Module 6: Routine HIV Testing of TB Patients

Learning Objectives Explain why TB suspects and patients should be routinely tested for HIV Summarize the routine HIV testing policy for Botswana List the advantages of using rapid HIV tests

National HIV Testing Policy in Botswana "It is expected that all patients presenting with symptoms associated with HIV/AIDS will be routinely offered an HIV test with the opportunity to opt-out should they so desire….Government would like to see more Botswana testing so that we may prevent further spread of the infection and reduce suffering among infected." President Festus Mogae, January 2004 His Excellency Mr. Festus Gontebanye Mogae President of the Republic of Botswana

Rationale for Testing TB Suspects and Patients for HIV Rates of HIV infection are higher among TB patients than among the general population HIV-infected TB patients can be identified for diagnosis, counselling, and follow-up HIV-infected TB patients can be referred to appropriate treatment and care services Data can be used to monitor HIV testing, as well as treatment outcomes of TB/HIV coinfected patients

Feasibility of Testing TB Suspects and Patients for HIV TB suspects make 2 clinic visits prior to diagnosis TB patients visit clinic daily for DOT Each patient visit is an opportunity to offer an HIV test –All untested patients should be offered a test at each visit –All HIV-negative patients should be offered a retest Within three months of an initial negative test (window period) Annually

Routine HIV Testing

What is Routine HIV Testing? Policy of testing all patients presenting for medical care Test should be offered by HCW (nurse, doctor, etc.) as standard part of the patient visit Test is performed by that HCW unless the patient declines the test

Routine HIV testing should be offered to the following: Patients with clinical signs and symptoms of HIV/AIDS* Pregnant women attending antenatal clinics Patients with sexually transmitted infections (STI) Any healthy individual going for general medical examination *Because TB is an AIDS-defining illness, all TB suspects and patients receive an HIV test. Botswana Policy for Routine HIV Testing

Why Should We Do Routine HIV Testing? Early diagnosis may improve life expectancy considerably By making HIV testing more accessible, the number of people who know their status increases Some patients prefer to be tested by a HCW during a regular medical visit Some patients prefer the privacy of an office-test to visiting the lay counselor cabin Routine HIV testing takes less time

How to Offer Routine HIV Testing (1) Give the patient enough pre-test information to enable him/her to understand why an HIV test is needed: – Clinical and preventive benefits of testing – Medical care service that is available – That he/she has the right to refuse, but test is routinely done for people with TB, and test is confidential Pre-test information session is brief More emphasis is placed on post-test counseling

How to Offer Routine HIV Testing (2) Patients who agree to be tested do not need pre- test counselling before their HIV test is done, just the short pre-test information session Can use either HIV rapid test or ELISA HIV-negative patients should –Repeat HIV test within three months –Patients with two-negative tests during treatment, should be reminded to repeat their HIV test annually

Example 1: Offering Routine HIV Testing is like Offering an X-Ray (1) Routine information and consent for an x-ray: Nurse: “It sounds like your bad cough and fever could be pneumonia. Pneumonia is easy to treat with antibiotics, but first we need to see if you have it. The best way to do this is to take an x-ray. Take this form down the hall to the left for your x-ray, then come back to me once it’s done.” Patient consents by taking the form and going for the x-ray.

Example 1: Offering Routine HIV Testing is like Offering an X-Ray (2) Routine information and consent for an HIV test: Nurse: “You have TB, and you’ve lost a lot of weight. These symptoms are concerning, and might mean you also have HIV. HIV is very common in people with TB. As you have probably heard, ARV therapy for HIV is available for free, and will greatly improve your health and allow you to live a long life with HIV. To see if you have HIV, we need to do an HIV test. Will you allow me give you a rapid HIV test ? The results will be available by the time we finish your exam today.” Patient: “Do I have to get an HIV test?” (Continued on next slide)

Example 1: Offering Routine HIV Testing is like Offering an X-Ray (3) Nurse: “We would never force you to have a test. But an HIV test is part of routine medical care for someone with your symptoms, and you need it for your own health. If your HIV is not diagnosed, it is only going to get worse. We will help you deal with the results and get proper treatment if you are HIV-infected.” Patient consents and nurse performs HIV rapid test.

What if the patient refuses routine HIV testing? The patient always has the right to refuse an HIV test Options after initial refusal: –Provide further counselling, if patient is receptive –Refer to counselor for more counselling –Tell patient they can request an HIV test when they are ready –Give patient educational materials to read at home –Offer routine HIV testing to the patient on next visit

Routine HIV Testing vs. Voluntary Counselling and Testing Routine HIV TestingVCT Who initiates? Health workerClient Pre-test counselling Pre-test information session Focusing on benefits of testing, medical services available, and right to refuse Full education and counselling session, including confidentiality, counselling, consent, and risk assessment/ reduction behaviours Type of HIV test ELISA or rapid test Who uses results? Health worker – to make a correct diagnosis and provide appropriate referral and treatment Client – to make personal life decisions Type of service? Confidential test with result documented in medical record to ensure proper care Anonymous or confidential

What is Rapid HIV Testing? HIV test that provide results quickly, often < 30 minutes using a drop of a patient’s blood Advantages: –Easy to perform –Lay counselors and others can be trained to do it because it only requires a finger-prick –Results are as accurate as other methods (e.g. ELISA, Western Blot) –More people accept testing and receive results –Can be integrated easily into any medical visit