1. Voluntary Counseling and
Testing (VCT) for HIV
DR M MUNAWAR KHAN
MBBS,DPA,MAS,MRSH

2. Objectives of HCT
• HCT assists individuals and couples to:
– Assess their HIV risk behaviors
– Develop a risk reduction plan
– Discuss testing of children
– Access HIV testing
– Adopt risk reduction behavior
– Access medical and psychosocial referral services
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3. Objectives
• Increase knowledge of and demand for VCT
services by select target groups
• Increased capacity of partners to implement
social marketing interventions
• Addressing issues related to decreased
stigma of HIV-positive persons and the use
of VCT services in high-prevalence
communities

4. Definitions
• HIV prevention (pre-test) counseling: An
interactive process of assessing
risk, recognizing specific behaviors that
increase the risk for acquiring or transmitting
HIV, and developing a plan to take specific
steps to reduce risks

7. Anonymous Testing
• No name is used
• Unique identifying number
• Results issued only to test recipient
23659874515
Anonymous

8. Confidential Testing
• Person’s name is recorded along with HIV
results
– Name and positive results are reported to the
State Department and the Centers for Disease
Control and Prevention
• Results issued only to test recipient

9. Deference Between
HEALTH EDUCATION & COUNCELLING
HEALTH EDUCATION COUNSELLING
•# A one on one interaction
• #It is a one to many involving
communication
confidentiality, anonymity, privacy
• #One deals with issues is
general •#One has to deal with personal
issues of the individual
• #One shares statistical
information, data and
analyses to show trends •#Have to understand the
and dangers of (i) individual to make an impact on
epidemics (ii) risky specific attitude and behavior
behavior.
• #he interaction is •#e interaction can be very
impersonal emotional

10. Elements:
Voluntary testing for HIV,
•Pre-test counseling,
•Post- test counseling
(mostly by lay counselors from communities)
Counseling

11. HIV Counseling and Testing
• HIV Counseling and Testing (HCT) is composed
of two types of testing:
VCT – Voluntary Counseling and Testing
PIHCT – Provider Initiated HIV Counseling and
Testing
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12. HCT: Foundation of
HIV Prevention and Care
ACCEPTING AND SUPPORT
LIVING POSITIVELY COPING
WITH HIV STATUS • FAMILY
• NUTRITION • FELLOWSHIP
• CLEAN WATER • HIV POSITIVE PEERS
• REDUCED STRESS
• WELLBEING
MEDICAL CARE
RISK REDUCTION • STI & TB TREATMENT
• TB & OI PROPHYLAXSIS
•
•
•
BEHAVIOR CHANGE
DISCLOSURE OF STATUS
PARTNER REFERRAL TO VCT
HCT • PEDIATRICS HIV
DIAGNOSIS, CARE AND
TREATMENT
• CONDOM ACCESS
PLANNING FOR FUTURE COMMUNITY INTERVENTIONS
PREVENTION OF
• FAMILY PLANNING MOTHER TO CHILD • SENSITIZATION
• ORPHAN CARE TRANSMISSION • MOBILIZATION
• FINANCIAL PLANNING • DESTIGMATIZATION

13. HIV Counseling & Testing
• HIV Counseling:
– Confidential dialogue between a client
and a care provider aimed at enabling
the client to cope with stress and make
personal decisions related to HIV and
AIDS.
• Voluntary Counseling and Testing
(VCT)
– A combination of two activities–
counseling and testing –into a service
that amplifies the benefits of both.

14. IMPORTANCE of VCT
• 90% of those infected do not know that
they are infected.
• Knowing one’s serostatus allows people
to alter their behavior.
• VCT provides an opportunity for
prevention counseling and referral to
care and support services.
VCT is an entry point and not the end
point.

15. IMPORTANCE of VCT
Cont…
• Effective prevention and care activities
require people to know their HIV
status.
• VCT promotes and sustains behavior
change (prevention).
• VCT facilitates early referral to care and
support services (including access to
antiretroviral therapy).
• VCT links with PMTCT, STI, and OI
services.
• VCT assists in stigma reduction.

16. Acceptance of
Serostatus and coping
Planning for Early
future orphan management
care; Will of OIs and STDs
preparation
Voluntary Reduces
Referral to mother-to-
social and Counseling child
peer support Testing transmission
Normalizes Facilitates
HIV/AIDS behavioral
change
Preventive therapy
(TB & bacteraemia)
and contraceptive
advice

17. VCT: Foundation of
HIV Prevention and Care
LIVING POSITIVELY ACCEPTING AND
COPING
WITH HIV STATUS SUPPORT
• NUTRITION
• CLEAN WATER • FAMILY
• REDUCED STRESS • FELLOWSHIP
• WELLBEING • HIV POSITIVE PEERS
RISK REDUCTION
MEDICAL CARE:
•
•
•
BEHAVIOR CHANGE
DISCLOSURE OF STATUS
PARTNER REFERRAL TO VCT
VCT • STI & TB TREATMENT
• TB & OI PROPHYLAXSIS
• CONDOM ACCESS
PLANNING FOR FUTURE COMMUNITY INTERVENTIONS
PREVENTION OF
• FAMILY PLANNING MOTHER TO CHILD • SENSITIZATION
• ORPHAN CARE TRANSMISSION • MOBILIZATION
• FINANCIAL PLANNING • DESTIGMATIZATION

18. VCT Program Components (2)
HIV Test
• Post-test counseling
HIV negative test result:
• Negotiate risk reduction plan
• Support for risk reduction plan
• Negotiate disclosure & partner referral
HIV positive test result:
• Identify source of support
• Negotiate disclosure and partner referral
• Risk reduction issues
• Referral
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19. Goals of VCT (1)
• Prevention of HIV transmission
– From +ve tested people to -ve or untested
partner/s
– From +ve tested mother to child
– From +ve or untested partner/s to -ve tested
people
• Early uptake of services
– Counselling for positive living
– Social support Medical care
– Legal advice Family planning
– Future planning Emotional care

20. Goals of VCT(2)
• Societal benefits • Increase adherence
– Normalisation of to:
HIV – ARV therapy
– Reduction of stigma – Preventive therapies
– Promote awareness – ARV regimens for
PMTCT
– Support human
rights – Infant feeding choices

21. Components of VCT
• Determining clients • Explaining the test
knowledge and obtaining
informed consent
• Giving accurate
information • Discussing
implications of HIV
• Conducting result
personalized risk • Assessing coping
assessment ability
• Developing a • Result notification
personalized risk • Providing
reduction plan psychological and
• Demonstrating emotional support
appropriate condom and referral as
appropriate
use

22. VCT as an Intervention Strategy
• Effective in promoting behavioural
change and providing psychosocial
support.
• Cost effective especially when it is
targeted to couples and “high risk
groups”.
• Feasible as a component of
comprehensive HIV prevention and care
strategies in developing countries.
• Facilitates the linkage to other HIV
prevention and care activities.

23. Barriers to VCT (1)
• Fear
• No cure or treatment
• Stigma
• No need: I’m faithful
• Partner with a negative HIV result
• Gender inequalities
• Lack of perceived benefit
• Lack of access to care and support services

24. Barriers to VCT (2)
Fear
“I feel if I tested positive it would just devastate me.
You know that, while I know I might be positive –
I had herpes zoster - there are times I tell myself that
its my father-in-law doing some black magic on
me. If I went and had a test and they said ‘you
have it’ then I know I would be dead in a week.”
• Woman 28 years, Kara Counseling and Training
Trust, Lusaka, Zambia

25. Barriers to VCT (3)
No cure or effective treatment
“I do not even want a test. What are you going to do
about it if I come out positive? Are you going to give
me medicines? If you tell me that you can give me
medicines or that you will cure the disease then I can
go for a test tomorrow.”
• Man 30 years, Kara Counseling and Training
Trust, Lusaka, Zambia

26. Barriers to VCT (4)
Stigma:
“ If you go for a test and the result comes out
positive your family will not take care of you
because you will be an outcast./outsider”
• Woman 22 years, Kara Counseling and Training
Trust, Lusaka, Zambia

27. Barriers to VCT (5)
No need
“Its not necessary since a test is only for those young
ones who have not followed their parents’ advice of
not indulging in things like careless sex.”
• Woman 56 years, Kara Counseling and Training
Trust, Lusaka, Zambia

28. Barriers to Access
(Linked to Stigma and Fear)
• Stigma/discrimination against PLWHA, as well as behavioral
related stigma (IDU and SW)
“I’m sure that 100 drug addicts all have the same thought.
They’re afraid of being isolated, kept away, and losing the
chance to go back to their family.” (Hanoi IDU)
• Being recognized by friends or acquaintances
• Issues related to Confidentiality
• Fear of positive result, and with no cure for HIV/AIDS, there is
no reason to get tested—hopeless and depression that would
accompany.

29. Barriers to Access
(More surprising)
• Among sex workers the fear that testing will
result in loss of income
“We accept the fact that we might contract the
disease, however we don’t dare to go for a medical
examination because people might start rumors about
our problem and keep away from us. Consequently, we
will find it difficult to continue our jobs, to earn
money, to feed our children. This is a reality”. (Hai
Phong street-based sex worker)
• Fear of being treated badly by health
workers

30. Barriers to Changing Sexual Behavior
Following VCT
• Partner communication difficulties
• Gender imbalances in sexual decision making
• Difficulties in changing sexual behaviour
• Desire to have children
• Stigma
• Economic deprivation

31. Pre-test Counseling
• Transmission
• Prevention
• Risk Factors
• Voluntary & Confidential
• Reportability of Positive Test Results

32. Counseling Skills for Counselor

33. Counseling is a Relationship
• Client and counselor both bring:
– Hope
– Knowledge
– Questions and answers
– Personal experiences
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34. Seven Qualities of a Good Counselor
• Self-confidence
• Empathy
• Acceptance
• Genuineness
• Trustworthiness
• Confidentiality
• Competence
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35. Skills and Characteristics of
Effective HCT Counselors
• Believes that HIV prevention counseling can
make a difference in preventing and controlling
HIV for the individual, the family, and the
community
• Balances well-selected, open-ended questions
with statements, summaries, and reflections
that guide the session and maintain the focus
on risk issues
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36. Skills and Characteristics of
Effective HCT Counselors (2)
• Uses active listening skills
• Feels and behaves comfortably when
discussing specific HIV risk activities
• Able to help a client develop a realistic and
relevant risk reduction plan
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37. Counseling Skills
• Remember to always:
– Demonstrate professionalism and maintain
rapport throughout the session
– Convey to the client that his or her confidentiality
will be strictly protected
– Speak with the client at his or her level of
understanding
– Conduct an interactive session focused on risk
reduction
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38. Counseling Skills (2)
• Clarify important misconceptions, but avoid
extended talk on issues not related to risk
• Stay organized, and avoid counseling outside
the protocol’s structure
• Know that it is all right to tell the client that
you will be covering something later
• Avoid collecting data about the client during
the counseling session
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39. Questioning Skills
• Acknowledge that you have heard and understood the client.
• Blend reflective, guiding, and directive statements with well chosen
open-ended questions.
• Ask questions that guide the client to consider their HIV risk, risk
reduction, coping, and support.
• Ask appropriate follow-up questions.
• Ask client to elaborate on unclear issues.
• Ask client to clarify confusing or contradictory information
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40. Closing a Counseling Session
• Remind client of pre-test information
• Assess client’s emotional state
• Give client space to ask questions
• Schedule client for further sessions
• Refer to appropriate services
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41. Ethical Principles
• Counselors must be respectful toward the
patient’s/client’s dignity and rights
• Dignity
– Acceptance
– Non-judgment
• Rights
– Confidentiality
– Privacy
– Autonomy
– Self-determination
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42. Ethical and Legal Issues: Disclosure
• Counselors cannot force disclosure of HIV status
• To whom and when is always the choice of the
patient
• Can encourage the partner to have an HIV test
• Can prevent the spread of HIV to the partner
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43. Ethical and Legal Issues: Children
• Persons 15 years-old and above can give
informed consent for testing
• Children under 15 years-old may only be
tested with consent of their parents or
guardians
• “Mature minors” between 13-15 years of age
are allowed to consent for HIV testing
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44. Ethical and Legal Issues: Children (2)
• Mature minors should be informed of their results
like adults
• Children 12 years-old and above should be informed
after appropriate counseling, and with the
involvement of their parents or guardians
• Children under 12 should not be informed of results
until they reach an age when they can understand
and parents/guardians give consent
• Counselors should carefully consider to whom they
disclose results, with the child’s best interests in
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mind

45. VCT Program Components-1
• Type of counseling session
– Individual
– Couple
– Family
• Pre-test counseling
– Introduction and orientation
– Risk assessment
– Discussion of testing children, if applicable
– Options for risk reduction
– Preparation for the test result
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46. PRE-TEST COUNSELLING
• Review why they have come for the test in a relaxing
manner
• Review their knowledge of (i) condom use, (ii) sexually
transmitted diseases, (iii) HIV/AIDS. Fill in the gaps in their
knowledge.
• Review and impress on them the consequences of risky
behavior
• Assess the degree of risk for the client
• Slowly go over the nature of the test and the consequences
of both a positive and negative result.

47. PRE-TEST COUNSELLING
• In case of a positive result review the difference between
HIV and AIDS. Stress the fact that the patient can still live a
productive life for even as long as ten or more years and
the prospects for therapy and cure are improving daily.
Discuss their support system (family and friends)
• In case of a negative result discuss the window period for
antibody based tests and the need for retesting after about
4 months depending on risk assessment. Impress on them
that a negative result does not imply immunity from
infection, and the need for a change in behavior.
• Obtain informed consent prior to the test.
• Schedule the next meeting a week after the test date

48. VCT Program Components (2)
• HIV Test
• Post-test counseling
– HIV negative test result
• Negotiate risk reduction plan
• Support for risk reduction plan
• Negotiate disclosure & partner referral
– HIV positive test result
• Identify source of support
• Negotiate disclosure and partner referral
• Risk reduction issues
• Referral
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49. Post-test Counseling
• Clarifies test results
• Need for additional testing
• Promotion of safe behavior
• Release of results

50. POST-TEST COUNSELLING
(TEST NEGATIVE)
• Immediately reveal that the test was negative
• Allow time for the relief and happiness to settle.
• Reevaluate whether the person could be in the window
period -- withing 3-6 months of having got the infection
during which period negative results of tests based on
detection of antibodies are not conclusive. If there is reason
for concern that this may be the case, schedule an
appointment for a retest in about 3-4 months and ask the
patient to abstain from sex (or at least from unprotected sex)
during this interval
• Reassess the knowledge base and awareness of the patient
• Reinforce risk reduction information
• Explore sustainable changes in behavior

51. POST-TEST COUNSELLING
(FOR DISCLOSING A POSITIVE RESULT)
• Reveal test result directly but in a gentle tone and show
empathy.
• Allow time for ventilation of feelings. In majority of cases
there is a emotional and physical breakdown. Allow the
expression of grief through crying. Often there is denial -- it
cannot happen to me, there must be a mistake in the test.
Sometimes there is a silent acceptance but turmoil within.
• Once the patient has calmed down sufficiently to the point
that you no longer fear that they may do themselves
harm, reassure them of all possible help in terms of
medical care, psychological support, and referrals to
specialists.
• Schedule a meeting one week later to begin therapy

52. POST-TEST COUNSELLING
FOR A HIV POSITIVE RESULT
• Go over very carefully the difference between HIV and AIDS
• Stress the benefits of a positive outlook to life in order to make
the best use of the future and to stay productive.
• Stress the need for a good, healthy, and balanced diet. (Lots of
fruits and vegetables. Avoid spicy and heavy foods. Take vitamin
and mineral supplements.)
• Need for regular exercise that does not cause fatigue. 15-30
minutes of brisk walking.
• Keep immune system strong. Avoid smoking, alcohol, drugs, and
stress. Rest often to avoid fatigue.
• Yoga and meditation help with maintaining a positive outlook
and a healthy body
• Explain the need for them to minimize risky behavior to avoid
transmitting the infection to another person

53. POST-TEST COUNSELLING
FOR A HIV POSITIVE RESULT
• Review need To treat minor infections early and properly
• Review the need for special attention to tuberculosis. Suggest regular
screening for TB and for other opportunistic infections. Provide a referral
service .
• Build a support system consisting of friends and relatives. Encourage the
patient to bring along one or more such persons to the counselling
sessions. Develop a system of home based care for common infections and
even for some of the simpler opportunistic infections
• Advise confidentiality of status with associates at work and other casual
associates. There is no need to advertise HIV status unless patient chooses
to become an activist.
• Establish the need for counseling, and continue to build trust and to
provide effective and regular counseling.

54. Advancing HIV Prevention: New Strategies
for a Changing Epidemic
• Four priorities:
1. Make voluntary HIV testing a routine part of
medical care
2. Implement new models for diagnosing HIV
infections outside medical settings
3. Prevent new infections by working with persons
diagnosed with HIV and their partners
4. Further decrease perinatal HIV transmission
MMWR April 18, 2003

55. Pre-Test Counseling
• What does the client understand about HIV?
• What does the client understand about HIV
testing?
• How does this information apply to the client?
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