Scaling up HIV Testing and Counselling in the Context of the 3 by 5 Initiative

1
Scaling up HIV Testing and Counselling in the
Context of the 3 by 5 Initiative

• Dr Buhle Ncube
• HIV Testing and Counselling Focal Point
• Regional Programme on HIV/AIDS
• WHO Regional Office for Africa
• Presentation to VCT Partnership Forum
• Harare, Zimbabwe
• 23 February 2005

2
Global Overview Treatment Gap

• 40 m people estimated to be living with HIV/AIDS
  in 2003 - 25 m in SS Africa
• 5 m new infections 3 m in SS Africa
• 3 m AIDS deaths occurred among adults and
  children in 2003 2,3 m in SS Africa
• 6m PLWHA in developing countries need ART - 4m in
  SS Africa
• 700,000 PLWHA in developing countries on ART by
  end 2004 310,000 in SS Africa

3
Benefits of ART

• Prolongs and improves quality of life of PLWHA
• Contributes to impact mitigation (safeguards
  human capital, reduces numbers of orphans)
• Supports prevention (strengthens testing
  counseling, PMTCT, STI services prevention for
  HIV positive people)
• These benefits, together with increasing
  feasibility of ART, reduction in drug prices
  existence of models experiences for ART
  delivery in resource-poor settings led to the
  declaration of 3 by 5 Initiative

4
3 by 5 Initiative

• Sets target of placing 3m PLWHA in developing
  countries on ART by end of 2005
• Attainment of 3 by 5 target depends on scaling up
  ART in Africa Region (2m out of 3m target)
• Harnesses the collective action of all
  stakeholders at country, regional and global
  levels
• Utilizes all opportunities for identifying PLWHA
  eligible for ART

5
3 by 5 Initiative contd.

• 5 pillars of the 3 by 5 Strategy
• Leadership, advocacy strong partnership
• Urgent sustained support to countries
• Simplified, standardized tools for delivering ART
• Effective, reliable supply of medicines and
  diagnostics
• Learning by doing rapidly reapplying new
  knowledge

6
Centrality of TC to ART Scale-up

• HIV Testing and counselling TC is the gateway
  to care, treatment and support for PLWHA
• People have a right to know their HIV status
• Currently lt 1.5 of people in developing
  countries know their HIV status
• To scale up ART, we need to considerably expand
  services for TC

7
Scaling Up HIV Testing

• Simplified Model for HIV Testing
• Use of rapid HIV tests which are
• - accurate, easy to perform, interpret and
  store
• - rapid (results in less than 30 minutes)
• - low cost
• Minimal laboratory equipment needed
• Use of non-laboratory personnel to perform tests
• Simplified algorithms that are cost-effective
  (serial versus parallel testing)
• Innovative approaches at community level
  integrating TC in CHBC programmes

8
Scaling Up HIV Counselling

• Simplify counselling approaches
• Training different counselling cadres to work at
  community and facility levels
• Intensified community mobilization to raise
  awareness of available services, including ART
• Normalization of TC in communities to reduce
  stigma and discrimination, and increase support
  for PLWHA
• Reviewing counselling approaches used in clinical
  settings, in view of human capacity constraints

9
Entry Points- OPPORTUNITIES- for HIV Testing
and Counselling

• TB clinics
• Acute care in-patient services for adults
  children
• STI services
• PMTCT services TC
• Community and Home Based Care (CHBC) services
• VCT centres
• Services for vulnerable groups e.g. sex workers,
  youths, MSMs, Injecting Drug Users

Entry-points for ART scale up
10
UNAIDS/WHO Policy Statement on HIV Testing

• Four types of HIV testing to be clearly
  distinguished
• Client initiated approach
• 1. Voluntary counselling and testing
• Provider-initiated approaches
• 2. Routine offer of HIV testing by health care
  providers
• 3. Diagnostic HIV testing
• 4. Mandatory testing

11
Client-initiated VCT

• Effective in promoting knowledge of HIV status
• Usually targets worried well
• Pre-test counselling is on an individual basis
  or in group settings, with individual follow-up
• Use of rapid tests provides results timeously
• Need to establish referral linkages for continued
  care and support
• Need to address stigma and discrimination
• Can be used for outreach programmes

12
Changes in voluntary counselling and testing in
South Africa more sites more tested
1,800
300,000
VCT sites
1,600
250,000
Clients
1,400
1,200
200,000
1,000
Number of clients
Number of VCT sites
150,000
800
600
100,000
400
50,000
200
0
0
2001
2002
2004 Report on the Global AIDS Epidemic (Fig 26)
Courtesy Fareed Abdullah
13
Client-initiated voluntary counselling and
testing

• Establishing a VCT culture need for dramatic
  scale up of VCT services, offered where people
  are community, workplace, schools, FBOs
• Increased attention to couple-focused VCT which
  has been shown to be associated with behaviour
  change
• Service design
• - quality services
• - assistance with disclosure
• - models parental rather than antenatal
  testing premarital testing etc.
• AIDS 2003 Allen et al Lancet 2000 Voluntary
  HIV 1 Counselling and Testing Efficacy Study Group

14
Limitations of VCT Approach for ART Scale up

• In Africa Region, main emphasis has been on
  client-initiated VCT
• Poor coverage, slow uptake and time consuming
  nature of VCT are bottlenecks to be addressed
• Sole reliance on VCT inhibits timely
  identification of PLWHA ART scale up
• Different TC approaches needed to access
  different groups of people

15
Diagnostic HIV testing e.g. TB settings

• Indicated -whenever a person shows signs or
  symptoms that are consistent with HIV-related
  disease or AIDS
• - when there is need to aid clinical
  diagnosis and management
• 14m PLWHA are co-infected with TB 70 in SSA
• TB most common cause of death in PLWHA in less
  developed countries
• Best initial entry point since many patients
  in need of ART will be found immediately
• Offers best opportunity to scale up ART

16
Routine offer of HIV testing Clinical settings

• High proportion of HIVinfected patients are in
  medical clinics and hospital wards adults and
  children
• gt50 of in-patients have HIVrelated disease
• In clinical health service settings, HIV is
  prevalent and antiretroviral treatment is
  available
• Need for urgent implementation of Routine offer
  of TC as STANDARD OF CARE

17
Routine offer of HIV testing - STI services

• Some STIs facilitate transmission of HIV early
  diagnosis effective treatment crucial
• Control of STIs is among the few interventions
  shown to prevent HIV infection
• STIs affect 1 in 20 young people
• most are curable but left untreated
• Youth-friendly services needed
• Need for Routine offer of TC for STI patients

18
Routine offer of HIV testing - PMTCT services

• Many MCH and PMTCT programs now offer TC
  services
• PMTCT important in extending ART to infected
  mothers and their families
• Opt-out approaches to be advocated for, as
  STANDARD OF CARE in ANC settings

19
Routine offer of HIV testing - CHBC services

• CHBC programs focus mainly on chronically ill
  HIV-infected individuals
• Provide ready pool of individuals who need to
  commence ART urgently
• Need to scale up clinical evaluation for ART in
  CHBC programs
• Need to generate demand for TC through community
  education and social mobilization Right To
  Know Campaigns

20
Targetting vulnerable groups

• These include
• sex workers, youths, MSMs, injecting drug users
  (IDUs), marginalized people due to poverty,
  migration, civil unrest, stigma, discrimination
• Have increased vulnerability to HIV infection and
  reduced access to services
• Need to reach out to these people who do not
  seek out services on their own, esp. young people
• Important to strengthen linkages with all sectors
  private, NGOs, FBOs, CBOs etc.

21
Challenges

• Resource gaps
• Cost of ARV medicines
• Geographical distribution of services
• Human resource capacity
• Improvement of infrastructures for delivery of
  care and treatment

22
Provider-initiated TC Approaches

• Paradigm shift needed in clinical settings to
  facilitate identification of people needing
  treatment provider-initiated approach
• Offer of TC should be considered the STANDARD
  OF CARE in all clinical settings
• However, human rights requirements must be
  fulfilled in the universal offer of TC services
  i.e. counselling, confidentiality, consent and
  voluntarism

23
Key Points

• TC is the gateway to ART
• 3 by 5 Initiative requires massive scale up of
  TC
• Increase efficiency and effectiveness by
  targeting where there is highest likelihood of
  HIV infection
• Need to reach out to vulnerable groups
• Simplify and standardize TC through different
  models

24
CONCLUSION

• TC is central to HIV treatment, care
  attainment of the 3 by 5 target
• Expanded TC in various settings will support
  prevention
• ART access will be scaled up if opportunities for
  accessing HIV testing are dramatically increased
  through diagnostic, routine offer of testing
  VCT
• Countries - with partners support - need to
  modify their testing counselling policies,
  strategies programmes for rapid scaling up.

25
Together we can make a difference !!
26

• THANK YOU