stimulate demand for testing too.
In the setting where I work, what we have noticed is that we increased voluntary counselling to a limited extent [when treatment was not available]. Its only in the past three to four months [since it became available] that weve seen a steady increase in the numbers coming forward for testing. At the moment less than 10% of HIV-infected South Africans know their HIV status - treatment and voluntary counselling and testing can build each other, said Dr Salim Abdool Karim of the University of Natal, South Africa, at the launch of the working group report.
In Khayelitsha, uptake of HIV testing rose dramatically with the introduction of HAART, from 1,000 tests conducted in 1998 to 12,000 in 2002. A 2002 survey of nine sites, including Khayelitsha in South Africa, found that Khayelitsha residents reported the highest levels of male condom use, willingness to use a female condom, willingness to have an HIV test, and desire to join an AIDS club (CADRE, 2002).
In lower prevalence settings, says Chris Green, what is needed is a much more suspicious approach by health care workers, to identify patients who have had risky behaviour. Currently doctors in this country spend around five minutes with each patienthow can they possibly address this in so short a time?
He also highlights the potential for further stigmatisation, especially in low prevalence settings such as Indonesia and other South East Asian countries.
Given lack of resources, it is essential that we focus on those more likely to be infected. The downside of this is that we again are seen focussing on high-risk groups, and we exacerbate the existing stigma surrounding HIV infection. So the challenge is to address HIV-related stigma and discrimination while focussing on just those groups who are already marginalised for other reasons.