Targeting ProviderInitiated Testing to STI Patients in Swaziland

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Targeting Provider-Initiated Testing to STI
Patients in Swaziland
International HIV Counseling and Testing
Workshop
Lusaka, Zambia, January 21-24, 2008

• Rejoice Nkambule (MOH)
• Victoria Masuku (PSI)
• Peter Vranken (CDC)

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UNAIDS 2004

• Untreated STIs increase the risk of HIV
  transmission in the event of unprotected sex.
  Thus prevention, proper diagnosis and treatment
  of sexually transmitted infections are essential
  components of an effective HIV prevention
  strategy

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Genital Ulcers
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All STIs, Age Distribution
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Key Observations

• STIs are still a major problem in Swaziland
• STIs make up a considerable part of the commonly
  seen morbidity
  
• Age groups most severely affected are
• 20-24 and 25-29
• These are, obviously, the same age groups that
  are hardest hit by HIV
  

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STIs and HIV Infection
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STI/HTC Strategy Objectives

• Develop systems and policies to facilitate a
  focused HTC rollout in STI services
  
• Improve the facility level capacity to provide
  HTC in STI services
  
• Improve/promote availability and use of HTC
  services where STI services are provided on a
  small scale
  
• Develop and adapt existing messages to
  incorporate STI/HTC integration

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STI/HTC Strategy Objectives

• Promote linkages between STI/HTC services and
  other care and support services for a HIV
  continuum of care
  
• Conduct ongoing ME to ensure implementation of
  quality STI/HTC services
  
• Promote strategies aimed at reducing HIV stigma
  and discrimination within STI settings

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SWOT Analysis

• Strengths
• Well developed infrastructures at all levels
• Large geographical coverage
• Well trained staff for STI syndromic case
  management
  
• Initial efforts with PMTCT and TB to guide
  programming
  
• National policy articulates the need to scale up
  HTC
  
• Opportunities
• ART scale up

• Weaknesses
• Lack of Laboratory testing facilities in clinics
  
  
• Inadequate IEC/BCC material on the strategy
• Shortage of trained manpower in HTC
• Threats/Challenges
• Fear of service providers to initiate an HTC
  offer to clients
  
• Laboratory capacity to scale up testing services

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STI/HTC Strategy Implementation

• HIV screening is recommended for all persons
  presenting at STI or sexual health services with
  an STI (routine offer).
  
• Programming in these services also provides HTC
  for sexual partners, either as couples or
  individuals through referral for HTC services.
  
• No client is denied services because she has not
  agreed to be tested and counseled for HIV.

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STI/HTC Flow Chart
Client triaging
Group counseling
STI Room STI Screening Offer HTC
HTC not accepted
HTC accepted
Confirm STI Diagnosis Offer STI care
Confirm STI diagnosis Offer STI care HTC
HIV Positive Post test counseling Continue STI c
are
HIV Negative Post test counseling Continue STI
care

Refer to VCT Partner Slip
Refer for HIV Chronic care Partner Slip
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Achievements

• Reviewed and updated the STI Manage-ment Training
  Manual to include HTC
  
• Conducted a Training of Trainers for STI
  Trainers (revised Manual)
  
• Involved Regional Health Management Teams on
  STI/HTC integration and rollout strategy for
  ownership and sustainability
  
• Conducted trainings for STI service providers to
  integrate HTC as a standard of care
  

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Achievements

• Carried out mentoring visits to STI treatment
  facilities to integrate HTC into STI care
  
• Promoted linkages between HTC services and other
  care and support services for a continuum of care
  in HIV services
  
• Incorporated HTC indicators into ME for STI
  care
  
• Development of STI Register with HTC data

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Achievements
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Achievements

• For now, the HTC uptake is still very low, but
  considering the fact that this initiative was
  introduced In June 2007,it might be premature to
  make conclusive judgments.

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Interviews with STI Clients

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Quotes from STI Clients

• If the provider offers (HIV testing) I will
  tell him/her to wait since I am not ready
  
• If my partner can go with me maybe I can
  test (male client)
  
• It is necessary but scary when I know I will
  die
  
• Knowing your HIV status costs, because I then
  will have to change my life style
  
• Are we adequately addressing the fear that
  surrounds HIV testing ?

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STI Services Provider with a Client
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Quotes from STI Services Providers

• The people who know they are HIV positive are
  easy to deal with, but the ones who do not know
  are difficult to convince to opt in.
  
• The testing happens in the Lab. Some clients
  simply dont go there, and in that way they
  refuse to test.
  
• Sometimes, for the interest of the client, I
  use a bit of coercion and it helps.
  
• Maybe it should not be given as an option but
  routinely so that all clients access HTC
  
• Should HTC be routinely offered, like RPR?

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Challenges

• Stigma and discrimination especially self stigma
  resulting in fear in accessing HTC services
  
• Shortage of human resource capacity to conduct
  rapid HIV testing to scale
  
• Rigid policies in adopting testing in the
  counseling rooms or introducing a bridging cadre
  
• Counselor care for health providers for
  psychosocial support

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Challenges

• Test kits supply chain management to sustain
  testing services by health facilities
  
• Infrastructure not well developed to cope with
  service expansion
  
• Communication messages to sensitize for HTC
  integration have not been developed
  

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Lessons Learned

• MOH support and leadership is instrumental in
  rolling out HTC in clinical settings
  
• Laboratory services and QA should be strengthened
  for HTC rollout to be successful
  
• STI providers should be allowed to conduct on
  site testing in order to increase access to
  integrated services
  
• Supply chain management is critical to avoid test
  kits stock outs

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Lessons Learned

• Referral of clients to VCTs for ongoing
  counseling should be strengthened considering the
  long queues at health facilities
  
• Preparedness for health care infrastructure to
  meet HTC demand should be prioritized
  
• Partnership between implementing partners ensures
  maximum use of resources and increase coverage

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Way Forward

• Compile data base of trained HTC/STI providers to
  monitor impact of training on service provision
  
• Pilot/roll-out of STI registers incorporating HTC
  indicators
  
• Develop QA strategy for provider initiated HTC to
  ensure quality service provision
  
• Develop communication messages to increase risk
  perception for STI clients
  

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Siyabonga!Thank you!