The Voluntary Counseling And Testing Health And Social Care Essay

Sub-Saharan Africa continues to be the hardest-hit area of the world with respect to HIV/AIDS. In Ghana HIV has spread at a slower rate than in other African countries with prevalence in 2012 of 1.5%. This would not have been possible without effective interventions such as voluntary testing and counseling (VCT). VCT is offered by a variety of healthcare providers. Its dual goals are preventing further transmission of HIV and diagnosing HIV-positive individuals enabling treatment, care and support. This paper examined the factors influencing the utilization of testing and counseling services amongst staff of Komfo Anokye Teaching Hospital. Stratified random sampling was used to select 150 respondents to self administer the questionnaires. The collected data was analyzed by the use of percentages and descriptive analysis. 80% of the respondents indicated that they have tested for HIV before and 30 representing 20% said otherwise. The respondents gave existence of treatment, plan for the future, live a healthier life, protect their partners from infection, get counseled on how to live with HIV if infected and get counseled on how to live if the result is negative as reasons for testing. The other respondents who have not tested gave reasons like scared of knowing their status, scared of discrimination, scared of being stigmatized, scared the results will not be kept confidential, scared of dying, scared their partner will reject them and scared that their job will be threatened.

Key Words: Counseling, Stigmatization, Discrimination

Introduction

Voluntary counseling and testing (VCT) is the practice by which a person undergoes counseling, allowing him/her to make a knowledgeable option about being tested for HIV. In modern days, voluntary HIV testing, in mixture with pre- and post-test counseling, has become gradually more significant in international care and prevention efforts. Information about sero-status through VCT can be an inspiring force for HIV –negative and –positive person alike to accept safer sexual behaviour, which allows sero-positive individuals to stop their partners from being infected and those tested sero-negative to stay negative. This interference also make possible to prevention services for sero-negative individuals and is access to care and support services for people who are HIV-infected. This comprises access to involvements to lessen mother-to-child transmission (MTCT) of HIV, interventions to prevent opportunistic infections such as tuberculosis and other supportive and medical services that can help people living with HIV to live healthier and longer lives.

Knowing and accepting one’s HIV status allows well-versed planning for the future, including for one’s dependents. Experiences have also revealed that VCT is one of the factors that aid to lessen secrecy and stigma surrounding HIV/AIDS. HIV testing is undertaken in diversity of health providing situations and for a number of diverse reasons. Persons are tested in settings such as private and public hospitals, laboratories and clinics as well as at non-governmental organizations (NGO’s), within workplace programs and at mobile outreach clinics (Branson, 2003). In addition, the motives for testing range and vary from clinical diagnoses to walk-in client, voluntary testing to learn one’s HIV status to the provision of testing at antenatal care clinics for the prevention of mother-to-child transmission of HIV (PMTCT). Mandatory testing is also undertaken to fulfill requirements for marriage and visa applications and entry into the military, religious orders or for scholarships applications (Brugha and Zwi, 1998).

The government of Ghana has formed a Ghana Aids Commision (GAC) that coordinates all HIV and AIDS activities in the country and advises the government on HIV matters. It consists of representatives of political leaders, some ministries, chiefs and experts. The Commission has produced a national policy that serves as a guideline to all the actors in HIV and AIDS prevention and care and this includes ministries, non government organizations, community organizations and the private sector. The policy describes the role of various stakeholders such as national leaders, various governmental ministries, non-governmental, the private sector and community based organizations, PLWHAS and individual community members in the national response to the HIV and AIDS epidemic.

VCT services are said to be one of the most significant elements in HIV and AIDS prevention and management. In Ghana, though it has been reported that there are diverse service usage rates for diverse groups, for example, age and gender groups, were not making use of the service at the same rate. Many studies try to explain the motives why people are not fully utilizing the VCT services, for example, Chiisa and Bennel (2001); Lipinge, Hofnie and Friedman (2004); Mark and Senak (2000). The available literature shows that various factors may lead to the low utilization of the service and some of these factors are related to the individual and their psychological or socio- economic situations and some issues may be related to VCT service providers. It is against this background that the researcher wants to investment ‘who has utilized or not utilized an HIV and AIDS VCT service and the reasons for accessing or not accessing VCT’.

KATH has been selected for the purpose of this study based on geographical location, easy access to information. The hospital was established in 1954 and now has developed into a 1000 bed capacity facility registering over 450,000 Out Patient Department attendances and 43,000 admissions annually. The mission of the hospital is "to provide quality services to meet the needs and expectations of all clients. This will be achieved through well-motivated and committed staff applying best practices and innovation".

LITERATURE REVIEW

Voluntary Counseling and Testing

In the United Nations General Assembly Declaration of Commitment on HIV/AIDS, HIV prevention is a central component. The statement calls for expanded access to voluntary counseling and testing by 2005 (United Nations, 2001). VCT is considered one of the nine established prevention strategies, which also includes blood donation screening, the use of mass media, AIDS education in schools, social marketing of condoms, treatment of sexually transmitted infections, peer education for commercial sex workers, prevention activities for intravenous drug users and the prevention of mother-to-child transmission of HIV (UNAIDS, 2000). The WHO has recently stated that "people have a right to know their HIV status, and testing and counseling should be widely accessible" and, importantly, it is an entry point for services related to HIV, additionally reducing the risks of infection and transmission, and that "high priority should be given to scaling-up HIV testing and counseling to maximize the opportunities to reach those with HIV infection or at high risk" (World Health Organization, 2003). Additionally, it has been shown in both South Africa and India that an increased availability of VCT in combination with media promotion has increased the demand for HIV testing.

VCT is a service which can be offered and accessed at sites provided by the governmental/ public sector, non-governmental organizations and the private sector. Settings can include freestanding VCT sites, integration into hospitals and through organizations. An increased role may also be seen in the private sector due to the presence and use of simple, rapid HIV tests (UNAIDS, 2000). Regarding this point, UNAIDS has also written that "the monitoring and evaluation of VCT services in the private sector presents additional challenges".

UNAIDS describes five goals of voluntary counseling and testing: the prevention of HIV transmission and acquisition, early and appropriate uptake of services, societal benefits and counseling for adherence. Prevention of HIV infection includes both the prevention of transmission from HIV-positive to HIV negative partners as well as the prevention of mother-to-child transmission. Prevention of HIV acquisition includes the prevention of HIV-negative individuals from acquiring the virus from HIV-positive or untested partners. Early and appropriate uptake of services targeting HIV-positive persons includes access to medical care (such as treatment of opportunistic infections or ARV therapy), family planning, emotional care, counseling for positive living, social support, improved coping and planning for the future and legal advice. For those HIV-negative, it includes emotional care, family planning and planning for the future. Societal benefits include the normalization of HIV, decreasing stigma, improving awareness and the support of human rights. Lastly, counseling for adherence seeks to ensure adherence to ARV and other therapies (where available), enhance the ability to cope with side effects and offer counseling regarding adherence in PMTCT interventions (FHI, 2001).

In a little different manner, Family Health International and USAID state the rationale behind VCT thusly: a demand for VCT exists; it is an entry point to other HIV/AIDS services; there are benefits for both those who test positive and negative and VCT "offers a holistic approach that can address HIV in the broader context of people’s lives" ((FHI, 2001). As the availability of treatment increases, it is expected that the demand for VCT services will also increase. Access to ARV therapy, which began there in 2001, is seen as one critical factor in this increased uptake along with a broad approach to AIDS care.

In Ghana, the Ghana AIDS Commission and the National AIDS Control Program in collaboration with UNAIDS, FHI, WHO, USAID and others completed a draft of Guidelines for the growth and implementation of HIV VCT in Ghana to help standardize HIV testing and counseling.

Guidelines on HIV Test-related Counseling

a. "VCT services should preserve individual needs for confidentiality"

b. "When testing is for diagnostic purposes…similar procedures for pre-test counseling should be followed" and those who refuse testing should give informed dissent and their decision should be respected.

c. "Confidentiality should be apparent in all activities of the VCT site. All members of staff should observe confidentiality."

d. Anonymous VCT services should be available

e. "Obtaining informed consent must be given special attention...and consent forms must be signed or thumb-printed by the client before testing."

f. "The ‘standard’ VCT package of pre-test counseling followed by blood draw (where client decides to test) and post-test counseling should remain the ‘golden standard’."

g. Individual pre-test counseling should be provided to all those requesting VCT and for those testing for diagnostic purposes or for other reasons where the client will be informed of the test result.

h. The "window period" should be explained and retesting after 3 months for those having had recent (< 6 months) risky behavior should be encouraged.

Importance of HIV and AIDS VCT services

VCT for HIV is important as it offers people the opportunity to test and once tested, individuals can access the appropriate services depending on their HIV status (FHI, 2002; ROB, 2004). Testing is important as those who test HIV-negative are counseled on how to stay that way, while those who test HIV-positive are counseled on how to live with the virus so that they may live a healthy life, and are counseled on how not to spread the virus, hence this could lead to behavioral change. Depending on their immune system they may be given treatment for prevention of certain infections, such as TB (MASA, 2002). Walker, Reid and Cornell (2004) asserted that TB was directly implicated in the epidemic, as people with HIV are susceptible to opportunistic infections of which TB is one. Because their immune systems are depleted, they are less able to fight off the disease and this was therefore a major cause of mortality

The effects of TB have led the Botswana government to adopt measures to prevent TB among

HIV- infected persons. HIV positive persons are entered into TB preventive therapy to prevent them from developing active TB. This is crucial as the treatment can prolong a person’s life; it helps prevent the spread of TB and helps the person to be healthier and carry on with a normal life. For pregnant women, who tested positive, they can be referred for Prevention of Mother to child transmission Therapy (PMTCT) in order to prevent their unborn children from being infected (Whiteside and Sunter, 2000).

Also, through VCT one can be given anti-retroviral drug therapy if necessary. The Anti-retroviral drugs reduce HIV mortality and morbidity, improve quality of life and prolong survival. The treatment is believed to be able to reduce the duration of acute illness and the risk of transmission of the virus. In Ghana the therapy was introduced in 2002. HIV-positive people with a CD4 count equal or less than 300cell/mm3 are given the treatment as they are at risk of developing AIDS-related diseases and dying within a few months. The treatment is said to reduce these risks. Also, treatment is recommended to those people with severe or recurrent HIV-related diseases such as TB, wasting syndrome, and chronic diarrhoea. These patients, regardless of their CD4 count, are given the treatment. However, this is contrary to the international experiences especially western counties where the recommendation for the therapy is given to all those who tested positive and have a CD4 cell count below 350 cell/mm3.

HIV and AIDS is said to be associated with stigma, discrimination, denial, rejection, and the isolation of infected and affected persons. Stigma and rejection are said to create an environment that has the potential for increased HIV infections. According to the FHI (2002) VCT can help reduce stigma. According to ROB (2004) this will happen as VCT provides an opportunity for people to know their status, and as more " people know their HIV status and that knowledge becomes more common place and acceptable, stigmatization due to one’s HIV status becomes less and less an issue".

The importance of VCT is, therefore, that it can help "clients to understand the antibody test, to make more informed decisions by weighing up the pro and cons of having the test, to consider what might be their greatest concern if they were either HIV-positive or -negative, to access information about the personal, medical, social, psychological and legal implications of being diagnosed either HIV-positive or HIV-negative, and to prepare for difficulties they may face in future" (Stone, 2001). Hence Volberding et al (1990) have argued that VCT should be made accessible to all people.

However, Green and McCreaner (1989) identified a model that suggested that there were however disadvantages towards telling people of their HIV status if tested positive. The model suggested that there was a possibility that those infected and told the results may go out and intentionally infect other people. They say that this has been reported in many areas of the world. However, the duo argues that the risk is outweighed by the advantages of people being told their status.

Barriers leading to the low utilization of HIV and AIDS VCT services

Even though VCT can be beneficial to people, the low utilization of this service is a prevalent problem all over the world (Mark and Senak, 2000). The studies below bring to light some of the reasons for the low utilization , some factors related specifically to HIV and AIDS service providers and some related to people’s perceptions and attitudes regarding HIV and AIDS testing.

According to the FHI (2002) there are many successful HIV and AIDS VCT programmes around the world, however, Rachier et al, (2004) that in Sub Saharan Africa, HIV and AIDS VCT was relatively new and was faced with various challenges. Below are some of the challenges and recommendations that were made in a three- day conference by the HIV and AIDS VCT counselors from various Sub Saharan Countries. From the conference it was established that the counselors in these countries needed training to at least a certificate level in general counseling before they specialized in HIV and AIDS VCT.

Also, it was established that the HIV and AIDS VCT training should include client centered approaches where the focus is on the person as a unique and singular individual. Hence counseling should be made to address the individual needs and also the general needs of certain groups in society.

It was established that HIV and AIDS VCT centers in these countries needed to develop adolescent- friendly policies in order to facilitate young people testing. However the report did not specify the age groups it considered as young. It was suggested that the centers should be designed in a way that addressed the specific needs of youth appropriately, such as sex, drugs and sexually transmitted infections. It was established that the centers in these countries were gender insensitive as they did not address the needs of the women who were in subordinate positions. Hence it was recommended that the centers should give special attention to the needs of females, married and unmarried, young and old. Also it should address the issues of violence, abuse, rape and family planning. In addition it was suggested that the centers should also provide training in self- esteem and assertiveness for this group.

It was also established that there was a shortage of HIV and AIDS VCT services or centers in

these countries especially in rural areas; hence they suggested that there should be a provision of house to house HIV and AIDS VCT services in order to cover everyone (Rachier et al, 2004).

HIV counseling

WHO (1994) defined HIV counseling as "a confidential dialogue between a person and a care provider aimed at enabling the person to cope with stress and personal decisions related to HIV/AIDS. The counseling procedure includes an evaluation of personal risk of HIV transmission and facilitation of preventive behavior." The goals of HIV counseling are the prevention of HIV transmission, support for those considering testing, both in deciding to take the test and in dealing with testing outcomes. Within the context of VCT, this may be divided into pre-test and post-test counseling. Additional forms of counseling include (but are not limited to) ongoing counseling (for HIV-positive persons), partner counseling (can also include family or friends) and counseling without testing (UNAIDS, 2000).

HIV Rapid Testing

The use of rapid tests for HIV testing has several implications. Their ease-of use, low cost and high specificity and sensitivity have led to their widespread use in developing countries and resource-poor settings. Results are obtained and able to be given within minutes and, due to their simplicity, use by non-medical/laboratory staff such as counselors is possible. There are public health advantages that include an increased number of people able to be tested an increased return rate where clients or patients receive the results of their test, decreased waiting time for the client/patient for his or her results and there is less dependence on laboratory services for getting results (WHO, 2004). Additionally, the significance of effective counseling in centers where rapid tests are used as clients may have less time to prepare for the results has been emphasized. The WHO has recommend "wherever possible, the use of rapid tests should be a significant component in the expansion of testing and counseling services", but also cautions that they can "also lead to people being tested without adequate counseling and informed consent" (WHO, 2004).

In Ghana, there are a number of different types of simple, rapid HIV assays. Rapid assays have been developed which utilize whole blood, serum and/or plasma, as well as urine and saliva. Urine and saliva assays are, at present, uncommon in Ghana as they have yet to be evaluated and approved by the NACP and its collaborating partners.

HIV and AIDS in the workplace

According to the UNAIDS (2002), report HIV and AIDS dramatically affects labour, sets back the economic activity and social progress as it affects in particular, productivity, as the vast majority of people living with HIV and AIDS are the economically active population aged between 15 and 49. Lisk (2003) has posited that the fact that HIV and AIDS has its primary impact on the working age population means that those with important economic and social roles are prevented from making their full contribution to economic development. He also stated that in developing countries there was already lack of skills and there was loss of more skills due to HIV and AIDS, and this had a major impact on development. The ILO report according to Lisk (2003) has estimated that in ten to fifteen years time, the labour force will be between 10 and 30% smaller in higher prevalence countries as results of AIDS. Other studies on the impact of HIV and AIDS in the workplace can be found in Kelly, Parker and Gelb (2002) who through literature review established the effects of HIV and AIDS on operating profits of industries, workplaces and sectors.

The Global Compact Policy Dialogue on HIV and AIDS (2003) has quoted the Director

General of ILO, Juan Somavia as saying that "two out of three people living with HIV and

AIDS go to work every day- it makes the workplace a vital entry point for tackling HIV/ AIDS".

According to Mwamadzingo (2003) workers, through their national and international organizations are instrumental in furthering the fact that the workplace must be seen as probably the most important and effective starting point in tackling the disastrous effects of HIV and AIDS.

Methodology

The nature of the research was descriptive. According to Mouton (1996) and Arkava and Lane (2003) a descriptive study attempts to describe the behaviour, opinions and attitudes of a sample group. Data for the study was gathered from both primary and secondary sources. The primary source dealt with information gathered from selected members of the staff. Data collection was achieved by the use of questionnaire for the participants. Also, secondary source was dealt with all the needed documents that exist in relation to VCT. The sample population of this study is all staff of Komfo Anokye Teaching Hospital (KATH). The total population of KATH staff is three thousand (3000) according to HR (2012). Probability and non-probability sampling was used to draw the samples for the study. Stratified random sampling was used to select 150 respondents to self administer the questionnaires. The data that collected was analyzed by the use of percentages and also descriptive analysis. .

Result/Discussion

Most of the respondents (35%) were between the ages 18-29 followed by the 50 - 59 (29%) year olds. 17% were 30-39 years and the least (14%) were between 40 - 49. The above indicates that, majority of the respondents fall within the youth group who has more years ahead to work. Also, the study review that majority of the respondents in the study were female (69%) and male were 31%. Most of the respondents who participated in the study hold certificate (51%) of the entire sampling size. This is follow by those who are holding diploma thus 41%. Lastly, are those who are holding degree, they represent 8%.

When the question of those who have tested HIV before was posted to the 150 respondents, 120 representing 80% of the respondents indicated that they have tested for HIV before and 30 representing 20% said no. Out of 80% who have tested 10% were as a result of been exposed to person living with HIV/AIDS. When the risk assessments of those who had tested HIV before were done, it was identified that most of them had involved in a risky behavior before. This is in line with what Chilisa and Bennel (2001) said that there is a positive relationship between those people who perceive themselves as being at risk of getting HIV and AIDS and the utilization of the HIV and AIDS services.

When the respondents who had tested HIV before were asked if they visited VCT, all of them said ‘yes’. And were asked to give reasons, most of them said that now there is a treatment for people living with HIV/AIDS, therefore they wanted to test to get treatment in case the result was positive. Other reasons the respondents gave were to plan for the future, live a healthier life, protect their partners from infection, get counseled on how to live with HIV if infected and get counseled on how to live if the result is negative. As ROB (2004) noted that it is important as it offers people the opportunity to test and once tested, individuals can access the appropriate services depending on their HIV status. Testing is important according to MASA (2002) as those who test HIV-negative are counseled on how to stay that way, while those who test HIV-positive are counseled on how to live with the virus so that they could live a healthy life, and are counseled on how not to spread the virus, hence this leads to behavioral change.

The 30 respondents representing 20% of the entire sampling size of the study indicated ‘no’ meaning they had not tested for HIV before. They gave reasons like scared of knowing my status, scared of discrimination, scared of being stigmatized, scared the results will not be kept confidential, scared of dying, scared their partner will reject them and scared that their job will be threatened.

Conclusion

The results show that the most significant reason for testing amongst the staff of KATH that did test for HIV and AIDS was that they felt they needed to undergo counseling before they tested and this may have been influenced by the perception of the importance of testing. However amongst those that did not test the most important reason for not testing was that they were scared that the results will not be kept confidential. Their most important concerns hence are different from the concerns that those respondents that tested had before testing. Though, as acknowledged by Mark and Senak (2002) even though VCT can be beneficial to people, there is a sign that some people have not utilized the HIV and AIDS service.