Personal thoughts on Voluntary Testing & Counselling in India

[Guest guest]

Dear All,

I would like to place my personal thoughts on the state of Voluntary

Testing & Counselling programs in India before the forum members. These

comments are not to criticise but to initiate discussion on the issue

along with list some of the possible options.

(1) NACP -II target: One Voluntary Testing & Counselling centre has

to be established in each district in the country according to the

targets set in National AIDS Control Program Phase II.

* Will the targets be realised at the present rate of expansion?

There might have to be either revision of the targets or speeding

up of the scale of expansion especially in the Northern states

(Uttar Pradesh & Bihar). There are quite a few VCT models, which

could be replicated or scaled up.

* Will the expansion program compromise the counselling process? The

worry is that the rapid expansion of VCTs might compromise the

counselling process for more HIV testing. It is important to

distinguish the goals of VCT from surveillance testing. A system

of safeguards needs to be set in place, which could prevent VCTs

from being misused for gathering data on HIV prevalence &

incidence in local areas. VCTs can at best be used as an adjunct

for monitoring trends in the acceptance of the concept of

voluntary testing among populations that it caters to.

(2) Structure of existing counselling centres: 2 counsellors have

been posted in each Voluntary Testing & centre for 5-6 days a week.

* Is the remuneration to counsellors enough? Counsellors are paid Rs

4000/ month as honorarium. Lot of counsellors in big metropolitan

cities have told me that it was not enough to sustain them and

their families. There is a need to look again at the pay structure

of counsellors especially in big cities.

* Are there sufficient support systems in place for counsellors?

There are no support systems for the counsellors to vent their

feelings at the end of the day/week etc. There is a felt need for

having a structure in place where in the counsellors will debrief

on a daily/ weekly basis to a supervisor. In addition, the

counsellors should also be provided space & time to ventilate

their feelings. This could at least partly stem the growing cases

of burnouts occurring among counsellors. There is also a need to

clearly lay down the job description of counsellors.

* Are there sufficient linkages to ongoing care & support services?

At the present time, very few VCTs offer linkages with care &

support programs and are usually run by NGOs (Torch in NICD,

Delhi) or Consortium of NGOs (NGO Forum in Safdarjung hospital,

Delhi). There is a need for greater involvement of NGOs who have

expertise in HIV/AIDS programs in running counselling centres.

* Is there a resource directory of care & support services available

at all counselling centres? Very few counselling centres have a

comprehensive resource directory for referring PLHAs to locally

available care & support services. This needs to be addressed at

the earliest.

* Is HIV testing procedure up to the mark? It has been seen that the

quality of HIV testing kits and the expertise required for routine

HIV testing leaves a lot to be desired in large number of centres.

In addition, there is also the perennial problem of periodic

shortages of testing kits, reagents etc. Quality control at HIV

testing centres and adequate supply of testing material is

essential for the smooth functioning of VCTs.

* Is confidentiality being maintained in counselling centres? One of

the most important elements of HIV/AIDS counselling is the

maintenance of confidentiality. Experiences from various

counselling centres around the country has shown that there is

breach of confidentiality at various levels - at the HIV testing

level (everybody knows the result especially HIV positive result

in the laboratory), relay of test result to client or treating

doctors, at ward level (all the doctors, nurses, ward boys,

sweepers along with other patients know earlier than the admitted

client) and at the time of disclosure (consent of the client is

not taken before family members are informed). It is important

that a protocol is set up for the relay of HIV test results to

clients only by a trained counsellor. There is also a need to

clearly define the term 'treating health care worker' as there are

at least 10-15 doctors (Head of unit, consultants, Senior

residents, Post graduate students, junior residents and interns),

10 nurses on rotation duty and 10 ward boys & sweepers in each

unit in major hospitals. Who decides who needs to know and who

need not know?

(3) Quality of counselling

* Who are the counsellors? Most of the counsellors posted in VCTs in

most of the Northern states had little or no experience in

counselling or HIV/AIDS issues. There needs to be a set criterion

for selection of counsellors, which should not be influenced by

any other consideration. Opportunity should also be provided for

PLHAs to become counsellors. There is also a need to differentiate

between lay counsellors & professional counsellors and clearly

demarcate the roles & responsibilities of each category.

* What is the content of counselling in VCTs? Most of the

counsellors seem to be providing advice rather than providing

options/choices for the clients attending VCTs. In addition, there

seems to be little effort to explain the implications of HIV tests

(both positive & negative) and clients are advised to undertake

the HIV test. There should be a standard protocol for all

counsellors to follow in pre & posttest counselling. It has

becomes even more important to be careful that HIV positive

mothers are provided all possible options and are not advised to

undertake a particular step with the introduction of PMTCT

programs all over India.

* Is periodic training available for counsellors? There is an acute

lack of periodic training for counsellors in VCTs. The refresher

training courses should deal with upgrading skills & information

levels of counsellors. In addition, the counsellors must also be

provided with the opportunity to work in grass root level

organisations & conduct field work in the afternoons so that they

get a better understanding of the needs of clients especially

PLHAs.

(4) Monitoring & Evaluation systems

* Are there established systems for maintenance of documents and

monitoring quality of counselling? Very few centres have put

into place proper systems for monitoring of counselling that is

provided by the counsellors. A standardised system for

documentation needs to be instituted. Format for weekly/monthly

quantitative & qualitative reports needs to be devised.

* Has there been evaluation of VCTs? Only a handful of VCTs have

been evaluated to date. Internal & external evaluation is

essential for measuring systems & procedures, quality of

counselling and impact of VCTs. One could use existing tool kit of

UNAIDS to evaluate VCTs.

(5) Training programs for counsellors

* Are there sufficient training centres for counsellors in India?

The number of counsellors required to man all VCTs and antenatal

clinics in India is mindboggling. There are very few training

centres (Naz Foundation - Delhi, Torch - Delhi, NIMHANS -

Bangalore, Christian Medical College - Vellore, TISS - Mumbai,

CINI & Vivekananda Education Society - Calcutta, SIIAP - Chennai &

NARI - Pune) are the NACO recognised regional training centres in

the country. Existing centres are not sufficient to train

sufficient numbers of counsellors. There is a real need to augment

& continually fund existing centres and identify new ones to meet

the demand without any compromise on quality of training provided.

* Is there a standard protocol followed for training counsellors?

Most of the regional training centres have a 5-7 day training

program with a follow-up training for 3 days. SIIAP, Chennai has a

much more intensive training course for the period of one year

with field/community work & supervision. Naz Foundation conducts

training on various modules for 4 -7 days each. NACO is shortly

coming up with a protocol for ensuring standardised training to

counsellors all over the country. There is also a need to ensure

that training is periodic and regular. Evaluation of existing

training centres in terms of quality, content, cost effectiveness

and impact also needs to be conducted.

* What happened to all the master trainers & counsellors trained in

the NACP -Phase 1? No attempt has been made to find out what

happened to all the master trainers & counsellors who have been

trained earlier during NACP -Phase I. The biggest failure of the

previous round of training was the absence of any clear criterion

for selecting master trainers and counsellors in each region and

development of an action plan to ensure further training of

counsellors. For the next round of training, these aspects will

need to be kept in mind.

(6) Relationship between counsellors & health care workers

* Is there tension and friction between counsellors & health care

workers? In most of the counselling centres that are situated in

health care settings, there is a lot of friction between

counsellors & health care workers. Most of the counsellors are

seen as activists for patients/clients without any appreciation of

the constraints in which health care workers function. There is a

need for dialogue between both groups so that there is a better

understanding of each others role in meeting different needs of

clients/patients. There should also be a monthly/quarterly meeting

between the counsellors & health care workers to ensure smooth

functioning of the VCT.

(7) Improving accessibility of Voluntary counselling centres

* Is there sufficient publicity of existing counselling centres?

There is still lack of awareness about the existence and the

location of VCTs in various parts of the country. There is a need

for a publicity campaign carried out with a great detail of

sensitivity so as to prevent stigmatisation of the VCTs. Care

should also be taken while naming/labelling the counselling centre

- avoid HIV or AIDS counselling centre tags wherever possible.

Social marketing of VCTs is another possibility. Linking

telephonic counselling with VCTs could also be strengthened.

* Is there any other method for increasing accessibility of VCTs?

Unfortunately almost all of the VCTs are located in health care

settings. There is a need for establishment of community based

counselling centres with linkages to HIV testing centres.

Identification & training of staff in counselling & sample

collection & transport will need to be provided to community-based

organisations.

(8) Innovations

Have new innovative methods been introduced in VCTs? Innovative steps

have not been incorporated in improving the functioning of VCTs in

India. Availability of rapid HIV testing kits has led to a revolution in

VCTs around the world with pre & post test counselling being conducted

on the same day without any delay. Unfortunately, as yet, there are not

enough rapid HIV kits available for VCTs in India.

VCTs play a very important role in 'normalising' the epidemic. If VCT

were more available and more people were counselled and tested, more

would know their status and it is likely that this would decrease the

stigma and fear attached to the disease and lead to a more open approach

to HIV prevention and care. VCT could act as a catalyst to improve HIV

care in other hospital departments and health services, as well as raise

awareness and acceptance among health care workers. VCT may allow more

appropriate care for patients with HIV in general. VCT also serves as an

entry point into Continuum of Care and is an excellent link between

prevention & care HIV/AIDS programs. But in India, NACO & State AIDS

Societies really need to accelerate their efforts if VCT program is to

succeed and help in controlling the HIV/AIDS epidemic.

Regards,

Dr Bitra

Salaam Baalak Trust & Sharan

bitra_george@...

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