USAID's Activities: Voluntary Counseling and Testing
HIV prevention and care are inextricably linked components of the stepped up war against AIDS. HIV voluntary counseling and testing (VCT) serves as a unique bridge between the two. The U.S. Agency for International Development supports HIV negative and HIV positive persons to create personalized plans to reduce their risky behavior through its long-standing VCT programs in sub-Saharan Africa and its newer initiatives in the Latin America and the Caribbean, and Asia and the Near East. USAID activities have established testing sites, trained and supported counselors, and promoted community outreach around VCT to enhance community acceptance of HIV/AIDS activities. Currently, USAID supports VCT programs in more than 25 countries.
Benefits of Voluntary Counseling and Testing
Prevention
of HIV transmission. A key component of infection control is the identification of those infected with the disease, coupled with efforts to interrupt transmission. Studies in both the U.S. and the developing world have demonstrated that VCT can lead to self-reported changes in high-risk sexual behavior among both HIV positive and HIV negative people. In U.S.-based studies, participant reports of sexual behavior change have been further corroborated by a reduction in sexually transmitted infections. The body of evidence is especially strong for VCT as a tool to help HIV positive persons to reduce their high-risk behaviors to avoid spreading the disease to uninfected persons. VCT counselors work one-on-one with clients to help them to assess their individual risk for HIV and engage them in a focused discussion of realistic ways to reduce their risk. In addition, a USAID-funded analysis found VCT to be as cost-effective as the provision of nevirapine to pregnant women in countries with a high HIV prevalence rate.
Gateway between prevention and
care: In addition to its role in prevention, HIV testing and counseling is a critical first step in identifying those who are HIV positive so as to effectively link them with HIV treatment, care, & support services. These services include the prevention of HIV-related illnesses, (including tuberculosis), psychosocial and family support, and comprehensive treatment with antiretroviral therapy, as it becomes available. Knowing one’s HIV status also provides essential information to better enable HIV positive persons to plan for their own future and that of their family. VCT can help to connect clients with services including hospice care, legal services, and support for orphans and vulnerable children. Experience has shown that VCT clients benefit from ongoing support and counseling to cope with their diagnosis and facilitate disclosure.
Reduction of stigma. HIV-related stigma and discrimination contribute to the creation of a barrier to participation in VCT, disclosure of HIV status, and seeking care, treatment and support by people living with HIV/AIDS. Involving the community in VCT and related programs helps to increase participation in VCT and fosters community ownership of the programs. This approach can help people living with HIV/AIDS to be accepted within their communities, thereby reducing stigma and denial. Providing VCT with quality counseling and appropriate linkages, referrals, and prevention and care services can enhance the opportunities for people living with HIV/AIDS to access care, treatment and support.
Challenges of Voluntary Counseling and Testing
Gender-Related: Most VCT clients report positive experiences with disclosure of their HIV status, yet HIV positive women may remain more vulnerable to negative effects. Studies have shown that fear of a violent reaction by a male partner because of a positive result is a barrier to both VCT and subsequent disclosure of results to male partners. USAID has sponsored research examining the implications of partner violence and HIV on VCT programs. Most women who disclosed said that their partners showed support and understanding. A woman’s HIV status was found to be strongly associated with partner violence, which raises important questions about violence as a risk factor for HIV infection. USAID continues to support further research on ways to reduce violence in the lives of HIV positive women.
Support for counselors: One of the most important lesson learned from USAID-supported VCT sites and related research is the need for supportive, ongoing, supervision of counselors. This should be coupled with frequent information updates, and acknowledgement of and education about ‘emotional labor’ in counseling. Without constant support and incentives, counselors, may become less motivated and perceive VCT as a burden.
Improving Access to Voluntary Counseling and Testing
Demand and Service Provision: National surveys in Kenya,
Tanzania, and Zimbabwe have shown that while around 60 percent of adults
want to know their HIV status, only 15 percent or less have had access
to VCT. Carefully designed radio, television, and print advertising have
increased awareness and use of VCT services. In Zimbabwe, USAID-supported
social marketing of VCT has resulted in a more than four-fold increase
in client visits to several VCT centers launched by the government since
1998. Similarly, eye-catching billboards in Kenya pose different “hook” questions and invite readers to discuss the questions at “a VCT center near you.”
USAID uses a variety of VCT models and approaches to maximize program coverage, while ensuring the accessibility and affordability of VCT. In addition, USAID has been a major proponent and user of rapid HIV testing for the past five years. Rapid HIV testing with same-day results increases demand for VCT services, while having to wait for or return for HIV test results depresses demand. In countries in which rapid HIV tests are not yet widely available, many people do not return for their HIV test results. In countries in which rapid HIV tests have been made available, USAID-supported services have found that a change to same-day results led to a significant increase in both the number of VCT clients and the proportion of clients who actually received their test results. In Malawi, for instance, this proportion increased from 69 to 99.7 percent.
Prevention of Mother to Child
Transmission: USAID is committed to preventing the transmission of HIV from a mother to her baby. HIV testing and counseling for pregnant women and their families is a critical step in this process. As part of President Bush’s International Mother and Child HIV Prevention initiative, USAID will continue to expand programs to prevent transmission from a mother to her baby.
Integration: In Rwanda, USAID-supported programs have integrated tuberculosis and opportunistic infection preventative therapy for eligible VCT clients at two sites and antiretroviral therapy for eligible clients at one VCT site. In Kenya, USAID has explored programmatic options for integration of family planning into VCT and will be undertaking operational research to test its integration strategies. In Uganda, USAID-supported research is exploring the effect of integration interventions on the extent to which VCT clients receive tuberculosis, sexually transmitted disease, and family planning services. In Zimbabwe, USAID is providing both sexually transmitted infection treatment services and family planning services at its downtown VCT center.
USAID continues to support the expansion of high-quality VCT services as part of its comprehensive prevention and care strategy. USAID strives to identify and overcome barriers that inhibit demand for services, while effectively meeting the needs of those most at risk for HIV infection.
March 2003
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