Counselling for HIV testing in the Pacific Region

1. Counselling for HIV testing in the Pacific Region Alistair Mac Donald Counselling Training Officer American Samoa – May 2008 Secretariat of the Pacific Community 1

2. Presentation purpose: Provide an overview of the current status of regional counselling and counselling training services Raise Pacific ‘counselling’ matters for consideration in developing regional HIV testing algorithms 2

3. What is ‘counselling’?

4. Counselling in the Pacific • Varied experience and teaching of undergraduate medical, nursing and other health and social work professionals in psychology, psychiatry, counselling, and inter-personal communications • Counselling experience from pastoral, faith /church-based, or school guidance environments – i.e. often ‘advice giving’ • BUT – no good understanding by technical agencies about what ‘counselling’ is or means to Pacific people • Services still ‘embryonic’ – often provide unreliable services, cease operation or rely on one ‘key’ person • In the Pacific and internationally – little comfort amongst health professionals discussing sexuality (personally and professionally)

5. Counselling and counselling training in the Pacific • Until recently, no ‘minimum standards’ for training and counselling practice in many places • Many varied forms of baseline training in ‘counselling’ for HIV Testing (CTR/VCT/VCCT/PITC) • CDC CTR training in US affiliates (4 – 5 days) • Elsewhere: 1, 2 – 10 day and 6 week training in ‘VCCT’ in various countries and from varied agencies • Frequently little assessment of trainee competency or follow up • Other forms of related training which also address HIV testing and counselling – e.g. PMTCT or PPTCT, rapid testing systems

6. Varied forms of baseline training • Many different training providers – poor coordination • Assume prior knowledge or skills • On line and group based forms of training • Varied and often no Selection criteria for ‘counsellor’ training • Training often ad hoc or on an ‘urgent’ basis – such as response to a first positive diagnosis • Training curricula vary • In quality • Content • Training methods • Duration • Generally not oriented to meet the needs of the mostly ‘low prevalence’ Pacific environments – majority of clients will be HIV negative (or have another STI) • Not oriented to preventative counselling • Curricula content low in managing proportionally more ‘false positive’ results and a ‘point of care’ approach

7. “Knowledge is nothing without understanding”

8. Important considerations: Privacy and Confidentiality • Prevailing poor levels of confidentiality in health services • Strong interconnectedness in Pacific societies • Often small communities – few large metropolitan environments providing ‘anonymity’ • Patient or client privacy - reported as generally poor • Privacy as a ‘human right’ not always well understood • Sexual behaviours and HIV – high curiosity

9. Other considerations: Systems • Often a poor understanding of the need for ‘counselling’ in health services by management • Procedural and quality assurance systems for both counselling and the blood testing - ‘highly variable’ • Still few but growing documented systems or policies - often ‘oral’ • Little to no professional supervision of staff – NB: counselling is not easily observed and happens behind closed doors • Many Pacific services have seen no or few people with HIV – high anxiety • Integration of counselling with existing related services a challenge (such as ANC, STI, RH, blood transfusion)

10. Other considerations…. • Highly stigmatised conditions and behaviours - high level discomfort for clients in coming forward for testing for both HIV and other STI • Personal discomfort from health professionals – ‘shame and blame game’ • Promotion of counselling and testing services patchy • Demand for counselling and testing varies: • Most testing in blood transfusion services – reports of little to no counselling • Antenatal clinics – Opt out approach and reports of large numbers being tested but not counselled • At dedicated services, generally the numbers of clients seen – low

11. Low client throughput results in: • Loss of skill/knowledge • Loss of staff confidence • Low staff morale • Assignment of staff to other work • Staff absenteeism and attrition

12. A typical scenario • Staff member selected via ad hoc criteria and attends ‘counselling’ training – often requiring out of country travel • Returns home enthusiastic but nervous • Returns to low level collegial support and understanding • Recognised by other staff as the ‘Counsellor’ • Finds it difficult or meets resistance to establish systems, policies and procedures • No to low follow up by trainers • Practice competence not regularly assessed • Confidence decays or does not match ability • Often assigned to other work

13. Summary • Prior understanding often limited and technical training in test counselling or counselling micro skills inconsistent and/or inadequate • Resulting understanding and skills set often basic and practice confidence low • Supervision problematic • Supporting laboratory quality assurance systems – often weak • Many services have multiple competing priorities and often no to low levels of HIV – vary levels of support for establishing and maintaining counselling services • Very small pool of skilled staff - with little succession planning • Promotion of counselling and testing services patchy • Generally - service trust and confidence low

14. Thank youFa’afetai