HIV Counseling and Testing (HCT) is widely used as the main entry point to wider HIV prevention, care, prophylaxis and treatment of HIV related illness, psycho-emotional and legal support for people tested positive and negative. The goal of VFCT programs is to achieve HIV prevention, treatment, care and support gains at behavioral, psycho-social, relational and community levels among HIV negative as well as positive clients. To achieve sustainable HCT services as a primary HIV prevention strategy, Nepal is moving from NGO-based standalone HCT services to HCT services integrated public hospital-based primary health care services. The effectiveness of the aforementioned HCT services and their relative advantages and disadvantages are not adequately understood, especially in the context of a low HIV prevalence country like Nepal.
The review has looked HCT services of standalone NGO-based and public hospital-based HCT services in achieving HIV prevention, treatment, care and support gains among seasonal migrant workers in the Achham district of Western Nepal. Desk review was conducted along with 3 NGO-based and 2 public hospital-based HCT centers. The review was expected enhance an understanding of how-and with what success-HIV counseling and testing can potentially be used as an effective HIV prevention strategy among seasonal migrant workers
Despite the widespread belief that scaling up of Voluntary HIV Counseling and Testing (HCT) programs has significant HIV prevention benefits through a reduction in risk behaviors in a cost effective manner, these claims are often difficult to verify in developing countries with a low prevalence of HIV1-3. Results from a meta-analysis of HCT efficacy data also supported the intervention as an effective behavior change strategy for persons infected with HIV. Few studies from developing countries were either available or matched the inclusion criteria for these reviews. As a result, the majority of studies included in these reviews were conducted in developed countries in North America and Europe4. In these low prevalence areas, the lower utilization of services is one side of the problem, but the understanding of its effectiveness in terms of changing behavior is another. To date, the effectiveness of HCT services in Nepal has not been documented, making it extremely difficult to ascertain if the strategy has succeeded or failed.
In the wider context, there are some studies that suggest a reduction of HIV risk behavior after utilization of HCT services. In a Randomized Controlled Trial (RCT) conducted in Kenya and Tanzania, men and women who were offered personalized voluntary HIV counseling and testing were more likely to reduce their practice of risky behaviors than their peers who received HIV education in a general setting.2 In another study in Mozambique, reported use of condoms while having sex with friends and/or prostitutes increased over each time period in the HCT group 3.
Results from a number of studies also suggest that HIV safe behaviors are not necessarily instigated by the knowledge of HIV positive status. A study conducted among 218 HIV positive patients in a STI clinic in Cape Town, South Africa, found that 34 (16%) had engaged in unprotected vaginal or anal intercourse with uninfected or unknown HIV status sexual partners in the previous month6. Similarly, a study in Wales suggested that 76% of PLHIV were sexually active and 42% had casual partners. One in six sexually active persons reported having unprotected sex with HIV negative or unknown status partners7. On the contrary, there is evidence that knowledge of HIV positive status is associated with reduced HIV risk behaviors. A study in Kenya showed that significant prevention gains were recorded in clients receiving health centre-based HCT services in comparison to the clients receiving general health education only8.
HIV situation in Nepal:
National HIV estimates indicate that approximately 60,000 adults and children are living with HIV in Nepal, with an estimated prevalence of about 0.35% in the adult population (15-49 years old)9. As of November 2014, a total of 19,369 cases of HIV, 5,578 cases of AIDS, and 1423 AIDS-related deaths have been reported to the National Centre for AIDS and STD Control (NCASC). Nepal’s HIV epidemic, driven by injecting drug use and sexual transmission is characterized by higher HIV prevalence in key populations at higher risk of exposure. Most recent estimates of PLHIV show that 42% of all positive cases in Nepal are seasonal labor migrants, 15% are clients of sex workers, and 26% are wives or partners of HIV-positive men9.
HIV Response in Nepal:
Noticeable programmatic gains have been made in recent years in improving access to HCT, syndromic management of STI, access to ART, palliative care, management of opportunistic infection and involvement of PLHIV in overall HIV program implementation. Behavioral data indicates increased use of condoms among Sex Workers (SWs), reduction in needle sharing among Injecting Drug Users (IDUs) and improved rate of HCT utilization among both groups9. Despite reasonable success in specific groups, a major proportion of HIV infections have consistently been reported among seasonal migrants traveling to India for labor-based work. A 2006 study of Nepali migrants traveling to Indian cities found that 27% of men engaged in unprotected sex and were frequently visiting sex workers in India. HIV prevalence among migrants at a national level is documented at 1.9%. Almost 6 million Nepalese live overseas; 4.1 million in India and among them approximately 2 million are seasonal labor migrants working in cities with high HIV prevalence rates9. Despite a lack of studies, the migration pattern in Nepal is observed to be seasonal. Those who travel for work in India come back home during festivities and social occasions to stay with their family and spouse who mostly remain in Nepal.
In 2005, Nepal started scaling up HCT services to HIV most-at-risk populations (MARPs) through NGOs responding to calls for more accessible HCT services among MARPs. The number of HCT centers increased from 13 in 2005 to 171 at the end of 2009. The increase resulted in an exponential growth in the number of clients tested for HIV, treatment of patients with STI, and number of people on ART13.
Nepal faces challenges sustaining and expanding such interventions to MARPs. There were three major HIV funding channels in Nepal. USAID is phasing out most of its 17 year long HIV program in 2011. DFID is phasing out its 25 million pound support to the National HIV response in 2011. The available funding from the Global Fund and the World Bank is shifting its focus towards strengthening HIV programs through a public health sector reform approach. This advocates the delivery of essential HIV service packages through government run primary health care set up. The national government spending in HIV is less than 100,000 USD per year13. As a result of lower health sector spending on HIV coupled with shrinking donor funding, more and more HCT services are shifting from standalone specialized interventions to public hospital based settings.
With the change of risky sexual behavior by combining personalized counseling with knowledge of one’s HIV status, HCT is believed to motivate people to change their behaviors to prevent the transmission of the virus. The extent of such gains in a cost effective way in a low HIV prevalence developing country like Nepal has not been adequately studied. The comparison of the effectiveness of these services also has not been carried out to a depth which can provide sufficient understanding needed to guide the strategic shift.
HIV situation and HCT services in Achham district:
Achham is one of the most remote and poorest districts in Nepal. The per capita income of the majority of residents is well below USD 1 per day. The district was also among the most conflict affected regions during a decade of Maoist insurgency. These driving forces have induced large scale migration in search of work mainly to large Indian cities. Statistics show that of the approximately 250,000 in the male population of the district, 58% migrate seasonally to India. Also overall health indicators are one of the worst, recording maternal mortality of 1 in 125, 64 stillborns in every 1,000 live births, and 83 deaths in 1,000 children before the age of five10. The HIV prevalence among seasonal labor migrants to Indian from the district varies from 3.7% to 7% in different studies11-12.
Achham has 3 NGO-based and 2 public hospital-based HCT services. Also, 1 ART site, 8 community-based PMTCT sites, 3 crisis care homes and community home based care programs are operational in the district.
Outreach-based HIV prevention education (based on interpersonal communication) coupled with HCT and syndromic management of STI services are offered through the NGOs. To ensure that the health needs of clients are adequately addressed, HCT services are strongly linked with tertiary care services, PMTCT, ARV programs, and psycho-social care services.
The NGO-based HCT services are designed as per World Health Organization (WHO) recommended optimal facilities and personnel for resource limited settings. These centers are run by service center manager, counselor, laboratory technician, community health worker/outreach worker, and a network of peer volunteers. The service centers have a dedicated counseling room, laboratory room, waiting area, and administration/meeting room. The staff have specialized training on targeted BCC, based on stage of change theory. The counsellors are trained to provide risk reduction counseling specific to migrants only. Services are often delivered through peers of the target community. The program also focuses on community sensitization and advocacy among key stakeholders in the community.
In public hospital-based HCT, HIV counseling is provided by a staff nurse who also has overlapping duties within and in-patient ward. HIV tests are performed by a lab assistant in a general lab setting. There is a dedicated HIV counseling room, but lab experiments and tests are carried out in general lab settings alongside other patients. The district hospital is a public health facility providing primary health care services with a 15 bed in-patient facility. There are 11 personnel in the hospital, including 2 medical doctors, 5 nurses, 1 lab assistant, and 3 administrative staff.
- Coates TJ., Grinstead O A., Gregorich S E. et al., The Voluntary HIV-1 Counseling and Testing Efficacy Study Group, Efficacy of HIV-1 counselling and testing in individuals and couples in Kenya, Tanzania, and Trinidad: a randomised trial, Lancet, 2000, 356(9224): 103-112.
- Sweat M. et al., Cost-effectiveness of voluntary HIV-1 counselling and testing in reducing sexual transmission of HIV-1 in Kenya and Tanzania, Lancet, 2000, 356(9224):113-121.
- Mola O. D, et al., Condom use after voluntary counselling and testing in Central Mozambique, Tropical Medicine and International Health 11 no 2 pp 176–181 2006
- Weinhardt, L. S., Carey, M. P., Johnson, B. T., et al. Effects of HIV counseling and testing on sexual risk behavior: A meta-analytic review of published research, 1985–1997. American Journal of Public Health, 89(9), 1397–1405.c
- AIDS MEDS, viewed March 16, 2010, http://www.aidsmeds.com
- Seth C. K., Leickness C. S., Demetria C. HIV transmission risk behaviours among HIV seropositive sexually transmitted infection clinic patients in Cape Town, South Africa The European Journal of Public Health Advance Access 20, 85–92, 2009
- Browning MR, Evans MR, Rees CM, Continued high-risk sexual behavior among HIV-positive people in Wales. Int J STD AIDS. 2003 Nov;14(11):737-9.
- Arthur G., Behaviour change in clients of health centre based Voluntary HIV counselling and testing (HCT) services in Kenya Sex Transm Infect doi:10.1136/sti.2007.026732
- Bunnell, R., et al., Changes in sexual behavior and risk of HIV transmission after antiretroviral therapy and prevention interventions in rural Uganda. AIDS, 20, 85–92.
- National Center for AIDS and STD Control. Nepal UNGASS Country report; 2009
- Ministry of Health. Nepal. National Annual Health Report; 2008
- FHI, HIV/STD Prevalence and Risk Factors among Migrant and Non-Migrant Males of Achham District in Far-Western Nepal; 2002
- UNDP, The annual programmatic report to the global fund, 2009 ( unpublished report)
- Ana P. Johnson M., Pinkerton SD. et al. Cost-Effectiveness of a Community-Level HIV Risk Reduction Intervention for Women Living in Low-Income Housing Developments The Journal of Primary Prevention, Vol. 26, No. 4, July 2005 (C _ 2005) DOI: 10.1007/s10935-005-5392-2
- Van de Perre P, HIV voluntary counselling and testing in community health services, commentary, Lancet, 2000, 356(9224):86-87.
- Sears D. et al., Sexual risk behaviour among HIV-positive patients at an urban clinic in Santiago, Dominican Republic, AIDS Care: Psychological and Socio-medical Aspects of AIDS/HIV, 1360-0451, Volume 20, Issue 2, 2008, Pages 191 – 197
- Julie A. Denison E. Kevin R., et al HIV Voluntary Counseling and Testing and Behavioral Risk Reduction in Developing Countries: A Meta-analysis, 1990–2005 AIDS Behav (2008) 12:363–373 DOI 10.1007/s10461-007-9349-x