Less and more: condensed HIV counselling and enhanced connection to care
xpansion of access to HIV treatment is a global priority. In July, 2013, UNAIDS, in collaboration with WHO, the Global Fund to fight AIDS, Tuberculosis and Malaria, and the US President's Emergency Plan for AIDS Relief (PEPFAR) jointly issued Treatment 2015, which advocates for a worldwide treatment target of 15 million adults and children on antiretroviral treatment (ART) by 2015. Despite the huge increase in HIV testing and treatment in the past 10 years, the HIV treatment cascade remains a major barrier to this goal. In the WHO report Global Update on HIV Treatment 2013, evidence is presented that, in the WHO African Region, only about 25% of people who test HIV positive actually start ART. UNAIDS and WHO recommend prioritising 30 countries with treatment gaps and implementing key actions ranging from promotion of HIV testing, decreasing stigma and discrimination, increasing investment, and technology transfer.
In this issue of The Lancet Global Health, Rhoda Wanyenze and colleagues present the results of a randomised controlled study in Uganda which addresses two of the key actions called for by UNAIDS and WHO: normalisation of HIV testing in health-care settings and linkage of recipients of HIV testing services with follow-up HIV services. Designed long before the UNAIDS document, but relevant to the actions needed to reach global goals, this research studied both abbreviated pretest and post-test HIV counselling and enhanced linkages to care and treatment. The study is of particular importance because testing in health-care facilities has sometimes been hampered by the belief among health-care workers and HIV counsellors that an extended counselling session (called “traditional” HIV counselling and testing in this study) is needed to explore risky sexual behaviours and facilitate a personalised risk reduction plan.
Uganda has been a pioneer in HIV in many areas, including the establishment of the first centre for HIV testing and counselling in Africa in 1990. In a period of 3 years in Mulago Hospital, Kampala, Wanyenze and colleagues' study enrolled 3415 patients seeking health care who had either never been tested before or had tested negative more than a year previously, suggesting that the UNAIDS key action of “normalizing HIV testing in health care settings” is a goal not yet achieved, even in Uganda. The need for HIV testing in health facilities is evident: 30% of patients enrolled tested HIV positive, although the national HIV prevalence in Uganda is estimated at 7% in adults. In Wanyenze and colleagues' stud]y, an abbreviated counselling session lasting about 16 min (compared with 47 min in traditional counselling) did not compromise reductions in risk behaviour even up to 1 year after the intervention. This finding is of crucial importance in determining more efficient methods to deliver HIV testing in settings where there are shortages of health-care workers.
Linking recipients of testing to follow-up services, another key action recommended by UNAIDS and WHO, was also studied. Even in settings where a lengthy risk reduction counselling session is commonly regarded as a requirement for HIV testing, services to ensure referral and linkage to care are often inadequate. Wanyenze and colleagues' study assessed two methods of referral: a fairly typical approach comprised of information about nearby services and a paper-based referral compared with “enhanced linkage” which included counselling about barriers to care, assisted disclosure, a scheduled appointment in the HIV clinic, and reminders by phone or home visits. The enhanced linkage approach resulted in significantly shorter time to ART initiation, particularly for men, who are now underserved by ART programmes and have higher AIDS-related mortality, especially in Africa.
Key issues remain unclear. It is not yet known whether the abbreviated counselling approach can be applied effectively to HIV testing in non-medical settings, such as communities and homes. Further study is also needed of practical elements to enhance linkages as described in this study, including costs, the potential role of non-health workers such as expert patients, and use of mobile phone technologies. Finally, it must be noted that risky sexual behaviours after testing were reported by 28% of people in the study, irrespective of the length of counselling. On the basis of the results of this study and others, a counselling session at the time of HIV diagnosis seems to have only a moderate effect on sexual behaviour change.
Overall, this study provides evidence that HIV testing can be integrated or normalised into routine health care without a lengthy counselling session, but, crucially, that patients who test HIV positive need more intensive counselling and follow-up to ensure enrolment in care and timely treatment initiation. If widely applied in the countries prioritised by UNAIDS and WHO, these modifications will help improve and expand two of the key actions needed to achieve the goal of 15 million on treatment by 2015: normalising and increasing HIV testing in health facilities, and effective linkage to care and treatment.
The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention or the World Health Organization. We declare that we have no conflicts of interest.