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HIV & AIDS have ravaged the African continent. Worldwide, approximately 68% of individuals infected with HIV have been identified as originating within sub-Saharan Africa.(2) Above this, current estimates suggest that 72% of the 1.8 million deaths occurring due to HIV & AIDS-related causes in 2009 were Africans.(3)
Among the key interventions identified internationally for curbing the spread of HIV & AIDS is voluntary counselling and testing (VCT). A Policy Statement on HIV Testing released by the Joint United Nations Programme on HIV & AIDS (UNAIDS) and the World Health Organisation (WHO) states: “Without effective HIV prevention, there will be an ever-increasing number of people who will require HIV treatment. Among the interventions which play a pivotal role both in treatment and in prevention, HIV testing and counselling stands out as paramount.”(4) In fact, VCT has been consistently promoted by both organisations as a routine and essential part of HIV testing in developing countries.(5)
Any individual who seeks to know their HIV serostatus will ideally undergo this process, expanded upon in the paper which follows. The experience of learning one’s serostatus is widely accepted to be psychologically taxing, with possible implications for the mental health of the presenting client. Conversely, and of equal importance, is the ability of the counsellor to provide a psychologically supportive environment in which the diagnosis may be received. This paper therefore serves to explore the tenuous nature of the HIV testing process. Despite its touted importance and effectiveness as a means to combat the spread of HIV & AIDS, it remains a psychologically threatening process for many, and this may continue to hamper the potential efficacy of this critical point of intervention.
VCT in sub-Saharan Africa
According to a 2010 progress report released by the United Nations Children’s Fund (UNICEF), UNAIDS and the WHO, the median percentage of people in sub-Saharan African living with HIV who are aware of their serostatus is below 40%.(6) Further, the report suggests that at present, “considerable gaps remain between testing and counselling needs and existing practices.”(7) These ‘gaps’ highlight deficiencies in the capacity for care in this region, and call attention to the need for policy and practice to be revised accordingly.
Examining the availability of testing services of approximately 40 countries in sub-Saharan Africa, the median number of facilities per 100,000 members of the population improved from 5.9 in 2008 to 8.4 in 2009, while the median number of tests per 1,000 members of the adult population improved from 58 to 66.(8) These figures suggest an increasing availability and uptake of testing services throughout the region.
Despite these improvements, however, the number of people who have never been tested for or know their serostatus continues to outweigh those who do. There are a number of possible reasons why these figures are low, ranging from socio-culturally based motivations to individual anxieties and concerns around the testing process. It is also likely that it is a combination of these factors that presents barriers to an individual’s willingness to test. It is therefore important to consider the nature of the counselling and testing experience as experienced by the client.
Voluntary counselling and testing
Voluntary counselling and testing represents, as mentioned, a core intervention against the spread of HIV. Procedurally, it is composed of three key segments: pre-test counselling, the HIV test, and post-test counselling. The review which follows is based on WHO regulations and guidelines, as they appear in the Voluntary HIV counselling and testing: Manual for training of trainers,(9) as well as the manual titled Guidance on provider-initiated HIV testing and counselling in health facilities.(10)
The initial intake session aims to assess the client’s motivation for finding out his or her serostatus. The counsellor will assess the client’s current risk behaviour profile and advise him or her accordingly. This establishes the basis from which the client must now decide whether to seek testing or not. Ethically, one of the central tenets of this process is that the client must elect to undergo the HIV test. After being given appropriate time to consider, should the client decide to undergo the test, the pre-test counselling session will also entail talking with the client about the potential outcomes of the test, and appropriate coping strategies to apply in these instances.
Most testing centres employ a rapid HIV test. Once the results of the test have been obtained, the presenting client will enter into a post-test counselling session –with his or her consent– to receive the results of the test. The content of this session will be determined by the serostatus diagnosis of the client. Should the client obtain a diagnosis of being HIV-negative, the counsellor will discuss with the client his or her feelings, as well as the importance of appropriate lifestyle choices to maintain this state. Additionally clients will be reminded of the window period, during which one may be infected but testing will not yet be able to detect the presence of the virus.
Should the test return an HIV-positive diagnosis, the counselling session will involve a number of aspects. Primarily, the counselling session will focus on the emotional content of the diagnostic experience. It is the responsibility of the counsellor to ensure that the news is received in a safe and sensitive environment. The client’s coping skills and support systems will be assessed as it is crucial to ensure that he or she is equipped with the necessary resources to adjust to the diagnosis. Counsellors will also focus on how to make appropriate and reasonable plans for the client’s now altered future. These discussions will include the necessity to seek and establish an appropriate treatment regime based on the client’s particular profile. Also of crucial importance is encouraging the client to share his or her diagnosis with present as well as past sexual partners. In some instances the opportunity for ongoing counselling will be made available to clients.
Implicit in this discussion is the fact that both pre- and post-test counselling sessions must proceed with sensitivity and caution, and require some therapeutic micro-skills on the part of the counsellor. If one examines training materials and VCT guidelines, these skills are often identified to include verbal and non-verbal behaviour. The former is composed of types of questions, appropriate phrasing, and language sensitivity, as well as active listening to allow for thoughtful and insightful reflection. The latter is characterised by appropriate body language (including body orientation, eye-contact, gestures and facial expressions) and paralinguistic cues (including voice pitch, volume and fluency). These skills are employed by the counsellor to put the client at ease, and to optimise the efficiency of any session. Additionally, counsellors must be contextually sensitive–particularly in a region characterised by its crucible of cultures, each with its own specific dictates surrounding the norms and dynamics of interpersonal and therapeutic interactions.
The counselling and testing experience
Having acknowledged the importance of VCT in encouraging individuals to test for HIV as well as its potential to facilitate the process of discovery, one must acknowledge that in order to initiate this process an individual needs to make the conscious decision to find out his or her diagnosis. In order to do this, a supportive environment must exist which would allow for the individual to feel safe and comfortable in the decision to test.
Research has shown that the diagnostic testing procedure and receiving the test results are associated with moderate to intense levels of anxiety and distress for the client.(11) One prominent issue here is that of stigma. Stigma represents a considerable threat both to people who are concerned about their statuses and to those living with HIV & AIDS.(12) A study conducted at a South African university revealed that while the main benefit of VCT was seen to be ‘knowing your status’ the main barriers were described as a fear of being stigmatised and a fear of being diagnosed HIV positive.(13) Further, the study showed that AIDS-related stigma was attributed to three main factors–a lack of HIV & AIDS related knowledge, the life-threatening character of the disease, and blaming those who have contracted the virus for their infection.(14) Despite the considerable advances which have been achieved in the options available for care for those living with the virus, interpersonal, communal, and societal-based discrimination remains rife. At a psychological level (as well as social and communal levels) this stigma represents a considerable barrier even before the process has begun.(15)
Another important factor to consider in terms of the psychological components of the testing experience is the fact that although HIV has come to be conceptualised as a chronic illness, at a more intimate level, as well as within certain culture-bound settings, a diagnosis as HIV positive is still strongly associated with a death sentence.(16) Of concern is the fact that it has been suggested that even certain health care professionals continue to view the diagnosis in this way.(17) The notion of an HIV diagnosis as a ‘death sentence’ can have adverse implications for healthcare. Firstly, the possibility of receiving such a decree may act as a deterrent from presentation for testing. Fear of psycho-social abandonment as a result of one’s diagnosis presents a significant barrier in such instances. Secondly, should one receive a diagnosis of a positive serostatus, the experience can be regarded as emotionally traumatic. On receiving a positive diagnosis, the client will likely undergo a paradigm shift in terms of their self-concept and experience concern and fear regarding their future and prognosis.
Addressing this shift, Stevens and Doerr, in their exploration of the narratives of women who had been diagnosed with HIV, described how each participant referred to the traumatic nature of the diagnosis.(18) Their report highlighted the sense of ‘imminent demise’ and helplessness with which these individuals reported being faced.
Notably, Olley, Zeier, Seedat and Stein have described how recently-diagnosed patients may present with symptoms indicative of Post-traumatic Stress Disorder as a result of the acutely traumatic event of being diagnosed as HIV& AIDS positive.(19) They note how when infected individuals receive their serostatus diagnosis they may experience intrusive and recurrent thoughts or dreams of illness and death, and in addition may also avoid people, activities and places that serve as reminders of the illness.(20) The capacity of the event to affect the psyche in this way highlights the potential influence on the mental health of any presenting client.
Post-test counselling, as well as long-term counselling or support-group meetings must be sure to take cognisance of this inherent trauma, and the emotional consequences of the diagnostic experience. Counsellors are charged with the responsibility of imparting appropriate information and skills to clients to ensure that they are able to cope, both physically and psychologically, with the consequences of diagnosis.(21) Coping skills, available support networks and services are therefore core components of HIV-specific counselling sessions.
It is clear that at each stage of the VCT process the adoption of a psychological lens adds depth to an understanding of the efficacy of the intervention. Whether it is the micro-skills necessary to facilitate the session on the part of the counsellor, or the fears, concerns and emotional complexities of the decision to test and the diagnosis of the client’s serostatus, sensitivity to these aspects must be shown at all times. To present for testing suggests that one is already intimately associated with the nature of infection with HIV & AIDS. The psychological journey undertaken when choosing to test is by its nature complex and extremely sensitive. This paper therefore contends that it is imperative that an empathetic and psychologically supportive environment be established as core components of the VCT experience.
With the incidence of HIV & AIDS rife in sub-Saharan Africa, it is critical the VCT service be seen to be a psychologically safe and supportive one, in order to ensure an optimal opportunity to effective intervention. Willingness to test is impacted by such factors as a fear of stigmatisation, discrimination and blame for the need to test, let alone a positive diagnosis. Thus by adopting the lens described, and allowing it to inform the process of intervention, as well as advocacy and information dissemination around this important topic, this service will be increasingly able to reach its maximum potential.
(1) Contact Deanne Goldberg through Consultancy Africa Intelligence's HIV & AIDS Unit (firstname.lastname@example.org).
(2) 'Fast facts of HIV/AIDS', WHO/UNAIDS, 2010, http://www.who.int.
(3) 'Global Health Observatory - HIV prevalence', WHO,2011, http://www.who.int.
(4) 'UNAIDS/WHO Policy Statement on HIV Testing', WHO/UNAIDS, June 2004, http://www.who.int.
(5) Meursing, K. & Sibindi, F., 2000. HIV counselling- a luxury or a necessity? Health Policy and Planning, 15(1),pp.17-23.
(6) WHO, 2010. Towards Universal Access: Scaling up priority HIV/AIDS interventions in the health sector. Geneva: WHO Press.
(9) ‘Voluntary HIV counselling and testing: Manual for training of trainers: Module 5’, WHO, 2004, http://www.searo.who.int.
(10) WHO,2007. Guidance on provider-initiated HIV testing and counseling in health facilities. Geneva: WHO Press.
(11) Worthington, C. & Myers, T,2003. Factors underlying anxiety in HIV testing: Risk perceptions, stigma, and the patient-provider power dynamic. Qualitative Health Research, 13 (5), pp.636-655.
(13) Meiberg, A.E, Bos, A.E.R, Onya, H.E., &Schaalma, H.P., 2008. Fear of stigmatization as barrier to voluntary HIV counselling and testing in South Africa. East African Journal of Public Health,5 (2), pp.49-54.
(16) ‘HIV: Death sentence or chronic and manageable disease?’, KIT website, http://www.kit.nl.
(18) Stevens, P.E. & Doerr, B.T., 1997.Trauma of discovery: women's narratives of being informed they are HIV-infected. AIDS Care, 9(5), pp.523-538.
(19) Olley, B.O., Zeier, M.D., Seedat, S., & Stein, D.J., 2005. Post-traumatic stress disorder among recently diagnosed patients with HIV/AIDS in South Africa. AIDS Care, 17(5), pp.550-557.
(21) WHO, 2007. Guidance on provider-initiated HIV testing and counselling in health facilities. Geneva: WHO Press.
Written by Deanne Goldberg (1)