Voluntary Counselling and Testing

Historically, because a positive result was a terminal diagnosis and because of concerns about its impact on the individual, HIV testing was done on an ‘opt-in’ or ‘client-initiated’ basis. This means two things have to happen in sequence:

  • The patient has to specifically come forward and request an HIV test.
  • Specific consent, written or verbal, is obtained and recorded, during a pre-test discussion. Such recorded ‘consenting’ is generally used for more serious procedures that carry a degree of risk, such as operations and biopsies, to establish that the patient was made properly aware of the risk and agreed to take it.

The perceived importance of only performing HIV tests on an informed patient who had clearly expressed his or her consent was underlined by the fact that the phrase ‘Voluntary Counselling and Testing’ (VCT) was most often used, especially in lower-income country contexts.

The WHO defines this approach as: “individuals actively seeking HIV testing and counselling at a facility that offers these services. Client-initiated HIV testing and counselling usually emphasizes individual risk assessment and management by counsellors, addressing issues such as the desirability and implications of taking an HIV test and the development of individual risk reduction strategies.”

The importance attached to this was underlined by the fact that some jurisdictions – New York State in the USA being one example – passed laws making pre-test counselling a legal requirement in HIV testing.

However, even in populations that might be expected to have high rates of testing – such as pregnant women – such approaches were not detecting enough HIV infections and were letting too many individuals slip through the net.

To take the example of pregnant women in the UK, while treatment for pregnant women had brought the HIV-infection rate in infants down from over 25% in 1993 to 12% in 1999, only 60% of women were choosing to have an HIV test at this point.

Opt-out testing was introduced in 1999. By 2003, the infection rate in babies of mothers with HIV was down to just over 2% and has remained there ever since, and the proportion of pregnant women tested for HIV was up to 96%.1

Similar findings apply to low-income countries: in a review of VCT services for pregnant women in Zimbabwe, for instance, the proportion of women who took an HIV test in VCT programmes ranged from a minimum of 20% to a maximum of 63%.2

VCT allows people a clear choice of whether to have an HIV test, but it also places on them the responsibility to seek one – perhaps at a time when they might prefer a responsible healthcare provider to make that kind of decision. Some experts have felt that the requirement for pre-test counselling and consent can act as a disincentive to test.

Providers have been slower to adopt opt-out testing for non-pregnant adults, but over the last few years arguments in its favour have been gaining ground and a number of HIV-testing guidelines now recommend opt-out testing for various different categories of adults. We look at the US and UK guidelines below.

References

  1. Health Protection Agency HIV in pregnant women. HPA, 2009
  2. Chandisarewa W et al. Routine offer of antenatal HIV testing (“opt-out” approach) to prevent mother-to-child transmission of HIV in urban Zimbabwe. Bulletin of the World Health Organization 85(11):821-900, 2007
This content was checked for accuracy at the time it was written. It may have been superseded by more recent developments. NAM recommends checking whether this is the most current information when making decisions that may affect your health.
Community Consensus Statement on Access to HIV Treatment and its Use for Prevention

Together, we can make it happen

We can end HIV soon if people have equal access to HIV drugs as treatment and as PrEP, and have free choice over whether to take them.

Launched today, the Community Consensus Statement is a basic set of principles aimed at making sure that happens.

The Community Consensus Statement is a joint initiative of AVAC, EATG, MSMGF, GNP+, HIV i-Base, the International HIV/AIDS Alliance, ITPC and NAM/aidsmap
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This content was checked for accuracy at the time it was written. It may have been superseded by more recent developments. NAM recommends checking whether this is the most current information when making decisions that may affect your health.

NAM’s information is intended to support, rather than replace, consultation with a healthcare professional. Talk to your doctor or another member of your healthcare team for advice tailored to your situation.