It is vital to facilitate the integration of VCT within the setting of primary care services. The constraints of time and space in a busy clinic must be balanced against the need to ensure appropriate patient privacy and participation in the decision-making process. 15,16 The reality for busy clinics in the developing world is that pre-test counseling must be brief so as to minimize disruption of the flow of patient services.17 The same practitioner—whether nurse, social worker, or physician—who sees the patient for the presenting complaint provides counseling during the same session and refers the patient directly to the lab for rapid HIV testing; the patient returns to the referring provider to receive and discuss the test result. This streamlined approach to VCT minimizes the inconvenience and effort imposed on the patient, since returning to the clinic at a later date presents considerable difficulty for many people in impoverished settings.18
If the initial rapid HIV test is positive, a second (different) rapid test is performed as confirmation. If both tests are positive, the patient is definitively identified as HIV-positive. If the two tests are discordant—that is, if the first test is positive and the second test is negative—a third (different) rapid test or Western Blot analysis is performed and considered the definitive result. This process is illustrated in Protocol 2.1.*
*All protocols for Chapter 2 are grouped at the end of the chapter, immediately before the References.
Post-test counseling is critical in helping patients cope with a diagnosis of HIV.19 In order for care providers to adapt post-test counseling to the context of their patients’ lives, soliciting patients’ concerns and their understanding of HIV is crucial. In the ZL program in Haiti, post-test counseling occurs at the time of diagnosis and continues during subsequent clinic appointments and home visits by nurses, social workers, physicians, and accompagnateurs. Community-based support ensures that patients truly understand the nature and management of their disease, and that psychological and medical support exists to allow them a long, productive life. In PIH programs, the long-term relationships between patients, community health workers, and members of the clinic staff constitute the most effective ongoing counseling.
If the partner of an HIV-positive patient is HIV-negative, preventing HIV transmission from the infected patient to the uninfected partner becomes an important component of care. Disclosure of HIV status to one’s sexual partner(s) and children is encouraged and facilitated through counseling. However, issues of privacy, stigma, discrimination, and violence associated with HIV disclosure must be respected if the HIV-positive person chooses not to disclose his or her status.20 Condoms should be promoted and provided free of charge, as their correct and consistent use during sexual intercourse decreases the risk of transmitting HIV to the uninfected partner by up to 96 percent as well as providing protection against other STIs and unplanned pregnancies.21 If couples are not consistently using condoms, they should be advised against having sex during menses or in the presence of active STIs. HIV-negative partners should receive routine checkups, including counseling and HIV testing as well as screening and treatment for STIs, every six months.22
The infected person’s viral load and CD4 count influence the likelihood of transmission between discordant partners.23–29 Therefore, starting the HIV-positive partner on ART as soon as clinically indicated may significantly decrease the risk of infecting the HIV-negative partner.