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Provider-initiated Testing and Counseling
Integrating HTC into Health Services
Provider-initiated testing and counseling (PITC) is when HTC is offered to patients accessing health services, regardless of the reason for their visit. PITC allows for more people to learn their HIV status and get linked to treatment and support services. Here, AIDSTAR-One provides PITC resources including a selection of literature, country PITC policies, assessment tools, and reports and guidelines.
HTC is a critical component of and gateway to HIV prevention, care, and treatment services, which reduce morbidity, mortality, and HIV transmission. As access to HIV services has grown, numerous approaches to HTC have emerged, including client-initiated HTC (or "voluntary counseling and testing"), and community-based HTC, as well as PITC. To facilitate PITC, clinical providers initiate or recommend HTC as a standard component of medical care in a range of medical settings, such as tuberculosis (TB) clinics, voluntary medical male circumcision (VMMC) sites, antenatal care (ANC) and labor/delivery sites, drug treatment programs, and general clinical care.
The 2007 World Health Organization/UNAIDS Guidance on PITC in Health Facilities defines PITC as "HIV testing and counseling which is recommended by health care providers to persons attending health care facilities as a standard component of medical care." This approach to HTC is increasingly used to facilitate diagnosis and access to HIV-related services by engaging clients at health facilities, a key setting for reaching individuals in need of HTC services. As of 2009, two-thirds of the countries in sub-Saharan Africa, Latin America, and the Caribbean have developed HIV testing and counseling policies or guidelines incorporating PITC. Since the release of the 2007 WHO guidelines, researchers and implementers have published several studies on PITC, some of which supplement related AIDSTAR-One PITC materials.
The PITC Literature Selection also contains resources on the feasibility, acceptability, and efficacy of PITC, and discusses opportunities and challenges. The Literature Selection provides an abbreviated database of PITC information for HIV policymakers, program planners, and implementers initiating PITC policies or programs.
PITC strengths identified from the literature include:
- High feasibility and acceptability
- Increased uptake of testing in ANC, TB, pediatric, and general health care settings
- Ability to successfully link patients to HIV care and treatment
- Ability to engage lay counselors and incorporate task-shifting approaches.
PITC challenges identified from the literature across a variety of settings include:
- Poor linkages and referrals to high-quality HIV-related services
- Limited availability of rapid HIV test kits, other commodities, and medications
- Limited laboratory capacity
- Ineffective or limited data collection tools
- Limited human resource capacity, including the capacity to counsel and educate
- Limited space for counseling
- Problems with the quality and availability of HIV testing.
As approaches to implementing PITC evolve and HTC strategic scale-up efforts continue, the challenges with effective linkages and referral to care and treatment remain; there is limited literature on this issue. Please see the PEPFAR HTC Technical Considerations for specific guidance on approaches to PITC by epidemic type.
Routine HIV Testing in Health Care Settings: The Deterrent Factors to Maximal Implementation in Sub-Saharan Africa
Monjok, E., Smesny, A., Mgbere, O., et al. Journal of the International Association of Physicians in AIDS Care (2010), Vol. 9 No. 1, pp. 23-29.
This literature review looks at the regional, sociocultural, economic, and psychosocial barriers to implementing provider-initiated testing and counseling (PITC) in sub-Saharan Africa. It describes the controversial issues in the debate about voluntary counseling versus PITC, such as the inherent tension between PITC and the patient’s right to voluntary consent. While PITC has been effective in increasing testing uptake in some settings (e.g., Botswana, Malawi, Uganda, and Zimbabwe), not all countries can replicate this success due to such fundamental barriers as political instability, poor legal and health systems, and inadequate resources. Sub-optimal health systems, restricted access to treatment, and barriers to health care utilization are all highlighted as obstacles to full use of PITC in sub-Saharan African settings, as are stigma, discrimination, and inadequate legal protection. The review concludes with recommendations to overcome these barriers, such as reinforcing health care systems, linking PITC with access to treatment and HIV prevention, implementing widespread education efforts, and fostering a more supportive political and legal environment.
Provider-Initiated HIV Testing and Counseling in Low- and Middle-Income Countries: A Systematic Review
Kennedy, C.E., Fonner, V.A., Sweat, M.D. et al. AIDS Behavior, (2012), [Epub ahead of print]
A systematic literature review was conducted to identify the effect of provider-initiated testing and counseling (PITC) on behavioral, psychological, social, care or biological outcomes in low- and middle-income countries. Nineteen studies, all in sub-Saharan Africa or Asia, were identified that assessed the effect of PITC on HIV-related outcomes. Evidence showed that PITC increased HIV testing, yet effects on other outcomes are mixed. The authors suggest that PITC interventions should continue to be scaled up and evaluated.
Routine Voluntary HIV Testing in Durban, South Africa: The Experience From an Outpatient Department
Bassett, I. V., Giddy, J., Nkera, J., et al. Journal of Acquired Immune Deficiency Syndromes (2007), Vol. 46 No. 2, pp. 181-186.
This prospective study compares the outcome of voluntary counseling (VCT) and provider-initiated testing and counseling (PITC) in an urban hospital outpatient department setting in Durban, South Africa. In the intervention period, all adult patients were offered an HIV test and almost half accepted, compared with only a third who accepted testing during the standard of care (VCT) period. PITC detected almost five times more new cases of HIV compared to VCT. Both methods incurred similar costs per patient tested. PITC doubled the cost per HIV case identified, although the cost remained under U.S. $25 per case. The authors argue that because routine PITC can increase the number of HIV cases identified in outpatient settings and also normalize diagnosis and treatment, it should be widely implemented in South Africa and other areas of high HIV prevalence as long as treatment is available.
Routine Offering of HIV Testing to Hospitalized Pediatric Patients at University Teaching Hospital, Lusaka, Zambia: Acceptability and Feasibility
Kankasa, C., Carter, R. J., Briggs, N., et al. Journal of Acquired Immune Deficiency Syndromes (2009), Vol. 51 No. 2, pp. 202-208.
This study evaluated routine HIV testing of children admitted to a university teaching hospital in Lusaka, Zambia, over 18 months. During this period, 17,000 children were admitted, of whom over 15,000 had an unknown HIV status. Over 11,500 were tested, and almost a third of those tested were found to be HIV-positive. There was an association between age and having a positive result for an HIV test (DNA polymerase chain reaction): nearly 70 percent of all children who tested HIV positive were younger than 18 months old. The program’s main benefit was identifying and making antiretroviral therapy accessible to more HIV-positive children. In addition, the counseling session offered other benefits, such as promoting HIV testing for other family members and educating patients on prevention of mother-to-child transmission. The program also resulted in the introduction of an early infant diagnosis program based on DNA PCR testing. However, implementation of the program faced several challenges, including the extra human and material resources required, resistance of staff to pediatric HIV testing, and follow-up of HIV-positive children.
The Costs and Effectiveness of Four HIV Counseling and Testing Strategies in Uganda
Menzies, N., Abang, B., Wanyenze, R., et al. AIDS (2009), Vol. 23 No. 3, pp. 395-401.
This retrospective study analyzed the cost-effectiveness of four types of HIV counseling and testing: stand-alone HIV testing and counseling (HTC) in free-standing sites, hospital-based provider-initiated testing and counseling (PITC), home-based door-to-door HTC, and household member (index client) home-based HTC. The study analyzed data on over 84,000 Ugandans who were tested using one of these HTC strategies over a 27-month period. Per-client costs were similarly low for all four types of testing, with the lowest being door-to-door HTC (index client) and the highest being stand-alone HTC. Each testing strategy had its own strengths and limitations. Home-based strategies were best for reaching populations with low rates of previous HIV testing, while hospital-based PITC and stand-alone testing best identified people eligible for treatment. In countries such as Uganda with a generalized epidemic, there is a need for multiple strategies for HIV testing beyond key populations, the authors argue. Increasing home-based and hospital-based testing (PITC) may be a cost-effective way to achieve this.
Task Shifting Routine Inpatient Pediatric HIV Testing Improves Program Outcomes in Urban Malawi: A Retrospective Observational Study
McCollum, E. D., Preidis, G. A., Kabue, M. M., et al. PLoS One (2010), Vol. 5 No. 3, p. e9626.
This retrospective study compares two models of task-shifting for routine HIV testing in the pediatric department of a hospital in Lilongwe, Malawi. The first model shifted the task of testing from nurses and clinicians to lay counselors, while the second model went one step further by shifting program flow and advocacy from the lay counselors to “patient escorts”: volunteer parents of HIV-infected children. When the second model was used, the delay from admission to testing was shorter, and the number of patients offered HIV tests more than doubled, from 20 percent of the children hospitalized to 43 percent. Further, under the second model using patient escorts children were offered testing at a younger age, at an average 17 months versus 27 months in the lay counselor model. Patient escorts were able to take more time with patients’ caregivers, enabling the counselors to work more effectively by managing patient flow. Results indicate that both models produced similar rates of test acceptance and enrollment into HIV care.
Opt-Out Provider-Initiated HIV Testing and Counselling in Primary Care Outpatient Clinics in Zambia
Topp, S. M., Chipukuma, J. M., Chiko, M. M., et al. Bulletin of the World Health Organization (2011), Vol. 89 No. 5, pp. 328–335A.
A program offering provider-initiated testing and counseling (PITC) dramatically increased the number of HIV tests conducted in nine primary care clinics in Zambia. Over a 30-month period, almost 42,000 outpatients who did not know their HIV status were offered PITC by lay counselors, and 75 percent accepted. Of those tested, one in five was HIV-positive, and 2,515 patients were enrolled in HIV treatment and care. Testing became more acceptable over the course of the program, and given that demand for voluntary counseling and testing (VCT) also increased over the same period, it seems that PITC was not replacing VCT uptake. The study showed that lay counselors could be successfully deployed to offer PITC in a busy urban health care setting without disruption to existing service provision. However, such a program incurs additional costs.
Practicing Provider-Initiated HIV Testing in High Prevalence Settings: Consent Concerns and Missed Preventative Opportunities
Njeru, M. K., Blystad, A., Shayo, E. H., et al. BMC Health Services Research (2011), Vol. 11 No. 87, pp. 1-14.
This population-based study used both quantitative and qualitative methods to examine the impact of provider-initiated testing and counseling (PITC) with adults in three districts in Kenya, Tanzania, and Zambia. Findings showed that pre- and post-test counseling in this testing model was often sub-optimal, and the process was often not perceived as voluntary. Women were more likely to be tested through PITC in areas where prevention of mother-to-child transmission programs were widespread, in contrast to voluntary counseling and testing, which had similar testing rates for men and women. The limited availability of counseling meant that HIV prevention education opportunities were missed, and also raised ethical concerns. The perceived lack of choice about whether to be tested placed an additional burden on pregnant women. The study concludes that there is an urgent need to reevaluate the human rights aspects of current PITC provision.
The Complexity of Consent: Women's Experiences Testing for HIV at an Antenatal Clinic in Durban, South Africa
Groves, A. K., Maman, S., & Msomi, S. AIDS Care (2010), Vol. 22 No. 5, pp. 538-544.
Provider-initiated testing and counseling (PITC) may violate women’s right to informed, voluntary choice, according to this cohort study of 25 pregnant women who received PITC at an antenatal clinic in Durban, South Africa. Through interviews, the women were asked about their experience of HIV testing and disclosure during an interview at a subsequent antenatal or infant immunization visit. When the women were interviewed, only half of them described the decision to be tested as entirely voluntary, while others felt indirectly or directly coerced to do so. The authors argue that more research is needed to find models of testing that reconcile public health benefits with a woman’s autonomy in risk assessment for herself and her unborn child. The article also summarizes the main points in the ongoing debate about the relative merits of voluntary and opt-out testing approaches.
Provider Challenges in Implementing Antenatal Provider-Initiated HIV Testing and Counseling Programs in Uganda
Medley, A. & Kennedy, C. E. AIDS Education and Prevention (2010), Vol. 22 No. 2, pp. 87-99.
This qualitative study was based on interviews with 30 antenatal care providers in 10 central Ugandan clinics. The study assessed the challenges of implementing provider-initiated testing and counseling (PITC) in an antenatal clinic setting and its impact on prevention of mother-to-child transmission (PMTCT) services. Results found that in addition to general challenges, such as heavy workload and inadequate training, there were specific challenges before, during, and after PITC. The respondents cited obstacles to PITC that included clients’ refusal to be tested and the difficulty of reaching men through antenatal and PMTCT programs. They also raised other issues during the counseling and testing process, including shortage of space for counseling, inadequate clinic supplies, insufficient human resources, and language barriers. Respondents reported particular difficulty in counseling serodiscordant couples. After testing, the main challenges were loss to follow-up, low rates of serostatus disclosure, and sub-optimal referral and support. Recommendations for each challenge are provided.
Prevalence and Barriers to HIV Testing Among Mothers at a Tertiary Care Hospital in Phnom Penh, Cambodia
Sasaki, Y., Ali, M., Sathiarany, V., et al. BMC Public Health (2010), Vol. 10 No. 494, pp. 1-7.
This quantitative, cross-sectional study examined the prevalence of and barriers to HIV testing among 600 mothers delivering at one of Cambodia’s largest maternal and child care hospitals offering provider-initiated testing and counseling (PITC). The women were asked whether they had ever been tested for HIV and were also surveyed on their knowledge about HIV prevention and treatment. Three-quarters of the women surveyed had undergone HIV testing, with higher education level and occupational status significantly associated with the likelihood of having been tested. Commonly cited barriers to testing were the perceived need for spousal permission to get tested, lack of access to antenatal services, and poor understanding of HIV prevention and treatment. The authors recommend HIV education for mothers and their partners, as well as task-shifting of HIV testing to make it accessible in rural health facilities.
Routine Inpatient Human Immunodeficiency Virus Testing System Increases Access to Pediatric Human Immunodeficiency Virus Care in Sub-Saharan Africa
McCollum, E. D., Preidis, G. A., Golitko, C. L., et al. Pediatric Infectious Disease Journal (2011), Vol. 30 No. 5, pp. e75-e81.
This retrospective study compared the HIV testing rates for pediatric inpatients at a hospital in Malawi using non-routine testing (NRT) and routine testing, also referred to as provider-initiated testing and counseling (PITC). Four out of five children were tested when PITC was introduced, compared to only a third when testing was non-routine. The number of patients who used inpatient HIV care and enrolled at an outpatient HIV clinic was greater under PITC, and twice as many patients initiated antiretroviral therapy (ART) under PITC, compared with NRT. The study also looked at a subset of 337 children who were either HIV-positive or were exposed but uninfected. With PITC, three-quarters of the children received DNA polymerase chain reaction testing, which was more than double the number under NRT; however, no differences were observed in in-hospital or outpatient HIV care enrollment or ART initiation.
HIV Testing for Children in Resource-Limited Settings: What Are We Waiting For?
Kellerman, S., & Essajee, S. PLoS Medicine (2010), Vol. 7 No. 7, p. e1000285.
Inadequate provision of prevention of mother-to-child transmission (PMTCT) services, as well as other limitations in resources for infant and child testing, results in many children being undiagnosed for HIV until they are symptomatic. Until PMTCT access is improved, other ways to get children tested must be considered. These include provider-initiated testing and counseling (PITC) for screening newborns and babies receiving immunizations, and for children in other medical settings, such as nutrition rehabilitation programs. Non-medical settings can also help increase pediatric testing through community organizations that serve persons living with HIV or orphans. Other options include second-tier approaches, such as door-to-door and social network testing, where friends of HIV-positive or high-risk persons are targeted for HIV testing, or HIV-positive clients refer persons in their networks for testing; these may be more cost-effective than hospital-based testing. Beyond these lower-level strategies, a national-level coordinated effort is needed to identify children exposed to HIV and ensure that those infected receive care.
The Impact of Provider-Initiated (Opt-Out) HIV Testing and Counseling of Patients with Sexually Transmitted Infection in Cape Town, South Africa: A Controlled Trial
Leon, N., Naidoo, P., Mathews, C., et al. Implementation Science (2010), Vol. 5, No. 1.
This cluster-controlled trial compared HIV testing uptake rates among new sexually transmitted infection (STI) patients in 21 primary care clinics in Cape Town, South Africa. Seven clinics were selected to offer provider-initiated testing and counseling (PITC) by STI nurses, while 14 control clinics continued to offer voluntary counseling and testing (VCT). While 43 percent of new STI patients were tested for HIV in the VCT control clinics, 57 percent were tested in the clinics using PITC, even though substantially more patients in the latter settings declined testing (27 percent PITC vs. 14 percent VCT). PITC not only increased access to and uptake of HIV testing but also resulted in consistent implementation, with little variation in outcomes across different clinics. The authors make several recommendations to facilitate PITC in resource-poor settings, such as greater flexibility in human resources deployment, including the use of lay counselors to reduce the burden on nurses. Another recommendation is using a combination of PITC, VCT, and other community-based testing models.
Provider-Initiated HIV Testing and Counselling for TB Patients and Suspects in Nairobi, Kenya
Odhiambo, J., Kizito, W., & Njoroge, A. The International Journal of Tuberculosis and Lung Disease (2008), Vol. 12 No. 3, pp. S63-S68.
This study describes a pilot program to introduce provider-initiated testing (PITC) to confirmed and suspected tuberculosis patients. Patients were assured they could opt out of HIV testing without compromising other aspects of their care. Assistant physicians were the first to implement the program, offering testing to all newly diagnosed tuberculosis (TB) patients; 160 were diagnosed with HIV. After four months, front-line nurses routinely offered testing and counseling during the first consultation, before TB was confirmed or excluded. In 21 months, over 5,400 clients were offered PITC, and the vast majority (89 percent) underwent HIV testing. The pilot program proved the feasibility and acceptability of PITC among TB patients and clients seeking TB testing. The findings were used to inform the national response to the TB and HIV epidemics in Kenya.
Provider-Initiated HIV Testing and Counseling in TB Clinical Settings: Tools for Program Implementation
Bock, N. N., Nadol, P., Rogers, M., et al. The International Journal of Tuberculosis and Lung Disease (2008), Vol. 12 No. 3, pp. S69-S72.
This paper describes the policies and procedures required at different levels to implement provider-initiated testing and counseling (PITC) for patients at tuberculosis (TB) clinical settings. At the national level, coordinating the interests of all stakeholders and formulating national guidelines are necessary. At the district level, recording, reporting, and procurement are necessary. Finally, at the facility level, clinician training is an ongoing necessity. The authors describe a training package of tools and materials that can help identify the national-level decisions that must be made before implementing PITC in TB clinical settings.
Counseling and Testing TB Patients for HIV: Evaluation of Three Implementation Models in Kinshasa, Congo
Van Rie, A., Sabue, M., Jarrett, N., et al. The International Journal of Tuberculosis and Lung Disease (2008), Vol. 12 No. 3, pp. S73-S78.
This paper evaluated three different models for HIV testing and counseling (HTC) in tuberculosis (TB) clinical settings in the Democratic Republic of Congo. The models included 1) referral to an off-site, freestanding voluntary counseling and testing (VCT) center, 2) referral to a counseling and testing center within the same health care facility as the TB clinic, and 3) provider-initiated testing and counseling (PITC) offered by the TB nurse at the clinic. Acceptance of HTC was higher among patients referred to an on-site clinic (95 percent) or offered PITC (98 percent) than among those referred to the freestanding VCT center (69 percent). The authors note that uptake of PITC was particularly high, given that TB clinics could not offer antiretroviral therapy to those who tested positive, although referral to care and treatment was provided. The authors conclude that PITC in a TB clinical setting can be very successful but that it is only the first step to reducing the HIV burden among TB patients.
Patient and Provider Perspectives on Implementation Models of HIV Counseling and Testing for Patients with TB
Corneli, A., Jarrett, N. M., & Sabue, M. The International Journal of Tuberculosis and Lung Disease (2008), Vol. 12 No. 3, pp. S79-S84.
This qualitative study assesses the perspectives of patient and health care workers on three models of provider-initiated testing and counseling (PITC) for tuberculosis (TB) patients: 1) referral to an off-site, freestanding voluntary counseling and testing (VCT) center, 2) referral to a counseling and testing center within the same health care facility as the TB clinic, and 3) provider-initiated testing and counseling (PITC) offered by the TB nurse at the clinic. The study showed that both patients and health care workers overwhelmingly supported PITC as part of routine TB care, largely because there was a relationship between patient and provider based on trust, as well as continuity of care. However, there were concerns about assuring patients of confidentiality and ensuring that uptake was genuinely voluntary. Health care workers also expressed concerns about the increased workload associated with facilitating PITC.
Baseline Evaluation of Routine HIV Testing Among Tuberculosis Patients in Botswana
Gammino, V. M., Mboya, J. J., Samandari, T., et al. The International Journal of Tuberculosis and Lung Disease (2008), Vol. 12 No. 3, pp. S92-S94.
This cross-sectional study of baseline HIV testing rates among tuberculosis (TB) patients at 46 clinics in Botswana was conducted one year after the introduction of a nationwide policy to implement provider-initiated testing and counseling (PITC) but before systematic implementation of the policy. Data from the TB register showed that, of approximately 1,240 patients enrolled, only 47 percent had been tested for HIV, and among them, 84 percent were HIV-infected. A review of secondary data revealed that individual TB treatment cards were only available for 69 percent of the patients. These reflected similar testing rates and prevalence, but TB treatment card data on 15 percent of the HIV-positive patients were missing from the TB register and were therefore excluded from national surveillance data. Testing results from the TB register and TB cards were compared; overall, 79 percent of results were concordant. Mismatches between the register and cards represent lost opportunities for antiretroviral treatment referral and HIV prevention efforts. The country’s TB surveillance system should be reinforced to better detect and treat patients co-infected with TB and HIV.
HIV Testing and Care of the Patient Co-Infected with Tuberculosis and HIV
Williams, G., Alarcon, E., Jittimanee, S., et al. The International Journal of Tuberculosis and Lung Disease (2008), Vol. 12 No. 8, pp. 889-894.
This paper argues that failure to offer provider-initiated testing and counseling (PITC) to tuberculosis (TB) patients denies them the right to crucial care and treatment, given that TB is the most common opportunistic infection for people with HIV. However, before patients are offered PITC, procedures that enable patients to access HIV care and clearly defined care plans must be in place. The paper provides the rationale for PITC for TB patients, describes which resources are required, and covers such professional standards as confidentiality, counseling, and consent both before and after testing. It also discusses the standard of care for co-infected patients, covering prevention of other infections, antiretroviral treatment, prevention of HIV transmission, and potential complications when concurrently treating HIV and TB.
Implementing Voluntary Medical Male Circumcision for HIV Prevention in Nyanza Province, Kenya: Lessons Learned During the First Year
Herman-Roloff, A., Llewellyn, E., Obiero, W., et al. PLoS One (2011), Vol. 6 No. 4, p. e18299.
This study evaluated the extent to which health care facilities offering voluntary medical male circumcision (VMMC) fulfilled the minimum package of services specified under the Government of Kenya’s national VMMC program. Using data from a health facility needs assessment covering 81 clinics and from an evaluation study of 16 government clinics, the authors found that none of the facilities could meet all seven criteria for safe VMMC. They lacked infrastructure, equipment, and supplies, as well as sufficient human resources. Only one-third of the facilities offered voluntary counseling and testing (VCT), and it was prohibitively time consuming to offer it concurrently with circumcision counseling. However, replacing VCT with provider-initiated testing and counseling (PITC) at the VMMC clinics, with the help of partner organizations, doubled HIV testing rates.
Challenges in Delivering HIV-Care in Indonesia: Experience From a Referral Hospital
Wisaksana, R., Alisjahbana, B., van Crevel, R., et al. Indonesian Journal of Internal Medicine (2009), Vol. 41 Suppl. 1, pp. 45-51.
This paper describes the progress in HIV care in a referral hospital in West Java, Indonesia, covering a number of issues, including HIV testing and counseling. Several barriers impede uptake of HIV testing rates at early stages of infection, including lack of knowledge among patients and health care workers, stigma about HIV, a perceived lack of incentive to test for HIV, and practical barriers such as logistical and financial issues. To overcome these difficulties, the hospital introduced systematic HIV screening for several groups of patients: people who inject drugs, prisoners, and the partners of patients with HIV. It also introduced provider-initiated testing and counseling (PITC) for symptomatic inpatients, and also for patients with meningitis, who have a high prevalence of HIV at this hospital. The introduction of PITC doubled the proportion of patients tested for HIV and of patients enrolled in HIV care.
Linkage to HIV Care and Antiretroviral Therapy in Cape Town, South Africa
Kranzer, K., Zeinecker, J., Ginsberg, P., et al. PLoS One (2010), Vol. 5 No. 11, p. e13801.
This observational study focused on the linkage between HIV testing and counseling (HTC) and subsequent HIV care. The authors analyzed data on patients at a primary care clinic and hospital in urban Cape Town, South Africa, who received voluntary counseling and testing, and those who received provider-initiated testing and counseling (PITC) via antenatal, sexually transmitted infection, and tuberculosis services. Overall linkage to care was sub-optimal, with only two-thirds of HIV-positive clients undergoing CD4 count measurement within six months of testing and accessing antiretroviral care. However, linkage was higher among patients who were tested via antenatal clinic services, compared to other voluntary HTC and PITC channels.
Linkage to HIV Care and Survival Following Inpatient HIV Counseling and Testing
Wanyenze, R. K., Hahn, J. A., Liechty, C. A., et al. AIDS and Behavior (2011), Vol. 15 No. 4, pp. 751-760.
This randomized trial of medical inpatients in Mulago Hospital, in Kampala, Uganda, compared the impact on HIV care and survival among 500 patients who were offered either provider-initiated testing and counseling (PITC) while in the hospital, or referral for voluntary counseling and testing (VCT) one week after discharge. Almost all the patients in the PITC group were tested and received their results, while only two-thirds of the VCT group were tested, and of these only two-thirds received their test results. More patients in the PITC group were diagnosed with HIV than in the VCT group, and these patients were far more likely to disclose their HIV status to at least one other person. Referral for VCT was a missed opportunity for diagnosis, which underlines the need for earlier diagnosis and linkage to HIV care for inpatients.
Strengthening Health Systems at Facility-Level: Feasibility of Integrating Antiretroviral Therapy into Primary Health Care Services in Lusaka, Zambia
Topp, S. M., Chipukuma, J. M., Giganti, M., et al. PLoS One (2010), Vol. 5 No. 7, p. e11522.
This feasibility study assessed integrating HIV and non-HIV outpatient services at two clinics in Lusaka, Zambia. To achieve this integration, it was necessary to consolidate space and patient flow, standardize medical records, and introduce provider-initiated testing and counseling (PITC). Interviews with patients and health care workers indicated that integration was generally accepted. More than half of the patients offered PITC were tested, and of those who tested positive for HIV, approximately half enrolled in care. There were both gains and losses from integration: antiretroviral therapy (ART) services were associated with less stigma, and HIV case finding increased. However, patient waiting times increased at both clinics, and some patients on ART felt more inhibited about discussing their problems with fellow patients than they did in dedicated ART clinics. The study demonstrated that it is feasible to integrate HIV and non-HIV services in a high-prevalence, low-resource setting.
AIDSTAR-One has collected reports and guidelines on PITC to support programmatic efforts in the field.
PITC Reports and Guidelines
|Report or Guideline Name||Source||Summary|
|Assessment of Provider-Initiated Testing and Counseling Implementation: Cambodia||Spratt, Kai, and Maria Claudia Escobar. 2011. Assessment of Provider-Initiated Testing and Counseling Implementation: Cambodia. Arlington, Va.: USAID's AIDS Support and Technical Assistance Resources, AIDSTAR-One, Task Order 1.||This rapid assessment report of Cambodia's PITC approach identifies the following: 1) promising practices in HIV testing and counseling; 2) challenges experienced implementing routine referrals; 3) opportunities and barriers to the WHO PITC approach; and 4) opportunities to address unmet needs.|
|Case Study: The Private Sector: Extending the Reach of Provider-Initiated HIV Testing and Counseling in Kenya||Gachuhi, Muthoni, Cassandra Blazer, Maria Claudia Escobar, and Meghan Majorowski. 2010. The Private Sector: Extending the Reach of Provider-Initiated HIV Testing and Counseling in Kenya. Case Study Series. Arlington, VA: USAID's AIDS Support and Technical Assistance Resources, AIDSTAR-One, Task Order 1.||Provider initiated testing and counseling (PITC) is an emerging model of HTC that aims to increase testing rates. The private sector provides a significant portion of care in resource-poor countries, yet these providers are often left out of training or other capacity building efforts, which can affect a country's ability to effectively implement and expand health services, such as PITC. To our knowledge, APHIA II Western is one of few programs engaging private providers in PITC efforts. Lessons learned from this project can be applied to other countries seeking to initiate, roll-out, or expand PITC activities.|
|Towards Universal Access: Scaling Up Priority HIV/AIDS Interventions in the Health Sector (Progress Report 2010)||The World Health Organization, UNAIDS, & UNICEF. 2010. Towards Universal Access: Scaling up priority HIV/AIDS interventions in the health sector (Progress Report 2010). http://whqlibdoc.who.int/ publications/ 2010/ 9789241500395_eng.pdf||The WHO 2010 progress report presents findings of global efforts to combat HIV/AIDS in a variety of technical areas, including country findings on HTC. In 2009, countries adopting PITC policies, the number of health facilities offering HTC, and the number of HIV tests performed worldwide increased. However, individuals' knowledge of HIV status remains low.|
|Policy requirements for HIV testing and counseling of infants and young children in health facilities||WHO & UNICEF. 2010. Policy requirements for HIV testing and counseling of infants and young children in health facilities. http://whqlibdoc.who.int/ publications/ 2010/ 9789241599092_eng.pdf||The WHO and UNICEF provide background, policy guidance, and recommendations for HIV testing and counseling (HTC), including support of PITC for infants and children. The policy brief addresses: benefits and challenges specific to HTC for children; foundational guidance and special considerations for national policies addressing HTC for children; counseling and communication with children, parents, and caregivers; and stigma and discrimination.|
|Guidance on Provider-Initiated HIV Testing and Counselling in Health Facilities||World Health Organization (WHO). 2007. Guidance on Provider-Initiated HIV Testing and Counselling in Health Facilities. Geneva: WHO.||The WHO and UNAIDS report offers country-level guidance for PITC to reduce missed opportunities for HTC. The WHO recommends an "opt-out" approach to HTC in health facilities. The guidance stresses the importance offering PITC with linkages and referrals to prevention, treatment, care, and support services. It also provides specific recommendations for consent, confidentiality, and HIV pre- and post-test counseling for negative and positive results and counseling for special populations.|
|Statement and Recommendations on Scaling up HIV Testing and Counseling||UNAIDS Reference Group on HIV and Human Rights. Statement and Recommendations on Scaling up HIV Testing and Counseling. Geneva: UNAIDS. 2007. http://data.unaids.org/ pub/ ExternalDocument/2007 /20070905_rghr_statement_testing_en.pdf||The UNAIDS Reference Group on HIV and Human Rights responded to the WHO/UNAIDS global guidance on PITC in health facilities with an aim to highlight human rights concerns. The document defines priority issues that should be addressed prior to implementation of PITC, including ensuring: access to HIV prevention, care and support services; adequate capacity of health care providers; and programmatic attention to mitigate stigma and discrimination.|
Below are a variety of PITC tools, including those AIDSTAR-One used to conduct PITC country assessments.
Although these tools are not endorsed by PEPFAR/USAID, AIDSTAR-One is making them available for country use and implementation of PITC.
Related PITC Tools
|World Health Organization (2011).||This one-day training program is aimed at health care workers involved in provider-initiated testing and counseling (PITC). The four modules cover: introduction and overview, the benefits and barriers of testing, patient education strategies, and HIV test results and effective referrals.|
|World Health Organization (2010) (updated).||This handbook describes 10 elements of a framework for quality improvement in HIV testing and counseling (HTC); provides examples of a high-quality monitoring system for HTC; and provides tools to monitor HTC service quality. Sample tools and forms are provided along with an extensive list of related resources.|
|Centers for Disease Control and Prevention and World Health Organization (2007).||This resource provides tools to assist in design and implementation of HIV testing and counseling in tuberculosis (TB) clinics. The six workshop modules include: introductory session, provider-initiated testing and counseling (PITC) in the context of TB clinical services, preparing PITC providers, administration and procedures, clinical considerations, and a practical group exercise.|
|Testing and Counselling for Prevention of Mother-to-Child Transmission of HIV||Centers for Disease Control and Prevention (CDC), Global AIDS Program/PMTCT Team. 2005. Testing and Counselling for Prevention of Mother-to-Child Transmission of HIV (TC for PMTCT): Support Tools.||This is a set of visual and written materials that can be used to inform parents on infant HIV prevention and to guide providers on how to increase HTC uptake, including PITC.|
|Routine HIV Testing and Counselling for PMTCT: Prevention of Mother-to-Child Transmission of HIV Training Series||BOTUSA (Government of Botswana and Centers for Disease Control and Prevention (CDC)). 2006. Routine HIV Testing and Counselling for PMTCT: Prevention of Mother-to-Child Transmission of HIV Training Series. http://www.womenchildrenhiv.org/pdf/p16-gtp/gtp-02-00/gtp-02-04/gtp-02-04-17.pdf||This training module offers healthcare workers knowledge and introductory skills to conduct routine HTC in Prevention of Mother-to-Child Transmission and Sexual and Reproductive Health care settings in Botswana. The module is designed to take six to seven hours, which includes one small group exercise.|
|National Training on TB/HIV for Healthcare workers: Unit 22: Provider Initiated Testing and Counselling (PITC)||Tanzania Ministry of Health and Social Welfare and ITECH. National Training on TB/HIV for Healthcare Workers: Unit 22: Provider Initiated Counselling and Testing (PITC). 2009. http://www.searchitech.org/pdf/p06-db/db-51109/FG22_PITC.pdf.
Full packet: http://www.searchitech.org/itech?page=ff-17-01. PPT also available.
|The Tanzania Ministry of Health and Social Welfare and ITECH developed a training course for healthcare workers on the clinical management of tuberculosis (TB) and HIV, including a module on PITC. The complete course (23 units) is delivered over 6 days, including interactive classroom training and a practicum visit to a TB clinic. Course topics include: TB and HIV diagnosis, including PITC; TB/HIV co-infection management; referrals and linkages; and collaborative activities. Each section comes with a facilitator guide, participant manual, participant workbook, and power point slides.|
|The AIDS Support Organization (TASO). Provider Initiated HIV Counselling and Testing in Clinical Settings (RCT): Cue Cards for Providers Offering RCT in a Health Care Setting. Uganda.||These are cue cards for providers offering PITC in a clinical setting.|
Kenya PITC Tools
|National AIDS and STD Control Programme (NASCOP) and JHPIEGO. 2007. National Counseling Protocol for Provider Initiated Testing and Counseling. Kenya.||This job aid assists health care workers to conduct PITC in a clinical setting including the steps, key messages and interpretation of results.|
|National AIDS and STD Control Programme (NASCOP). 2007. Learning Resource Package for Skills Training in Provider Initiated HIV Testing and Counseling in the Clinical Setting: Course Notebook for Trainers. Kenya.||This is a trainer's guide for conducting a five-day training course on providing PITC in a clinical environment and improving access to HIV and AIDS Comprehensive Care. The clinical training uses adult learning techniques, behavioral modeling, and competency-based and practical training techniques. The manual includes participant activities with answer keys and detailed information for conducting the course.|
|National AIDS and STD Control Programme (NASCOP). 2007. Learning Resource Package for Skills Training in Provider Initiated HIV Testing and Counseling: Course Notebook for Participants. Kenya.||This is a participant manual for a five-day PITC training course. The participant notebook is designed for health care providers at all levels who are involved in the various components of HIV management or are interested in providing HTC. The notebook contains questionnaires, learning objectives, skills checklists, case studies, role plays, and clinical simulations.|
|National AIDS and STD Control Programme (NASCOP). 2007. Learning Resource Package for Skills Training in Provider Initiated HIV Testing and Counseling. Reference Manual. Kenya.||This reference manual provides an overview of the PITC training course. The manual offers five modules including: 1) HIV overview/epidemiology, 2) HIV counseling and communication skills, 3) HIV testing principles, 4) providing comprehensive care, and 5) records and reporting. The modules also offer step-by-step guidance and examples for working with clients.|
|National AIDS and STD Control Programme (NASCOP). 2007. Provider Initiated HIV Testing and Counseling Presentations. Kenya.||These presentations supplement the "Learning Resource Package for Skills Training in Provider Initiated HIV Testing and Counseling" modules, also included on the website. Extensive presentations correspond with each of the five modules: 1) HIV overview/ epidemiology, 2) HIV counseling and communication skills, 3) HIV testing principles, 4) providing comprehensive care, and 5) records and reporting.|
Cambodia PITC Assessment Tools
|AIDSTAR-One. 2009. Key Informant Interview: VCCT Site. Provider Initiated Testing and Counseling (PITC) Assessment. Cambodia.||Field interview guide to interview staff in VCCT clinics about HIV testing and counseling services. The interview aims to understand how the 'Linked Response,' which includes PITC, is being implemented in Cambodia.|
|Key Informant Interview: Healthcare Providers (PDF, 169KB)||AIDSTAR-One. 2009. Key Informant Interview: Healthcare Providers. Provider Initiated Testing and Counseling (PITC) Assessment. Cambodia.||Field interview guide to interview healthcare providers to learn about how PITC is being implemented.|
|AIDSTAR-One. 2009 Key Informant Interview: Senior Government Staff. Provider Initiated Testing and Counseling (PITC) Assessment. Cambodia.||Field interview guide designed for interviews with senior government staff to learn about implementation of provider initiated testing and counseling.|
|AIDSTAR-One. 2009 Pharmacy Interview. Provider Initiated Testing and Counseling (PITC) Assessment. Cambodia.||Field interview guide designed for interviews with pharmacists to learn about the about types of clients seen and their reason for visiting the pharmacy. As a part of this assessment, pharmacies were interviewed to determine if they referred patients for PITC.|
|AIDSTAR-One. 2009. Provider Initiated Testing and Counseling (PITC) Assessment: Client Exit Interview. Cambodia.||Field interview guide for clients attending ANC, STI, TB or other appropriate clinics to determine if they were advised to have an HIV test by a health care provider and/or provided with a referral to a VCCT site.|
Download the Provider-initiated Country Policy Review here (PDF, 702 KB)
|Country||Region||PITC Policy (Yes or No)||Date Adopted||Part of National Policy? (Yes or No)||Country-specific Notes|
• Routine HIV testing (RHT) was implemented in January 2004, following a presidential announcement introducing the policy. 1
• RHT guidelines were developed after the presidential announcement, and are being reviewed and updated. 2, 3
|Côte d Ivoire||Africa||Yes||2007||Yes||
National Policy (2007) calls for districts to lead prevention of mother to child transmission (PMTCT) activities as well as routine, opt out HIV counseling and testing (CT) and HIV rapid testing in maternity units. 4
|Democratic Republic of Congo||Africa||Yes||2009||No||
• PITC implemented in 14 TB clinics in Kinshasa County in 2006/07 6
• National AIDS program began rollout of PITC program in 2009 7
• Training provided to clinicians on PITC 12
• Non-health personnel can provide CT given they receive adequate training according to the human resource recommendations in the guidelines.
• National Testing Guidelines were adopted in 2008, covering all settings and models of CT. 13
• Optout diagnostic CT in clinical settings where HIV may be suspected 16,
• Universal HIV screening said to be emerging (as of 2007), as is also the case with routine tests in PMTCT settings 19
• The National HIV and AIDS policy also calls for routine diagnostic HIV testing for patients in TB, STI, and ANC settings or when a patient has signs or symptoms that are suggestive of an AIDS related syndrome. 22
• Malawi HIV/AIDS Action Framework 2005–2009 includes promotion of VCT and calls for the development of routine and referral mechanisms between STI management and HIV CT. 23
• Baylor Children’s Foundation Malawi, with Lighthouse, initiated a routine PITC program in 2007 in the pediatric department of Kamuzu Central Hospital. 26
• In 2008, the MoH approved guidelines regulating all HIV CT services provided in Mozambique. The regulations protect confidentiality, prohibit discriminatory practices, and establish criteria for the licensing and accreditation of VCT providers. 30
• Mozambique’s Act on Defending the Rights and the Fight against Stigmatisation and Discrimination of People Living with HIV and AIDS (2008) calls for mandatory testing of pregnant women, prisoners, and as required by the clinical condition of the patient. Furthermore, individuals can be subjected to mandatory HIV testing for criminal legal purposes. 31
• In 2006, MoH partnered with Jhpeigo to develop a strategy to integrate PITC into clinical settings. 32
• MoH adopted an optout CT strategy for pregnant women in 2002, which started out as a pilot program and expanded to all district hospitals by 2006.33
• Namibia’s 2006–2007 Country Report to the UN listed its PITC policy as for patients in PMTCT, ANC, and TB settings only and includes a provision for nonlaboratory personnel, including community counselors, to perform rapid HIV testing.34
• In 2001, Namibia implemented a Military Action and Prevention Programme, which included mandatory testing for members of the armed forces.35
• PITC implemented in health facilities by Global HIV/AIDS Initiative Nigeria; however, types and levels of facilities are not clarified.36
• In 2005, approximately 1 percent of women in ANC were tested for HIV. There was no serious promotion of either VCT or PMTCT until 2006, when the president was publicly tested.37
• Orthodox and Pentecostal churches require mandatory premarital HIV testing for those who wish to marry in the church; results are disclosed directly to the church before the couple is notified.38
• PITC started as a policy action in 200839
• Rwanda’s National Strategic Plan on HIV & AIDS 2009–2012 calls for 70 percent of adults of reproductive age to be tested by the year 2012 and places particular emphasis on couples for prevention in serodiscordinance.43
• The National Strategic Plan set a goal to have 90 percent of health facilities offering PITC by 2012, and emphasizes testing for mostatrisk populations.44
• HIV testing is mandatory for members of the armed services.45
• The National HIV and AIDS and STI Strategic Plan for South Africa 2007– 2011 recommends routine testing for at risk groups, promotes increased coverage to VCT, and promotes regular HIV testing.46
• The Strategic Plan lists PITC as a goal for patients in STI, TB, ANC, integrated management of childhood illnesses, family planning, and general curative services settings47
• The country is debating full adoption of routine testing; privacy and rights of clients are of concern.48
• Trial of PITC conducted for TB clients; authors concluded that use of an optout strategy was associated with significantly higher HIV CT rates.49
• There are currently 30 VCT sites in Southern Sudan located mainly in hospitals and primary health care centers, mostly in Central Equatoria and Western Equatoria states. 52
• The National Multisectoral HIV and AIDS Policy (2006) calls for PITC in clinical settings 53
• Opt-out HIV testing for patients in ANC and delivery settings 54
• The Second National Multisectoral HIV and AIDS Strategic Plan 2006–2008 set the goal of increasing the proportion of clients who receive facility based routine HIV testing by 25 percent in 2008. 55
• The guidelines for HIV CT in clinical settings called for PITC in both inpatient and outpatient clinical settings and has been a standard of care since 2007. 56
• The HIV and AIDS Prevention and Control Act 2008 promotes VCT for all pregnant women, husbands, and partners at all levels. 59
• PMTCT programs involve optout testing. 60
• IntraHealth International is running a Centers for Disease Control and Prevention (CDC)funded PITC project in Tanzania. 61
• Uganda’s National Policy Guidelines for HIV Counseling and Testing call for routine CT in clinical settings, but does not allow mandatory HIV testing. 62
• Routine CT was rolled out by the government starting with Regional Referral Hospitals, expanding to other health facilities, including for pregnant women.
• PITC was initiated in pediatric wards at two university teaching hospitals in 2005 using an opt out approach. 65
• PMTCT-specific PITC policy adopted in 2004 66
• Opt-in testing for pediatric in-patients at university teaching hospital 69
• According to Dr. Kanyanta B. Sunkutu of the World Health Organization HIV/AIDS Zambia Country Office, routine testing is practiced at most tertiary institutions. However, the farther away from the center, the less it is a standard. This is basically because of the issues of policy dissemination, training needs, etc. 70
• Zimbabwe’s National HIV and AIDS Strategic Plan (ZNASP) 2006–2010 called for HIV testing to be routinely offered in all PMTCT relevant settings, including ANC, family planning, and maternal health care facilities; priority was given to establishing new sites in currently underserved areas in the south of the country. 71
• In late 2007, the Ministry of Health and Child Welfare was finalizing the CT Strategic Plan 2007–2010, which included PITC.72
• In 2005, PITC was mainly offered in ANC clinics. 73
• Results from a PITC pilot study suggested phased implementation of PITC, beginning at 10 learning sites in each province, then implementation in districts. 74
• PITC was approved by the MoH and was introduced first in ANC clinics in 2002 with updated guidance in 2004.75 It expanded to TB clinics in 200676 and was introduced into select health centers and referral hospitals in selected provinces in 2007. 77
• Pilot PITC protocols in three cities, preformed by CDC Global AIDS Program, and in five urban and six rural sites under the China Comprehensive AIDS Response project 78
• Based on the results of these pilot studies, the China AIDS Centre revised its CT policy in June 2007 and introduced PITC guidance. 79
• The PITC guidelines were translated into Chinese in 2007 and are still awaiting approval by the MoH Division of Hospital Administration. A November 2009 report from the UN Joint Program on AIDS in China showed that the PITC guidelines were still in the process of being developed and implemented. 80, 81
• A study presented at the 2008 International AIDS conference showed PITC was conducted in most health care settings. However, many people were unaware they were being tested for HIV and did not receive their test results. 82
• PITC (optout) offered to three groups:
1. Patients with symptoms suggestive of HIV infection (pneumonia, TB)
• PITC introduced in late 1990s with the PMTCT program and recently as part of the national TB program; routine testing for pregnant women began in early 1990s and over the subsequent decade spread to most hospitals and private providers. 86
• PITC has been implemented for patients in TB, ANC, and STI settings. The service provided is optout CT, depending on the type of health service. 87
• Compulsory testing prohibited under the Law on Prevention and Control of HIV/AIDS (2006). 88
|Dominican Republic||Latin America & Caribbean||No||No||
• USAID Mission in the Dominican Republic is working to introduce opt-out testing 89
• No obligatory testing under the 1993 AIDS Law (5593) 90
• In 2004, the Human Rights Watch cited concerns about HIV testing especially in women: “inadequate HIV counseling, which prevents women from being able to exercise their right to informed consent on issues of testing and treatment; routine unauthorized release of confidential HIV test results; and decisions by doctors to carry out, postpone, or withhold medical procedures without properly informing the woman or obtaining her prior consent.” and called on the Dominican Republic government to stop all HIV testing without informed consent. 91
|Guyana||Latin America & Caribbean||No||No||
• The Revised National Policy Document on HIV/AIDS in Guyana calls for “no obligatory testing of specific groups such as men who have sex with men, commercial sex workers, prisoners, health care workers, or persons undergoing invasive surgery.” 94
• Four private hospitals have initiated HIV testing for pregnant women. 95
• In 2004, Guyana’s HIV/AIDS Service Provision Assessment Survey found that only 24 percent of facilities have guidelines for confidentiality and 18 percent can provide content of pre and post test counseling. 96
• Guyana’s HIV/AIDS Service Provision Assessment Survey (2004) calls for all pregnant women to be routinely offered HIV testing along with pre- and post-test counseling
|Haiti||Latin America & Caribbean||No||No||
• A private sector provider with support from the MoH, Groupe Haïtien d’Étude du Sarcome de Kaposi et des Infections Opportunistes (GHESKIO) , uses VCT as “the gateway to access other services.” 97
|Russia||Russia & Eastern Europe||No||No||
• According to the Country Progress Report of the Russian Federation on the Implementation of the Declaration of Commitment on HIV/AIDS, it appears that large scale and/or mandatory testing is conducted on select groups, including pregnant women, TB and STI patients, intravenous drug users, sex workers, men who have sex with men, and military recruits. 98
|Ukraine||Russia & Eastern Europe||No||No||
• Ukraine adopted a national VCT law called the Protocol of Voluntary HIV Counseling and Testing in 2005. 99
• VCT is within national AIDS law. 100
• However, various rights groups have claimed that HIV tests are often given without consent, particularly in TB hospitals and drug clinics. 101
• Pregnant women are sometimes tested for HIV without their consent; results are provided to their husbands and other family members without permission. 102