Horizons Report | December 2006 | Initiating HIV Diagnostic Testing and Counseling

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December 2006

Initiating HIV Diagnostic Testing and Counseling
Study in Kenya underscores need for adequate training of health providers

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In Kenya, a country noted for achievements in battling the HIV epidemic and a recent decline in national prevalence, the vast majority of adults living with HIV still do not know their status. According to the 2003 Kenya Demographic and Health Survey, only 14 percent of men and 13 percent of women ages 15–49 have tested for HIV. Despite massive national campaigns, there remains a large unmet need for HIV testing and counseling.

To address the challenge of increasing testing levels, the World Health Organization recommends that individuals who present to health care facilities, including hospitals and clinics, should receive HIV testing and counseling as part of their diagnostic assessment and clinical evaluation (2006). This is particularly relevant in Kenya because estimates suggest that up to 60 percent of all medical ward hospital beds are occupied by HIV-infected patients (NASCOP 2004). Provider-initiated testing and counseling, which includes “diagnostic testing and counseling” (DTC), can be a gateway to appropriate care and treatment services as well as an opportunity to boost HIV prevention efforts.

To assess the readiness of the Kenya health system to provide DTC, the National AIDS and STD Control Programme (NASCOP), in collaboration with Horizons and the U.S. Centers for Disease Control and Prevention, conducted a national study of health workers in 2005. The study surveyed nearly 1,900 providers working in 247 public, private, and faith-based facilities nationwide. In addition to doctors and clinical officers, the researchers interviewed registered and enrolled nurses, laboratory technicians, voluntary counseling and testing (VCT) counselors, and social workers based in hospitals, health centers, dispensaries, and maternity homes. The study also included focus group discussions with health workers and district health management teams (DHMTs).

Diagnostic Testing and Counseling in Kenya

DTC is the procedure whereby a health worker requests, as part of other investigative tests, HIV testing of a patient presenting with symptoms that could be attributable to HIV disease. DTC uses an opt-out approach, that is, it is assumed that patients who present with symptoms of HIV disease desire a diagnosis, therapy, and care. This therefore implies consent for diagnostic testing for other health conditions, including for HIV. However, patients must be informed that the test is being done and have a right to decline (Source: NASCOP/MOH 2004).

“This study represents a huge national effort to provide a picture of what is happening on the ground with regard to provider-initiated HIV testing and counseling and to document what training and support they need,” explained Dr. Karusa Kiragu of Horizons/PATH, one of the study’s principal investigators.

Need for DTC Training

The vast majority of providers interviewed worked at facilities that offered HIV testing, with only 12 percent working in facilities that did not. About half of the health providers surveyed said that they had conducted HIV testing or counseling. Of these, 72 percent had been specifically trained in that capacity, which means that over a quarter of health workers conducting HIV testing or counseling were doing so without relevant training, including 45 percent of doctors and 40 percent of clinical officers. The training itself varied—half of the respondents had been trained in HIV counseling and testing in the context of programs to prevent mother-to-child transmission, and 36 percent had received training in VCT. Only 18 percent had received specific training in DTC. Less than 15 percent of the entire sample had received any training in HIV counseling and testing during their pre-service education, suggesting a large missed opportunity.

Both health workers and members of DHMTs viewed the lack of appropriate training as a barrier to DTC. During focus group discussions participants expressed concern that health workers who lacked training and confidence in HIV testing and counseling may provide inadequate services to patients. A large majority of participants felt that all health workers should be trained in HIV testing and counseling.

. . . A patient may be seen to have symptoms but since one [i.e., health worker] isn’t trained, he neglects the patient or pushes him to VCT.
—DHMT member, Rift Valley

All staff should be trained [in HIV testing and counseling], as this will reduce the inconvenience of referring clients to other health workers. . . .
—Doctor, Rift Valley

When asked about specific training needed, around 80 percent of respondents felt they needed to strengthen their skills in how to recommend an HIV test to a patient, and how to provide post-test counseling for both HIV-positive and HIV-negative patients.

Other Barriers to DTC

The discussions also revealed other important barriers that hindered the ability of health workers to conduct DTC, especially lack of time and shortage of test kits. Many providers had to borrow test kits from other departments when they ran out. Providers also reported that some colleagues had counterproductive attitudes toward HIV testing that discouraged patients from accepting DTC.

The staff may sometimes say to patients: ‘You are healthy. Why should you test [for HIV]?’
—DHMT member, North Eastern Province

DTC Underway

When respondents were asked whether they had “ever ordered an HIV test on an adult patient,” 41 percent indicated that they had done so. Nearly all doctors (99 percent) and clinical officers (88 percent) had ordered an HIV test on an adult patient, compared to 42 percent of registered nurses.

Overall, providers reported that they followed the key steps outlined in the DTC guidelines. Among those who had ordered HIV tests, 91 percent informed their most recent patient themselves before the test was conducted, 92 percent made pre-test counseling available either by conducting it themselves or arranging for it to be done by someone else, and a similar percentage made post-test counseling available.

Requesting an HIV test for a pediatric patient was less common among the health workers surveyed. About 17 percent had ever ordered a test, and among these health workers, 69 percent said they or another provider initiated the last test of a pediatric patient, while 30 percent said the parent or guardian requested it. The vast majority (90 percent) of the health workers involved informed the patient’s parents or guardians before conducting the test and all providers who involved parents sought verbal (87 percent) or written (12 percent) permission to test the child. After the test, 90 percent either provided post-test counseling to the family or arranged for it to be done by someone else.

Couple Counseling

The DTC guidelines state that during post-test counseling, providers should discuss strategies that patients can use to disclose their serostatus to partners. The guidelines also encourage couple counseling when appropriate. In order to determine the preparedness of providers in this area, respondents were asked whether they knew what “couple counseling” was, and whether it would be appropriate for four categories of patients and their partners: patients who test HIV-positive, STI patients, TB patients, and pregnant women.

Just over three-quarters (78 percent) of respondents were aware of the term “couple counseling.” VCT counselors (99 percent) were the most likely to know the term and enrolled nurses (74 percent) the least likely.

In general, health workers in Kenya readily recognized the value of couple counseling within the context of HIV testing in clinical settings. Most were supportive of couple counseling; nearly all (including those who were not initially aware of the term) felt that this procedure should be provided to all the different groups asked about. In fact, when asked about their need for additional training, 90 percent of health workers requested training in couple counseling.

“Couple counseling may be our biggest challenge because of a high level of HIV discordance in the region,” noted Dr. Isaiah Tanui of NASCOP, another of the study’s principal investigators. “If health workers do not have the capacity to counsel couples, an important opportunity will be missed to address the needs of infected and uninfected partners. Building capacity for couple counseling is necessary if DTC is to be successful.”

Recommendations

DTC is underway in Kenya, with a large cross-section of health workers already undertaking the responsibility of ordering HIV tests for their patients. Where DTC has been conducted, it seems that health workers have followed the key guidelines—informing the vast majority of patients prior to testing and arranging for pre- and post-test counseling. However, a limitation of this study is that the data come from health workers’ self-reports. Therefore, as DTC is rolled out in Kenya, observational studies would be warranted to better understand the extent to which health workers actually follow the guidelines and how well they inform patients about the test and their right to opt out, counsel patients about the results, and maintain patients’ confidentiality.

Many health workers were highly supportive of provider-initiated testing and were willing to offer this service to their patients.

This study documents that many health workers were highly supportive of DTC and were willing to offer this service to their patients. As other countries adopt provider-initiated testing, they, like Kenya, will need to equip all health workers who conduct HIV testing and counseling in clinical settings with adequate skills through pre-service, in-service, and refresher trainings. They will also need to ensure that health workers who could conduct DTC but presently do not do so can undertake this task when needed as the service expands. Moreover, country programs will need to provide adequate infrastructure, develop clear guidelines to ensure that patients are adequately informed about the test, and implement strategies to meet unmet needs, such as testing of pediatric patients and couple counseling.

The study results and recommendations will be discussed with NASCOP and other key stakeholders at a meeting in Kenya in early 2007, which will generate detailed plans for follow-up. After this meeting the final report on the study will be available on the websites of NASCOP (www.aidskenya.org) and Horizons.

This article was written by Hena Khan and Ellen Weiss in conjunction with the study team which includes Isaiah Tanui, Godffrey Baltazar, John Wanyungu, and Meshak Ndolo, NASCOP; Lawrence Marum and Mary Mwangi, CDC-Kenya; Karusa Kiragu, Horizons/PATH; and Susan Kaai, Horizons/Population Council.

For more information about this study, contact Karusa Kiragu (kkiragu@pcnairobi.org).

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See Also

For additional information please contact:
Horizons
Population Council
4301 Connecticut Ave. NW, Suite 280
Washington, DC 20008
Telephone: +1 202 237 9400
Facsimile: +1 202 237 8410
E-mail: horizons@popcouncil.org

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This page updated
11 January 2007