Vicitoria KajaBy Victoria Kajja (EV 2010 from Uganda)

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Under a new strategy to increase access to HIV prevention and treatment, all people who seek treatment in public health centers in Uganda will undergo mandatory HIV testing. The decision to implement this intervention under the Provider Initiated Counseling and Testing (PICT) strategy, was announced five weeks ago during the launch of the ‘Know your status’  campaign by the Ministry of health. The provider initiated counseling and testing approach involves health care providers offering routine HIV testing and counseling services to persons attending health care facilities as a standard component of medical care. The strategy was initially piloted at regional referral hospitals on expectant mothers attending ANC and patients seeking general health care. The new roll out system will now include government supported private health facilities and public health referral facilities referred to as health centres, more specifically health centers III’s and IV’s.

Once considered a model country in addressing HIV/AIDS, Uganda has experienced an increase in the prevalence with the Ministry of Health AIDS indicator survey report of 2011 indicating increased prevalence from 6.4% in 2006 to 7.3 percent in 2011. In addition, Ministry of health estimates show HIV incidence has increased from 124,261 in 2009/2010 to an estimated 130,000 new infections in 2011/12. Besides Provider Initiated Counseling and Testing, other testing strategies that Uganda implements include: routine HIV testing for pregnant women, home-based HIV testing, client-initiated counseling and testing, couples HIV testing,  mobile HIV testing and moonlight (night-time) testing for high-risk groups such as sex workers.

According to an MOH official Dr Alex Ario acting manager of the AIDS control programme there are “many benefits of knowing one’s HIV status. Those who are HIV-negative will be careful and avoid engaging in risky behaviors. They will carry out preventive options such as partner notification, abstinence and safer sex. Those who are HIV-positive will be enrolled in antiretroviral treatment and have increased opportunities for social support to live normally.”

Despite the rising prevalence, Uganda has made huge accomplishments to strengthen prevention efforts. This includes progress in supporting individuals to know their HIV sero status. In the 2011 Uganda Demographic Health Survey report, 71 percent of the surveyed women and 52 percent of men had ever been tested and received results of the last test, compared to 25 percent of the women and 21 percent of the men in 2005. With most discordant couples unaware of their sero-discordant status, and given the low condom use in marriage and long standing relationships, there is a compelling need for increasing knowledge of HIV sero-status of partners.  In addition to influencing sexual behavior to prevent further spread of infection, knowledge of HIV sero-status is a linkage to timely care, treatment, and support services for infected persons.

The strategy to apply mandatory measures is driven by the need to complement efforts to lower Uganda’s HIV prevalence. These interventions though well intentioned, have raised concerns associated with what is already being termed as ‘mandatory’ or ‘forced testing’.

Given the importance that has been placed on testing as a key entry point to HIV prevention, a fuller understanding of testing within the context of HIV/AIDS interventions is important in promoting responses that empower people to utilize HIV/AIDS services. Greater attention to human rights is needed for effective responses. This calls for defining HIV Counseling and Testing measures within the human rights framework. Such measures would empower individuals to avoid onward transmission of HIV and protect themselves from HIV infection.

The stigma surrounding AIDS continues to be a major obstacle to curbing it. In assessing the level of stigma, the Uganda Demographic Health Survey  report findings registered only 22 percent and 34 percent of men expressing positive attitudes on the four stigma related indicators. In communities where there are still high levels of discrimination against Persons Living With HIV/AIDS, mandatory testing might suffocate attempts to encourage individual initiated testing and voluntary disclosure. This would particularly apply to women and girls who are more pre-disposed to abuses. Consequently they would avoid testing and treatment, and lose their willingness to disclose their status to their partners for fear of abandonment or violence.

While approaches to HIV testing evolved around voluntary, informed and specific consent of the person being tested, provider initiated testing has already been accompanied by inflammatory media coverage and labeled as ‘’mandatory ‘’ or forced HIV testing. In addition, WHO guidelines on HIV testing recommend counseling and testing as advisable and not mandatory. Concerns have been raised about the strategy provisions that might undermine the voluntary option to opt-out and in the likely event lose out on other services.  This is likely to discourage people from seeking care for other health related issues for fear of being ‘’forcefully tested’’ or worse still, it might lead them to refrain from honest talking or disclosing their status where they need to. Such labels can adversely undermine efforts to empower people to seek for testing, treatment and disclosure.

In the HIV context, practices to protect confidentiality may be compromised especially if seen to protect irresponsible individuals. See for example the currently pending HIV/AIDS prevention and control Bill.  If enacted the Bill would make provision for disclosure by health workers, allow mandatory testing for pregnant women and make the intentional transmission of HIV/AIDS punishable by up to 10 years imprisonment. These provisions in the Bill combined with what is already being termed as ‘forced’ testing are a threat to responses that empower people to initiate testing and counseling. Provider initiated model based efforts to scale up testing therefore need to be balanced to protect individual rights especially in the case of pregnant women who are tasked with the responsibility of recruiting spouses to go for tests.

With the recent donor aid cuts, concerns are being raised on how an already crumbling health system characterized by a shortage of medical supplies, understaffing, poor remuneration among others will cope to meet the scale up of HCT to absorb the increasing numbers.

Thus, as Uganda scales up PICT attention must be paid to the manner in which the implementation is being rolled out. The strategy, already perceived as mandatory contradicts global and national guidelines which emphasize the clients’ right to test or decline to test. Achieving maximum benefits from PICT will depend on a clear assessment of the broader context in which it is being implemented. Strengthening the health care system, more specifically the infrastructure, financial and human resources and developing a framework that does not infringe on rights and protects persons against discrimination remains vital if PICT implementation is to be effectively implemented. Efforts must be made to review measures and policies that allow compulsory testing and breach confidentiality. Clearly, there’s a need for more guidance on guidelines and requirements of the strategy.

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2 Responses to Provider Initiated HIV Counseling and Testing – The Ugandan Case

  1. Shishir Dahal says:

    Dear Victoria,
    I posted your article in escart CoP. I am sharing a comment made by one of our friend.
    Regards,
    Shishir
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    Dear Shishir

    thank you for sharing. Indeed PITC has been initiated in Uganda and many other countries following WHO guidelines several years ago. For countries with very high HIV prevalence where over 50% of inpatients maybe HIV positive PITC would yield the most positives. However PITC rollout has been very slow with many programs continue to use VCT which in some instances has very low yield and often may not lead to effective linkage to care. Victoria should however not have used the word mandatory because it is not implied in PITC.

    Here is a link to our opinion piece on PITC

    http://www.ncbi.nlm.nih.gov/m/pubmed/20485851/

  2. Jamie Uhrig says:

    The acting National AIDS Programme manager notes: there are “many benefits of knowing one’s HIV status. Those who are HIV-negative will be careful and avoid engaging in risky behaviors. They will carry out preventive options such as partner notification, abstinence and safer sex.”

    Nonsense.

    The evidence shows that those who test negative do not change their behaviour. There is a recent Cochrane review on this issue: http://tinyurl.com/bl3n58w. Why would a sane seronegative person engage in ‘partner notification’?

    The HIV prevention impact of testing on the 92% of Ugandans who are seronegative is negligible.

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