Voluntary counselling and testing (VCT) are essential components of HIV prevention and care programmes. But many people are reluctant to be tested if care and treatment are not on offer. As antiretroviral (ARV) therapy becomes increasingly available, more people may want to access VCT. How can health services ensure that VCT facilities offer the maximum benefits to users?

A systematic review of VCT and care services published by UNAIDS and the World Health Organisation examined the specific counselling needs and challenges for people accessing ARV therapy. VCT in clinical settings often concentrates on identifying people with HIV to guide their treatment and care. This approach may neglect the broader benefits of VCT for both HIV-positive and negative patients, their families, household members and carers. The cost-effectiveness of VCT will improve if these wider benefits are realised.

For ARVs to provide long-term benefit it is important for people to adhere to complex drug schedules. Several studies have shown that non-adherence is associated with higher blood levels of virus and treatment failure. Many treatments for people with HIV require long-term or lifetime therapy and some have adverse effects or drug interactions. As patients gain access to ARVs, counselling services may need to address a range of new challenges:

• Disclosure to partners, family members and carers - Most people are tested alone. Evidence suggests that people cope better if they share their HIV status with someone and counselling can help to facilitate this. Partners, friends or relatives can provide support for HIV-positive people taking ARVs. Carers may seek counselling themselves or patients may request joint counselling sessions.
• Adherence and adverse effects - Counselling helps to enable people to adhere to medical treatments and cope with adverse effects.
• Treatment failure, death and dying - Many people will do well on ARVs. But unfortunately some will not respond or will experience treatment failure. They may need counselling about end of life issues and help with planning for dependants.
• Support groups - Many people with HIV benefit greatly from the assistance provided by post-test clubs and support groups. For example, women taking ARVs for prevention of mother-to-child transmission of HIV can support each other and share experiences.

VCT and counselling services can also play an particularly important role in relation to psychological and psychiatric problems. Mental disorders are common among HIV-positive patients. People with HIV have much higher levels of psychiatric problems than the general population in both industrialised and developing countries. Among people with HIV attending an outpatient clinic in South Africa, 35 percent had a major depressive disorder and 21 percent suffered from a generalised anxiety disorder. Healthcare staff often do not recognise depression and other psychological problems in patients seeking treatment for related symptoms, such as fatigue. Counselling provides an opportunity to examine these problems more carefully.

To maximise their benefits to patients and other users, VCT services should:

• identify and refer or treat vulnerable patients with psychiatric illness or substance abuse problems to improve their adherence to drug treatment and general quality of life
• encourage and facilitate family and couple counselling
• recognise that counsellors may require further training to deal with these new challenges
• emphasise the importance of safer sex for people on ARV, particularly those with untested or HIV-negative partners, even if they have a low or undetectable viral load
• work closely with community-based and non-governmental organisations to increase the capacity of VCT and related medical services.

Source(s):
' The impact of Voluntary counselling and testing: A global review of the benefits and challenges' UNAIDS (2001)

Funded by: WHO; UNAIDS

id21 Research Highlight: 14 March 2002

Further Information:
Rachel Baggaley
Clinical Research Unit
London School of Hygiene and Tropical Medicine
Keppel Street
London WC1E 7HT
UK

Tel: 44 (0)20 7976 5695
Contact the contributor: rbaggaley@ukonline.co.uk

London School of Hygiene and Tropical Medicine, UK

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