As outlined in Chapter 1, ZL’s approach to expanding HIV care in Haiti is not to provide freestanding, NGO-managed VCT and HIV treatment alone. Rather, the goal is to integrate HIV prevention, testing, and treatment with primary health care in the setting of a public clinic. There are four critical program components—or “pillars”—that serve as entry points for HIV case detection (Figure 2.1):

1. people seeking primary health care;
2. people diagnosed with tuberculosis;
3. women seeking women’s health or family planning services; and
4. people diagnosed with sexually transmitted infections.

Figure 2.1 PIH’s Four Pillars of HIV Prevention and Care

The provision of VCT within the context of primary health services constitutes the first pillar. Rapid HIV testing has facilitated the linkage between addressing basic health concerns and the provision of VCT. In this model, sometimes called provider-initiated testing, all patients seen for primary care services are offered VCT if their symptoms may be associated with HIV or an opportunistic infection. HIV test results can be presented and explained to patients the same day as the testing is done. In addition, integrating VCT into primary health care decreases the perceived stigma of AIDS because patients need not implicitly or explicitly declare that they are at risk for HIV infection when presenting for care.⁴ Careful patient histories—including information about the status of the patient’s partner(s), the status of the patient’s parents, and the patient’s employment history (including migration for work and any history of domestic servitude or commercial sex work)—are always taken in order to elucidate social and epidemiological risk factors for HIV; patients with any explicit risk factors are also offered VCT.⁵ In addition to offering testing to patients who present with illness, risk factors, or a desire to be tested (i.e., passive casefinding), active casefinding is carried out by encouraging disclosure and the testing of children and partners, as well as through prevention and education programs at schools, churches, and community events.^6,7

The second pillar of ZL’s comprehensive and integrated approach is the linking of VCT to improved TB casefinding and treatment. Because TB is the most common opportunistic infection in HIV patients worldwide, all HIV patients should be screened for both active and latent TB, just as all active TB patients should be tested for HIV.^8,9 When the two screening services are provided concomitantly, a greater number of co-infected individuals are identified, increasing the likelihood of achieving improved outcomes for both diseases.

The third pillar is the linking of VCT to comprehensive women’s health services, with an emphasis on family planning and safe motherhood.¹⁰ The availability of antiretrovirals and antepartum, maternity, and postpartum care greatly enhances the uptake of HIV testing among pregnant women.¹¹

Finally, VCT should be offered to all patients presenting with STIs—the fourth pillar.¹² Numerous studies have shown that treatment of other STIs diminishes the risk of acquiring HIV.¹³ Additionally, the detection and treatment of STIs is an important avenue for providing HIV testing and prevention messages.¹⁴

The remainder of this chapter will lay out the main issues encountered in implementing this four-pillar approach.