1. How to improve the quality of VCT in existing services?  Client perspective Christiana Nöstlinger, HIV-SAM Project Working group 1

2. Aim of Voluntary Counseling and HIV Testing 1) Diagnosis - Reduce number of late diagnoses - Reduce number of undiagnosed HIV infections 2) Prevention - Discuss risk reduction strategies - Stigma reduction: opening conversation about HIV can contribute to normalizing HIV in the community  Focus is mainly on diagnosis

3. Aim of this workshop: How can we improve the quality of VCT in a way that it is cultural sensitive and contributes to prevention?

4. Guidelines for VCT Confidentiality must be guaranteed during the entire procedure 1. Pretest counseling - Informing about test process and implications of testing - Risk assessment and risk prevention - Coping strategies - Individual decision to test: informed consent 2. HIV Testing 3. Posttest counseling HIV positive HIV negative - news given - news given - risk reduction plan - risk reduction plan - support to cope with the diagnosis - discussion about disclosure - discussion about disclosure 4. Follow- up counseling and support Further differentiation between HIV- and HIV+ clients/patients.

5. Questions: Pretest Counseling 1.How should we address fears about confidentiality? Many fear that the counselor will tell other people in the community and this will lead to discrimination and exclusion  HIV-related stigma* * HIV/AIDS Alliance, 2006, Facilitators’ guide. Let’s talk about VCT

6. Questions: Pretest counseling 2. How should we discuss the implications of an HIV test? - Fear of death “This retroviral-something is just prolonging your live, eventually you will die (FG 6)” - Fear of social rejection / exclusion - “You will be stigmatized, people will run away from you, you will be an outcast (FG 1)” - Women with HIV are more likely to face domestic violence or divorce* - Fear of living with HIV (how to cope?) * Anderson & Doyal, 2004, AIDS Care

7. Questions: Posttest Counseling 3. How should we address the barriers of health professionals to do posttest counseling with persons with an HIV negative diagnosis? - “She said, if I don’t call you, you are ok. I called her almost every day to see if the results were there (FG 7)” - Evidence shows that increased sexual risk following receipt of a negative VCT result may be a serious unintended effect of VCT* * Sherr et al., 2007, AIDS

8. Questions: Posttest Counseling 4. How should we discuss a risk reduction plan with SAM who are diagnosed negative? Sex is rarely directly spoken about, even between couples* They make sexual decisions primarily on the grounds of emotion, rather than on health. They would rather ignore health risk than jeopardize a partner’s trust * Importance of reproduction* * Heald, 1995 * Rosenthal et al., 1998, Peart et al., 1996 * Caldwell, 1989 All in Kesby et al., 2003, Social Science & Medicine

9. Questions: Posttest Counseling 5. How should we discuss “disclosure” of HIV- testing with SAM who have been diagnosed HIV-negative?  Talking about having performed an HIV test Testing itself carries the connotation of blame* * Burns et al, 2007, AIDS care