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Aids and maternity in India

 | 
Patrice Cohen
, 
Suniti Solomon

Part 2. Prevention of HIV/AIDS mother to child transmission

7. Bridging Counselling and Care in the HIV/AIDS Epidemic: General Perspectives and the Case of Women

Shyamala Natarajan

Texte intégral

1A great deal of reference has been made to conselling in the prevention of parent-to-child transmission of HIV programme which is being implemented in several places in the state. I would like to focus this presentation on the content and the quality of counselling most widely offered. I do not speak of the exceptions that may well exist, for an epidemic is best tamed by a rule rather than an exception.

Recruitment and Training

  • 1 In South Indian AIDS Action Programme.

2One of the areas that NACO is increasingly emphasizing is training for counsellors. However, sufficient importance is not given to the processes of selection, the quality and duration of training and the provision of supervisory support. The emphasis on post-graduate qualifications at the cost of aptitude and life-experience can be self-defeating, as we found from our experience. We have been training counsellors1 in a structured, on-the-job training programme that culminates in a written assessment as well as a case examination by a panel of professionals.

3I will share some of our experiences in these years. In the first year, we recruited mainly post-graduates for the training, people who we felt had an aptitude for counselling. Almost all were from urban and semi-urban areas in the State. We found that although they were good at understanding the theory, they had too many inhibitions about sex and sexual behaviour to be able to work with a truly non-judgemental attitude. Coming from an educated background, they had learnt to intellectualize issues and found it difficult to address emotions, their client`s as well as their own. Instead they became health-educators and concentrated on giving information, the only activity they felt comfortable with.

4In addition, since most clients came from very poor socio-economic backgrounds, the counsellors were unable to empathize and instead started sympathizing, a behaviour that further alienated them from clients. Instead of helping clients to explore issues and arrive at decisions largely by themselves, they ended up imposing the common hospital practice of forcing testing upon the client under one guise or another.

5Of course, there were the exceptions who did very well but, for the most part, this batch has required the greatest amount of support over three years to improve to a point where they are doing a reasonably good job.

6The second year, we lowered our qualifying requirements to a graduate degree. We also looked for people from smaller towns, people with semi-urban as well as rural backgrounds. This was a good move in terms of familiarity and comfort with the local community, but the problem of a strong judgement concerning sexual behaviour still remained despite training. We have learnt that people can be trained to automatically say the right thing, but if they do not truly believe in what they are saying, it has no effect and the client is unable to bring himself/herself to trust such a counsellor.

7Since 1999, we recruit people on the basis of their comfort and familiarity with issues of sexuality and/or with HIV. We look for people with life-experience, in addition to academic qualifications. We do not recruit young, sexually inexperienced men or women fresh out of college. We give preference to training PLHAs, their family members or close friends. These people have learnt to deal with the issues around HIV and understand the situation of the PLHA. I have found that they make even better counsellors than positive people because they do not come with the emotional trauma that a PLHA experiences in this country - without access to quality counselling or care services.

  • 2 Excerpt from the NACO web site proposed by the editors as in August 2003: http://www.naco.nic.in/na (...)

VOLUNTARY COUNSELLING AND TESTING2 (NACO Programmes)
HIV voluntary counselling and testing (VCT) has been shown to have a role in both HIV prevention and as an entry point to care. It provides people with an opportunity to learn and accept their HIV serostatus in a confidential environment. VCT has become an integral part of HIV prevention programmes in many countries, as it is a relatively cost-effective intervention in preventing HIV transmission.
In India, as HIV testing becomes simpler to perform with the advent of newer rapid and simple kits, the National AIDS Control Organisation has plans for the expansion of testing facilities to all corners of the country in a phased manner. It is envisaged that within the next few years every district in the country would be equipped with HIV testing facilities. With easy accessibility and availability of testing it becomes necessary to improve the services of counselling and the guidelines clearly state that no HIV testing is to be undertaken without pre-test and post-test counselling. It is, therefore, important to document the benefits of VCT in order to promote and expand access to it. Improving Information, Education and Communication (IEC) to advocate the benefits of VCT and raising community awareness greatly contributes to the success of this strategy. Integrating VCT into other health and social services may improve access and effectiveness in some settings.
HIV testing services should be designated to address the multiple needs and rights of individuals at risk or already infected. A more humane and person-centred approach to HIV testing could be achieved by moving from HIV testing alone to Voluntary Counselling and Testing (VCT), where the primary emphasis would be to reach individuals with effective counselling, condom supplies and peer and community support, rather than focus on HIV testing. Such efforts to reduce stigma and discrimination, seek to ‘normalize’ community perceptions of HIV infection and AIDS, and make counselling services available to all who seek them, regardless of their willingness to be tested.
Voluntary Counselling and Testing
Voluntary HIV Counselling and Testing is the process by which an individual undergoes counselling that enables him or her to make an informed choice about being tested for HIV. This decision must be the choice of the individual and he or she must be assured that the process will be confidential. However, in concurrence with the Supreme Court decision, partner notification is necessary and this makes it imperative for the attending physician to disclose the HIV status to the spouse or sexual partner of the person. In spite of this, all efforts must be made to counsel the person for disclosure of HIV status to the spouse or sexual partner.
The potential benefits of VCT are: improved health status through good nutritional advice; earlier access to care and treatment; prevention of HIV-related illnesses; emotional support; better ability to cope with HIV-related anxiety; awareness of safer options for reproduction and infant feeding: motivation to initiate or maintain safer sexual practices; motivation for drug-related behaviour; safer blood donation
Voluntary Counselling and Testing Centres (VCTC)
Voluntary Counselling and Testing Centres will be located in the blood testing centres in the microbiology departments of all medical colleges, tertiary care hospitals and district hospitals where testing facilities for HIV are available.
However, VCT may be carried out in various other settings, depending on the demand and resources. Different models of VCT are available for the different settings. The choice of VCT service will depend on the needs of the community, HIV seroprevalence, maturity of the epidemic and attitudes towards HIV.
The VCTC can be -
• Part of the hospital services. The Model Counselling Centre functional at the Safdarjung Hospital, New Delhi and run by the
NGOs, is a fine example of the integration of services with that of the medical outpatient services.
• VCT can be an entry into the continuum of care/home-based care services.
• Industrial houses may have the option of having these facilities at the workplace clinics subject to the availability of HIV tests.
• VCTC may be made available for the following vulnerable groups: STD clinic attendees, sex workers, the prison population, IDUs, men having sex with men (MSM), orphans and street children
Remember:
• The VCT should be housed in a place that is easily accessible to the general public. It must be adjacent to the testing laboratory.
• There should be 2 rooms, one for waiting and one for counselling. The counsellors should have a private chamber where one-to-one counselling can be done. It should not be in view of the others who are waiting. The waiting room can provide information in the form of flip charts, handbills or booklets on HIV/AIDS and STDs.

8A valuable insight has been the extraordinary aptitude for counselling shown by homosexual and bisexual men, also referred to as MSM (Men having Sex with Men). They are very comfortable with the vagaries of sexual behaviour, are usually very sensitive and articulate. We have also trained several women in sex work to provide counselling services.

9However, we must emphasize that the training is on-going, usually about 21 days spread over several months. All trainees work right through this period, providing counselling services in the hospitals during OP hours and working in the community several afternoons in a week. In fact, this combination of institution-based services and community counselling is the factor most responsible for the success of Siaap`s counselling programme. Though there is no specific emphasis on formal education in the case of people form these communities, we ensure that trainees have completed class 10, as a minimum requirement.

10The optimum training group appears to be one that has a mix of people qualified in social work, psychology or sociology, PLHAs, and people with experience and understanding of sexuality-related issues such as MSMs and women in sex work. A good rule of thumb is to combine people from widely differing backgrounds - socio-economic, educational and lifestyle. In the case of students from an educated, middle-class background, it leads to very quick and real changes in perceptions, attitudes and judgements concerning behaviours. It inspires and encourages infected and affected people to take responsibility for their situation, and learn from the training to cope positively. And finally, it teaches trainers to use participatory methods more confidently, since there will be several trainees who are able to articulate their experiences.

Supervision

11One of the main things which all of you will have found in your work pertains to supervision. The ability to talk about what you are doing, to talk about the people who know, to talk about what it is all about. In this way, you can see the pitfalls that you are likely to get into.

12The experiences of the Christian Medical College (CMC), in Vellore, have highlighted the fact that without follow-up, 80 % of the counsellors trained by them did not continue with counselling.

  • 3 For VCTC, cf. the next table and appendix.

13Based on these experiences, Siaap organized an in situ and group supervision of counsellors as an integral part of the training process itself. This has led to a more than 80 % retention rate of counsellors. Most of them are now absorbed by the VCTC3 (Volontary Counselling and Testing Centres) and the PTCT (parent to-child transmission) counselling centres in the state.

14Tamil Nadu is one of the enlightened states that takes into account the parameters of aptitude and skills as well as qualifications and has obviously benefited from such an enlightened policy. A significant proportion of the counsellors in the state are from PLHA as well as other appropriate groups.

15The training batch for 2002 had 28 students from Karnataka and Tamil Nadu. The person who got the maximum mark (89 %) was a 23 year-old girl living with HIV who has studied only up to class X. We had eleven excellent scorers of which eight had studied up to classes X and XII.

PTCT Counselling Interventions

16In the last year, there has been a focus on counselling for PTCT in government hospitals. Many counsellors at these centres have been in training with us and we have some understanding of the kinds of interaction that occur between the client and the care givers.

Conceptual Framework

17We work within a concept of bridging prevention and care issues for the client. Perhaps this would be of interest to many of you who have worked in that area for long time. We attempt in every intervention, including in counselling, to work at three different levels, both in terms time as well as the person/people involved. Interventions may therefore be immediate-term, medium- or long-term and focus on sustainability.

18Simultaneously, we try to address the different people involved: the individual, the support services that are available, as well as the environmental context. This means we work with individuals, families, communities and institutions. With the first two sets of people, the intervention is usually limited to providing counselling services. At the next two levels, significant training inputs and advocacy efforts are called for.

Prevention of Mother-to-Child Transmission (MTCT) or Prevention of Parent-to-Child Transmission (PTCT)

19Let me share some results from a situational analysis which we undertook - this was for 8 months - on pregnancy and breastfeeding. We were trying to understand issues around PTCT before deciding whether we wanted to get involved. The situational analysis was conducted in four districts in Tamil Nadu: Namakkal, Dharmapuri, Chennai, and Cuddalore.

20One important finding was that couples obtain their legitimacy through pregnancy. Thus it was important to concentrate on issues around planning for pregnancy while keeping in mind viral loads and transmission possibilities. There is no concept of safe sex in marriages. People do not use condoms by and large. Women are not accustomed - as we all experienced-to exclusive breastfeeding. Pregnancy is usually unplanned; there is a need or pressure to have children as quickly as possible. Otherwise, of course, women face a lot of stigma.

21Women also want to breastfeed. There seem to be a lot of reasons: the conviction that it is the natural thing to do and good for the child, emotional bonding. If women are told not to breastfeed, they feel guilty. There is the inevitable talk about her being an unnatural parent and not caring for the child. In any case, a woman not breastfeeding is such a rarity that suspicion regarding her health is easily aroused. If you are going to advise them not to breastfeed, then that is going to be very hard for them.

22An important finding was that women wanted couple counselling at antenatal clinics. They said, “Why should we alone have to attend the antenatal clinic? We want our husbands to come along. We want them also to attend the counselling.”

23One of their biggest concerns was their need for confidentiality and their fear that it will not be maintained.

24The fear is well founded. According to a survey conducted in 11 counselling centres in Tamil Nadu, it became obvious that it is very difficult for the centres to maintain confidentiality for a variety of reasons. A primary resaon is that the result of the HIV test is accessible to a variety of people in the hospital. And people talk to each other about it. And - as Sheila said - the pregnant woman does not come alone, she generally comes with a member of the family. This increases the chances that the HIV test result will spread.

Some Problem Cases

25There was a women who had come to the hospital late in the evening well after her labour pains had started. The counsellor was told that he had to counsel her for a rapid test for HIV. She was walking around the ward; it was the middle of the night and one could see her face grimacing in pain. What was the counsellor to do in this situation? How ready would she be to listen meaningfully to anything he might have to say about HIV and testing and implications, that is, all the things a pre-test is supposed to include? What is the appropriate counselling at such a time?

26If we wish to make it a policy to test all pregnant women under all conditions, then we need to be straightforward about it and acknowledge that informed consent may not be the most appropriate process for our situation. But we are currently making a mockery of the whole process, with everybody claiming to have received informed consent while, in reality, it is nothing of the sort. In our eagerness to follow international guidelines, we follow neither the prescribed process nor the practical one. Instead, we adopt a convenient mishmash that actually harms patients.

27The pre-test and post-test guidelines as they exist do not take into account the reality and the context of people`s lives. You have women coming to the ANC for whom AIDS is rarely a primary concern. They are in a rush to get back home where a million chores await them. When you take a group of them, give them information and call it group counselling, they are not even listening half the time because they are preoccupied with a variety of things. And, at the end of your recital you say, OK, now do you have any questions? Of course they don`t. And they put their thumb imprint where you guide them, “here, just here”. And hey presto, you have informed consent. You have informed them and they have given consent.

28Here is a final case. This really disturbed me. A lady and her husband were working as brick workers in a village, a two-hour bus ride out of Namakkal, in the centre of Tamil Nadu. She had come to the ANC in the hospital, had been tested and agreed to be put on AZT. But obviously - once again - she didn’t know what the agreement meant in the context of her life. She didn’t come back for the follow-up visit although she had been told to do so. The social worker and counsellor were therefore asked to visit her at home. The hospital wanted the follow-up data, but it was very difficult for the counsellor to follow the directive since she knew this would amount to breach of confidentiality She nevertheless had no choice but to comply with the instructions of the doctor. Two visits were made to the house where the woman lived. With what result? The landlord evicted the family because he said that never before in the life of that community had a doctor visited a home. Obviously, therefore, it must mean that there was something seriously wrong with the family. The neighbours suspected AIDS and didn`t want them. In addition to being thrown out of their home, the woman and her husband, both daily wage labourers, lost their jobs at the brick kiln where they were employed.

29But the hospital had its records straight and the staff involved would go on to publish papers and attend international meetings to talk about their efforts. So what if a poor family lost out?

Need for Reflection

30Those cases present many uncomfortable issues that we are constantly brushing under the carpet. On the other hand, we claim we are following a set of minimum standards for counselling. Perhaps we can fool ourselves, but believe me, people aren`t fooled. It is not surprising that they don`t come back.

Strategies that Work: Community Counselling

31Some of the counselling interventions are addressed to individual behaviours. Others are addressed to the level of the community through community counselling.

32The principle behind community counselling is a link between user and service in a setting that allows the user the greatest possible emotional comfort. Basically, the counsellor identifies areas where most clients seem to be coming from; negotiates a space for use for a few hours every week, and provides individual, couple or family counselling as required. After the client visits the hospital, this provides an opportunity for follow-up by the counsellor. In addition, there are opportunities to discuss relevant issues with larger groups of people. Since the essence of the counselling relationship is the building of trust between the client and the counsellor that can work towards helping the client change his/her behaviour, community counselling is an important strategy.

33We have found that areas where this service was offered showed a marked increase in the numbers of people accessing services for STI treatments.

Couple Counselling

34Somebody asked - I think Shoba - why couple counselling is so important. In many centres across states in South India, we have seen women - 90 % of these are married women - coming and testing positive, while being in monogamous relationships. But when they were tested first and the positive result reached the family, they were in several cases thrown out. The men have also refused be tested themselves, blaming the women. Why is it that our interventions in this area constantly penalize women even while supposedly helping them?

35Perhaps one explanation may be found in the intervention terminology itself. We talk about mother-to-child transmission, which means that you put all the responsibilities on the mother - and none at all on the father, although, in most cases, he is the source of the infection.

36A strategy that we find can really help women, as well as the men, is to do couple counselling before offeing the test. The counsellor at the ANC encourages the woman to bring her husband along on the next visit. Both husband and wife are tested at the same time, so they have each other for support, as well as to share the responsibility in case they test positive. Since more than 90 % of the women testing positive at the ANC have acquired the infection from their husbands, the men do not have a chance to blame them and desert them by saying that the woman was the one responsible for the infection. This happens a lot currently. When both are tested at the same time, this does not happen.

Informed Consent and Choice

37Counselling is really about supporting people to make the most appropriate choices that they can live with. Once they`ve made that choice, the counsellor has to help them to work through it. This means the counsellor has to give people all the information that is necessary and available to help them to choose the right option. And then the counsellor has to support them to work through that option. Even if they choose not to test for HIV. Finally, the counsellor has to discuss safer sex and infant feeding options, including encouragement of exclusive breastfeeding.

38Some of our biggest supporters in this programme have been doctors - really sensitive doctors - who have learnt that it pays to address these issues. So much has changed with their help: availability of privacy, counselling intervention that address availability and easy accessability to relatively non-judgemental treatments, willingness to accept a client`s decision not to test. So doctors and other health care providers are at the heart of these challenging issues.

Confidentiality

39Then of course confidentiality. This is the battle we have not been able to win. Though everybody agrees, “yes” it is fundamental, they say it is almost impossible to maintain. So what does that mean to the client?

40The answer to that lies in a very good understanding and practice of informed consent procedures. If a client is aware that confidentiality may not be maintained, the choices he/she will make may be different from the one that he/she is making now. That is his/her right. Because, at the end of the day, the individual has to live with the consequences. If a counsellor follows good consent procedures, there is greater possibility of the institution and the individual working together in harmony.

Supportive Environments

41Finally, there is the need to build supportive environments. We have worked with 75 panchayats to help them pass resolutions to support PLHAs and oppose violence to women. Counsellors have helped in this process a great deal.

On-going Questions

42Finally I will reiterate the key questions I have raised here.

43What should we do to make consent processes truly informed and an opportunity for people to make a real choice? Alternately, let us agree that we think it is important to ensure that people test for HIV and will therefore do everything to make that happen. In which case we don`t have to worry about informed consent at all. However, it does mean we will need the courage to tell WHO and the World Bank and UNAIDS and others that this is what we believe is good for us and this is what we will do despite their gentle diktats to the contrary. Let us come clean and stop skulking around in this matter. The next question: Why don`t we make couple counselling and testing the rule in PTCT interventions? And finally, how will we define confidentiality and develop procedures to maintain it in our context?

44In conclusion, I want to say that rarely before have we faced so evident a dilemma between individual well-being and public health. In the PTCT programme, we are testing women, we are giving them Nevarapine. But, are we safeguarding their lives or are they, as always, just instruments used to improve some other life? All of us women here must ask ourselves this question. Exclusive breastfeeding seems to lead to earlier mortality for the women. What can we do that does not deny the woman her right to health and well-being? Women want to live with a reasonable degree of comfort and we have to assist them in this process. We have to come up with answers that can represent a favourable outcome for both the woman and her child.

Annexes

Appendix 7.1: Details of Voluntary Counselling and Testing Programme, as proposed by NACO4

HIV testing

The diagnosis of HIV testing has traditionally been made by detecting antibodies against HIV. There has been rapid evolution in diagnostic technology since the first HIV antibody tests became commercially available. Besides ELISA, newer rapid and simple tests are available which are comparable to ELISA on sensitivity and specificity. In addition they are easy to perform in limited resource settings like district hospitals and more cost-effective than ELISA.

The success of the voluntary counselling and testing strategy largely depends on the availability of cheap testing facilities that give results at the shortest possible time. This makes the rapid tests an attractive option where the client can be subjected to a pretest counselling, test result and post test counselling in one session. The National testing guidelines lays down the following strategy to be adopted for voluntary testing for diagnosis of HIVinfection-

Strategy I of the guidelines limits the use of HIV test to blood banks where the blood units are screened for HIV and this strategy of 1 ERS (ELISA/Rapid/Simple) test does not recommend its use for diagnosis of HIV infection in a person. Strategy II and III of the guidelines states that the blood must be tested for HIV antibodies with 2 or 3 tests conducted with ELISA/Rapid/Simple (ERS) with different antigen preparations or different principles. The tests may be 2/3 rapid tests or 2/3 ELISA or a combination of Rapid and simple and ELISA but no two tests should be of one kind of antigen or principle. This ensures a better reliability of the test. Two tests are undertaken when the person is symptomatic with any one of the underlying AIDS defining illnesses as laid down in the NACO guidelines. Three tests (Strategy III) is used for asymptomatic persons who have a suspicion of HIV infection.

When to declare HIV positive?

In voluntary counselling and testing centers the following procedures should be practiced-

  • The serum sample is first tested with one ELISA or Simple/Rapid assay
  • Any reactive sample is retested, using a different assay
  • Serum found reactive on the second assay is repeated for the third test.
  • Serum found reactive on all the three tests is considered HIV antibody positive.
  • Indeterminant result- serum that remains discordant in the second essay or reactive on the 1st And 2nd test but non-reactive on the 3rd test is considered to be indeterminate. In such cases, the person must be asked to report for a re-test after a minimum period of 2 weeks and if still indeterminate may be subjected to a confirmatory assay like Western Blot or Line immunoassay. In some cases the person may be followed up for 3, 6 or 9 months.

Counselling Process

The VCT process consists of the following: Pre test Counselling, Post test counselling, Follow-up counselling

The contents and approach of each type of counselling may vary and should be adapted to the needs of the clients and may be different for individuals, couples, families, men, women etc. Contents and approaches may also reflect the context of intervention, eg. Counselling associated with specific interventions like MTCT.

Counselling as part of VCT ideally involves at least two sessions (pretest and post test counselling). More sessions can be offered before and after the test or during the time the client is waiting for the test result.

Pretest Counselling-

HIV counselling should be offered before taking an HIV test. In this process the counselor prepares the client for the test by explaining what an HIV test is and also by correcting myths and misinformation about HIV/AIDS. This counselling can also be provided to groups to reduce costs and can be backed up by providing printed information. However, group counselling must be followed by individual sessions before the HIV test is undertaken.

Persons refusing pre-test counselling should not be prevented from taking a voluntary HIV test. But informed consent from the person being tested is usually the minimum requirement before an HIV test.

Posttest Counselling-

Posttest counselling should always be offered. The idea is to help clients to understand their test results and initiate adaptation to their seropositive or seronegetive status.

When the test is seropositive, the counselor tells the client the result clearly and sensitivitely, providing emotional support and discussing how he/she will cope. The counselor must ensure that the person has immediate emotional support from a partner, relative or friend. Sharing one’s HIV status with a sexual partner is important to enable the use of safer sexual practices. And should be encouraged.

Counselling is also important when the test result is negative. While the client is likely to feel relief, the counselor needs to discuss changes behaviour that can help the client to stay negative. The window period of HIV testing means that the patient may not be truly negative and the client may be asked to undertake the test again in 3 months time, depending on the history of risk behaviour.

Follow-up Counselling-

Most of the persons may require follow-up counselling immediately after post test counselling or anytime between 1 to 5 years following post test counselling. This often coincides with a crisis or change in personal circumstances. VCT services should therefore be flexible and either be able to provide ongoing counselling or have close links with other organizations for referral like community organizations, spiritual groups or health facilities.

As part of follow-up counselling, the VCT services should offer the opportunity of ongoing care and support for seropositive cases and should act as an entry point to medical care. Collaboration and cross referral can ensure that people with HIV receive appropriate medical care, including home care and supportive palliative care.

Counselling of women in antenatal settings for MTCT (Prevention of mother to child transmission) interventions special consideration should be given to –

  • counselling about infant feeding
  • counselling about MTCT options
  • family planning counselling
  • counselling about partner notification
  • involvement of partner in decision making.

A comprehensive manual on Counselling on HIV/AIDS is developed by NACO and counselors are required to be in tune with the procedures as laid down in this manual.

One of the benefits of VCT is that it can help people with HIV to make plans for their future and the future of their dependants. For VCT services to be promoted and developed it is important to document their usefulness in –

  • Reducing HIV transmission
  • Improving access to medical and social care
  • Facilitating MTCT interventions
  • Improving coping for people with HIV

Innovative approaches can be devised to help make the counselling component of VCT less labour –intensive. Group education prior to pretest counselling can shorten the length and time required for one to one counselling and hence reduce costs. Promotion of the advantages of VCT should be an integral part of HIV education programs and included IEC materials.

Confidentiality

Confidentiality may be defined as a protection of personal data and test results to ensure the rights and welfare of the individual from whom such data are collected. This information is not to be furnished under any circumstances to any other person without the individual’s explicit consent. However, as stated earlier, this information should be disclosed to the spouse of the person.

The VCT services should always preserve individuals’ records for confidentiality.

The Counsellors

Counsellors must be knowledgeable on the issues concerning HIV/AIDS. They should be adequately trained on HIV/AIDS pretest and posttest and follow-up counselling. Establishing good rapport and showing respect and understanding are necessary credentials for a sensitive counselor. The success of a VCT largely depends on the counselor and its communication skills. The counselors, as it is seen in all other countries, mostly belong to the social sciences. Besides, psychiatrists and other doctors are also equipped to counsel on HIV/AIDS.

The counselors must provide services to all persons referred to them and should include the family members of the persons as well.

Under the NACP II program, provisions have been made for 2 counsellors in each VCTC. These counselors may be provided by the NGOs and will work under the administrative control of the Officer-in-charge of the testing laboratory. One of the counselors should preferably be a female. The State AIDS Control societies while appointing Counsellors must ensure that they are abreast with the latest developments in the field of HIV/AIDS and must also ensure that the counselors are updated in their knowledge about HIV/AIDS.

Effective VCT services

In order to make the services effective the following points should be considered-

  • The location and opening hours of the services should reflect the needs of the community. In practice all VCTCs located in the blood testing centers should remain open during the laboratory working hours.
  • Counselling sessions need to be monitored to ensure that they are of high quality.
  • Informed consent must be taken before HIV testing. Here, it is emphasized that counselors should not be rotated from center to center and from one day to another since the rapport between the counselor and client is essential.
  • Counselling should be integrated into other services, including STI, antenatal and RCH clinics.
  • Adequate supply of condoms must be made available in these counselling centers. Individuals attending the VCTC should also be made aware about the outlets from which they can get condoms under various schemes.
  • Referral system should be developed in consultation with NGOs, community based organizations, hospitals and PLWA networks
  • Counselors need adequate training and ongoing support and supervision to ensure that they give good quality counselling and avoid burnout.
  • Linkages to crisis support, follow-up counselling and care for those tested seropositive should be developed.

Innovative ways of scaling up VCT services and making them more accessible and available should be explored.

Notes

1 In South Indian AIDS Action Programme.

2 Excerpt from the NACO web site proposed by the editors as in August 2003: http://www.naco.nic.in/nacp/program/

3 For VCTC, cf. the next table and appendix.

4 Excerpt from NACO Web site proposed by the editors: http://www.naco.nic.in/nacp/program/as in August 2003.

Auteur

South Indian AIDS Action Programme

© Institut Français de Pondichéry, 2004

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