Maximising HIV Test Counselling in STI Services

Integrating HIV Testing Counselling (HTC) into Sexually Transmitted Infection (STI) service delivery has not been successful thereby calling for the intervention of non-medical HIV Testing Counsellors and the Opt-Out Strategy in the country's STI Clinics.

STI patients are at high risk of HIV transmission therefore HIV counselling and testing should be the standard of care for all STI patients; this, according to the National HIV and AIDS policy.

Gift Kamanga of the University of Northern Carolina (UNC) Project at Kamuzu Central Hospital, says STI service providers such as nurses and clinicians do not have enough time to implement HTC adequately in STI clinics.

In this experience, it is clear that non-medical HIV testing counsellors have greatly contributed to the increased uptake of HIV Testing and Counselling services.

Delivering his presentation to this year's National HIV/AIDS Dissemination Conference in Lilongwe, Kamanga emphasized on the importance of providing quality STI services that include the capacity for HIV testing and counselling. The UNC project and Ministry of Health commitment effected the modernization of the entire STI facility at Kamuzu Central hospital that was undertaken in 2005.

Kamanga said the project has since had several improvements and expansion of STI clinical services, which have led to the increase in demand for the services by 46%.

"However, it should be noted that genital ulcers and urethra/vaginal discharge remain significant sexually transmitted infections," he said lamenting that females predominate the STI clinic.

Gift Kamanga advocates that similar clinical settings, with populations of high-risk behaviour such as men and women with high prevalence and incidence of HIV, are ideal settings for HIV preventions programs.

"Programs should include condom distribution, sexual risk reduction counselling, including couples counselling, HIV and Syphilis counselling and testing, partner notification and prompt STI treatment," he said.

However, Kamanga was quick to point out challenges facing the implementation of HTC services in STI clinics saying nurses and clinicians are overwhelmed with routine patient care services hence no proper time is given to concentrate on HTC.

"In addition to that, HTC trainings at the moment do not target the nurses or clinicians in STI clinics hence making implementation of HTC policy not operational," he lamented adding that there is also lack of perceived benefits by STI clients themselves, unlike in TB and PMTCT where HTC is directly linked to instant intervention with antiretroviral therapy.

The need for HTC in STI clinics has been observed by Kamuzu Central Hospital since it went into trials in 2005. KCH STI unit started HTC strategy using one counsellor and by July 2006, they had three.

Since then, nurses and clinicians do testing for HIV and detailed counselling is left to counsellors.

Kamanga said before the deployment of HTC Counsellors there was negligible HIV testing done at the STI clinic and there was less than 10% of new attendees.

"Since HTC Counsellors came in the rate has been increasing to over 60%," affirmed Kamanga.

He therefore called upon Ministry of Health to consider deploying a new cadre of HIV Testing Counsellors in STI clinics across the country to compliment the work of STI service providers.

UNC Project with Kamuzu Central Hospital has further intensified HIV services in the STI clinic by implementing a routine HIV testing through the Opt-Out Strategy in the STI clinic at KCH starting from July 2007.

According to Kamanga, this is a strategy where in the sensitisation process; STI patients will be told that they will undergo an HIV test as part of standard of care but are free to decline if not willing.

Sexually Transmitted infections greatly enhance HIV acquisition and the policy environment in Malawi encourages routine HIV testing for STI clients.

"But not much has happened country wide to make this policy operational in STI clinics," he said.

In the process of the Opt-Out Strategy, STI patients are sensitized on STIs and HIV in the reception area. Then they go for care in the examination room and if they consent, a short opt out HTC and syphilis rapid testing is performed. Then the patient is escorted to a counsellor for detailed post-test counselling. At times patients start with the counsellor for HTC then are escorted to the examination room for care.

On the other hand, the Opt-In Strategy where patients were only asked if they were interested and would be offered the HTC services, had less than 30% uptake thus not giving optimal opportunity for patients to be tested. Nevertheless, Kamanga said the Opt-Out Strategy has doubled the HTC uptake.

This is because messages were refined to reflect clearly the individual health benefits while recognizing patients' rights to opt out.

"Mere emphasis on STI risk to acquiring HIV did not lead to acceptance of HTC but messages for direct health benefit and clear referral mechanism for ART," he said emphasizing that in the course of Opt-Out Strategy service providers should be mindful of preserving patients' rights.

Opt-Out HTC in a busy clinic is possible, according to Kamanga, and therefore all STI clinics should do it. This can be achieved if the Ministry of Health deployed enough HIV testing counsellors in all STI clinics to compliment the work of STI service providers.