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Voluntary and Confidential Counselling and Testing for HIV

VCCT Handbook – for Counsellors and Counsellor Trainers

Authors: Dragan Ilić and Mila Paunić, Belgrade, 2006 Publisher: Institute for the Protection of Student Health, Belgrade

For the publisher: Dragan llić, Institute Director

Authors: Dragan llić, Mila Paunić

With the assistance of the Expert Group for Youth Development and Health, Health Ministry, Republic of Serbia Editor: Tamara Gruden Design and illustrations: Konstantin Petrović Press: Premis Circulation: 1500 Published: 2006

This publication was made possible by the unicef UNICEF programme focusing on the development of youth health services.

Publishing was supported with financial help from Irish Aid.

ISBN: 86-902625-4-7 On the top of the cover page: Voluntary and CIP - Kаталогизација у Confidential Counselling and Testing for HIV - публиKацији Circulation 1500. – Народна библиотеKа Handbook Authors: 79- 80. - Literature: page Србије, Београд 75-78. 616.98:578.828(035) ISBN 86-902625-5-5 1. Паунић, Мила а) Сида – Спречавање VCCT Handbook - for -Приручници Counsellors and Counsellor COBISS.SR-ID 134083852 Trainers / authors Dragan llić and Mila Paunić (Belgrade: Institute for the Protection of Student Health 2006). - 80 pages. Tables.: 25 cm Contents

Contents...... 1 Abbreviations ...... 4 Introduction ...... 5 1. HIV and AIDS ...... 6 1.1.Etiology ...... 6 1.2.HIV transmission routes...... 6 1.3.HIV infection, AIDS and therapy ...... 7 1.4.HIV diagnostics...... 7

2. Voluntary and Confidential Counselling and Testing for HIV ….. 9 3. HIV Pre-Test Counselling ...... 10

3.1.Basic information about HIV pre-test counselling ...... 10 3.2.Evaluation of HIV infection risk...... 10 3.3.Basic information about HIV testing ...... 10

3.3.1.HIV antibody testing ...... 11 3.3.2.Window period...... 11 3.3.3.What does a positive test result to HIV antibodies mean? 11 3.3.4.What does a negative test result mean?...... 11 3.4.Arguments for and against testing ...... 12 3.4.1.Medical reasons for testing ...... 12 3.4.2.Arguments against testing ...... 12 3.5.Making the decision to have the HIV test ……….……. 13 4. VCCT in Particular Situations...... 14 4.1. VCCT after possible recent exposure to HIV infection 14 4.1.1. Within 24 to 48 hours after exposure to HIV infection.... 14 4.1.2. More than 48 hours after exposure to HIV infection 14 4.2. VCCT after sexual abuse or rape...... 15 4.3. VCCT relating to the choice of sexual relationships between permanent partners . 15 4.4. VCCT during pregnancy...... 17 4.4.1. What if a pregnant woman has a positive HIV test result? 17 4.4.2.Announcing HIV positive test results to pregnant women 18 4.4.3.What if a pregnant woman has a HIV negative test result? 18 4.5. VCCT outreach work...... 18 4.5.1.The advantages of VCCT outreach work...... 19 4.5.2.The disadvantages of VCCT outreach work...... 19 4.6. Understanding safe sex and security measures in drug use 19 5. VCCT and people under 18 ...... 21 5.1. Counselling and testing of those between ages 16 and 18 21 5.2. Counselling and testing of those under 16 ...... 21 5.3. Specific aspects of youth VCCT ...... 21 6. Testing for HIV...... 23 6.1. Where to go for HIV testing...... 23 6.1.1.The role and place of primary health protection in VCCT 23 6.1.2.Choosing an institute for VCCT ...... 23

6.2. When to perform HIV testing ...... 24 6.3. How is HIV testing done? ...... 24 6.4. How long is the wait for HIV test results?...... 24 6.5. Can the HIV test determine when the infection occurred? 24 6.6. Testing at home...... 24 6.7. Validity of HIV testing...... 24

6.7.1.Sensitivity of HIV tests...... 25 6.7.2.Specificity ...... 25 6.8. False positive and false negative HIV test results 25 6.8.1.False positive HIV test results...... 25 6.8.2.Undefined or weak positive HIV test results...... 26 6.8.3.Diseases that cause false positive or false negative HIV test results 26 6.9. PCR test or HIV viral load test...... 26 6.10. HlV genome test...... 26 6.11. P24 antigen test...... 26 7. Confidentiality...... 27 7.1. Confidentiality in an AIDS Counselling Centre (Centre for Prevention of AIDS and STIs) 27 7.2. Notifying family physician/physician of choice about HIV status 27 7.3. Notifying other hospital physicians about HIV status 27 7.4. Who to share HIV positive test result with...... 28 8. VCCT for Particularly Sensitive Groups...... 29 8.1. Specific questions for gay men during VCCT...... 29 8.2. Specific questions for women during VCCT...... 30 8.3. Specific questions for drug users during VCCT...... 30 9. HIV Post-Test Counselling ...... 32 9.1. Announcing a HIV positive test result...... 32 9.2. Announcing a HIV negative test result...... 32 9.3. Notifying a partner about the outcome of HIV testing. 33 9.4. HIV and AIDS treatment possibilities...... 33

9.4.1.Diagnostics during treatment of HIV and AIDS...... 34 9.4.2.Is it better to wait until more effective treatments are developed? 34

10. HIV Counselling Process (Instructions for the Counsellors) 35 11. VCCT evaluation...... 38

11.1...... Evaluation of VCCT service provision...... 38 11.2...... Adequacy of the protocols for HIV counselling...... 38 11.3...... Adequacy of the protocols for HIV testing ...... 39 11.4...... Indicators for successful VCCT evaluation...... 39 12. Minimum Counselling Protocol...... 40 12.1. HIV pre-test counselling in 7 to 12 minutes …………………….. 40 12.1.1...... Introduction and explanation of the counselling process (1-2 minutes)...... 40 12.1.2. Assessing client’s self-awareness about the risk (2-3 minutes) 41 12.1.3. Investigation into the specifics of the client’s most recent risk incident (2-3 minutes) 41 12.1.4...... Identifying the client's constructive attempts for risk reduction, exploring behavioural change limits through understanding and support (1-2 minutes)...... 42 12.1.5. Summarising the client's risky behaviour through identification of his/her risky behaviour patterns and observing specific vulnerabilities and triggers of risky behaviour (1-2 minutes) 43 12.2. HIV post-test counselling in 7-15/25 minutes ……… 44 12.2.1...... Providing and giving test results (2-10 /20 minutes)...... 44 12.2.2...... Identification of a support system and person(s) to help increase the client's chances of reducing risk and to implement a risk reduction plan (1-2 minutes)...... 45 12.2.3. Development of specific, concrete and gradual plans for reduction of risk of HIV infection (2-3 minutes)...... 46 12.2.4. Enable follow-up visits on an as-needed basis (1 minute)……...... 47 Literature ...... 50 About the Authors...... 53 Abbreviations

AIDS - Acquired Immune Deficiency Syndrome AZT – azidothymidine or zidovudine, first antiretroviral medication for the treatment of HIV infection CAFOD - Catholic Agency for Overseas Development CSW - commercial sex workers DNA - deoxyribonucleic acid, carrier of genetic information VCCT - Voluntary and Confidential Counselling and HIV Testing EIA - Enzyme ImmunoAssay, a method used in HIV diagnostics ELISA - Enzyme-Linked ImmunoSorbent Assay, a method used in HIV diagnostics HAART - Highly Active Antiretroviral Therapy HIV - Human Immunodeficiency Virus IFA - ImmunoFluorescent Assay, a method used in HIV diagnostics IVDU - intravenous drug use JAZAS - Association against AIDS MSM - men who have sex with men PCR - polymerase chain reaction for the amplification of nucleic acids, a method used in HIV diagnostics PEP- post exposure prophylaxis STI - sexually transmitted infections RNA - ribonucleic acid, carrier of genetic information WHO - World Health Organisation UN - United Nations UNAIDS -Joint United Nations Programme on HIV/AIDS UNGASS - United Nations General Assembly Special Session UNICEF - United Nations Children's Fund ZZZZ – Zavod za zdravstvenu zaštitu, Institute for the Protection of Student Health WB - Western Blot, a method used in HIV diagnostics Introduction

The Voluntary and Confidential Counselling and Testing for HIV (VCCT) Handbook is primarily intended for counsellors employed in specialised AIDS Counselling Centres, where counselling and testing for HIV is performed. However, the majority of chapters, particularly those pertaining to counselling before testing for HIV can assist in different types of counselling in other Counselling Centres, such as centres for youth and STIs, as well as individuals doing outreach work with those who have an increased risk of HIV infection. This Handbook contains essential information about the quality implementation of VCCT. In addition, the Handbook encompasses detailed counselling processes for HIV counselling and protocols for minimal HIV counselling that will offer counsellors clear, step by step instructions in HIV counselling and will act as a reminder before commencing counselling. This Handbook contains theoretical VCCT information and can be used for the training of future VCCT counsellors. It complements the Guide for Trainers of VCCT Counsellors, which contains information about the preparation and training of future counsellors. In order to achieve the maximum quality of counsellor training, we recommend the Guide as a source of information when organising trainings for counsellors and this Handbook when preparing training content. The Handbook originated as part of the Strengthening of Services for Voluntary and Confidential Counselling and Testing for HIV programme by UNICEF and the Institute for the Protection of Student Health, Belgrade, with the assistance of the Expert Group for Youth Development and Health from the Health Ministry of the Republic of Serbia and the Group for Prevention of the Republic’s AIDS Committee. The general objective of this programme is to increase the access and quality of VCCT services, primarily for adolescents and younger people. Until 2002, when implementation of the programme started, many AIDS Counselling Centres performed testing without appropriate HIV pre- and post-test counselling. Now, the counselling is not only fully operational and an integral part of every HIV test, but is also recognised as one of the key strategies in the prevention of HIV infection. It is also recommended, in adaptation, for all other services that are focused on issues closely connected to HIV infection (for example, reproductive health, dependency diseases, etc.). Following WHO recommendations, VCCT is recognised in our country as one of the basic components of comprehensive health services for youth and adolescents. As part of this programme around 30 trainers for VCCT counsellors and over 100 counsellors for VCCT have been trained, primarily experts working on health protection for children and youth. This Handbook presents advanced support when building the protocol for VCCT at a national level. Its distribution and use with young people will enable them to receive correct, reliable and useful information, advice and support concerning protection from HIV infection. This can all be obtained in a variety of places, including specialised counselling centres for VCCT sponsored by the Institute for Health Protection (where people can also be tested for HIV) and the manifold youth counselling offices established in Health Centres throughout Serbia, and through outreach programmes and other activities by relevant non-governmental organisations. During the preparation of this Handbook, the authors’ wide experience in VCCT counselling and training of counsellors played an important role. Expert domestic and foreign literature was also utilised, as well as the knowledge obtained through education at home and abroad. Special contributions, suggestions and support to the improvement of the quality and accessibility of VCCT and the actual finalisation of this Handbook were given by Belgrade's UNICEF Office and suggestions and assistance were contributed by its youth programme coordinator Dr Jelena Zajeganović-Jakovljević. 1. HIV and AIDS

From June 1981, when the world HIV/AIDS epidemic began, until today, the terminology, epidemiological situations and epidemiological characteristics of HIV infection around the world as well as in our country have changed. Great advances were made in the study of etiology and pathogenesis, clearly defining the causes of the HIV/AIDS epidemic. Tests for HIV virus detection have been modernised, contact between virus and cells has been proven, new drugs were discovered and currently huge effort is being put into advances in retroviral therapy. Despite this, there is a worldwide increase in the number of infected and people with HIV-related illnesses, leading to the HIV/AIDS epidemic reaching pandemic proportions and remaining one of the world's leading problems. Even though AIDS was recognised as a separate clinical entity in 1981, isolated cases were discovered retrospectively in the USA and other parts of the world, such as Haiti, Africa and Europe. It is estimated that between the start of the epidemic until the end of 2005, worldwide, over 78 million people have been infected. Cumulative and annual records of people living with AIDS and those who have died from AIDS are highest in sub-Saharan Africa. By the end of 2005, AIDS had caused the death of over 33 million people. On our planet, there is not one country "immune" to the HIV/AIDS epidemic. And for this reason, every country has developed programmes for the prevention and elimination of HIV/AIDS. The most efficient implementation into practice requires complete political and social cooperation.

1.1. Etiology The Human Immunodeficiency Virus (HIV) is a retrovirus. There are two identified types: Type 1 (HIV-1) and Type 2 (HIV-2). These two virus types differ somewhat serologically and in geographical spread, yet have similar epidemiologic characteristics. Type 1 is more pathogenic. Generally, HIV-1 occurs more frequently worldwide, while HIV-2 is primarily dominant in West Africa, with some cases known in other countries where an epidemiological connection with that region exists.

1.2. HIV transmission routes

The source of HIV infection lies with humans, infected or diseased. HIV can be transmitted from one person to another by sexual contact (vaginal, anal or oral), by the shared use of needles and syringes, by transfusion of infected blood or its components or by transplantation of infected tissues or organs. Despite the fact that the virus can sometimes be found in saliva, tears, urine or bronchial secretion, there are no known cases of transmission after contact with these secretions. The risk of HIV transmission in sexual relations is less likely than the transmission of other sexually transmitted infections. However, the presence of other sexually transmissible infections, especially ulcerative, can significantly enhance HIV transmission. The main determinants of sexual transmission of HIV are the prevalence and form of risky behaviour such as sex without protection and sex with several partners. The risk of transmission through anal sex is higher than through vaginal sex due to anatomical characteristics, while it is assumed that the risk of infection by oral sex is unlikely. There are no laboratory or epidemiological data supporting the idea that HIV can be transmitted through insect bites. About 15 to 30% of children born to HIV positive mothers become infected during pregnancy, labour or after the birth through the mother's milk. The treatment of pregnant women with antiretroviral medications leads to a significant reduction of infant infections. Breastfeeding can transmit HIV infection and is responsible for about 50% of HIV infections passed from mother to infant. The average transmission risk of HIV infection for health workers after percutaneous exposure (i.e., accidental needle prick) to HIV infected blood or other bodily fluids is 0.3%, which is significantly lower than the risk of Hepatitis B infection (about 30%) after similar exposure. The contagious period begins soon after infection and lasts for the entirety of the person’s life. Epidemiological data suggest that the contagious state increases with the rise of immunodeficiency, appearance of clinical symptoms and the presence of other sexually transmissible infections (STIs). Epidemiological studies have shown that the contagious state is high even at the beginning of the infection. It is assumed that susceptibility to infection is indifferent to race, gender or pregnancy. The presence of other STIs as well as the absence of circumcision for men can improve contagiousness. Only one’s age at the time of the infection can influence the speed of the progression from HIV to AIDS. People infected with HIV at a younger age will have symptoms that appear earlier, and the disease will progress faster into AIDS, than will individuals infected when older.

1.3. HIV infection, AIDS and therapy After several weeks or months after HIV infection, a certain number of HIV infected individuals (about 35%) have symptoms similar to mononucleosis that last 1 to 2 weeks. After that, the infected individuals may not display any clinical signs or symptoms of the disease for months or even years. The seriousness of later opportunistic infections or cancers connected with HIV infection in principle is proportional to the degree of the immune system deficiencies. HIV is the virus that causes AIDS. The percentage of HIV positive individuals that will develop AIDS, unless they are treated with antiretroviral medications, is estimated to be over 90%. The incubation period may vary. Although it takes about 1 to 3 months from the time of infection until antibodies can be detected, the time from infection to diagnosis of AIDS ranges from less than a year to fifteen years or more. Without efficient anti-HIV therapy, approximately half of all infected adult individuals will have developed AIDS within 10 years of the incubation period. The average incubation period in children is shorter. In countries where people are exposed to tuberculosis and parasites, such as the one that causes malaria, this period will most likely be shorter. This period is significantly prolonged if, during earlier stages of infection, adequate antiretroviral therapy treatment is started. In developed countries, development of AIDS is significantly slower since efficient anti-HIV therapy became accessible to infected individuals in the mid-nineties. In the absence of truly effective therapy, the mortality rate is very high: in developed countries, the majority of those infected (80 to 90%) died within 3 to 5 years after the diagnosis was made. However, with the routine application of prophylactic medications against Pneumocystis carinii pneumonia and other opportunist infections in the USA and the majority of developed countries, the progression and its deadly outcome is delayed. The concept of a contemporary combination of antiretroviral therapy, applied in recent years, completely replaced the one-medication therapy, so that most often three medications are administered simultaneously. With timely and sufficient long-term control of virus replication, remission and certain immune reconstitution may take place after about one year of therapy.

1.4. HIV diagnostics See also chapters 3.3., Basic Information about HIV Testing and 6. Testing for HIV. Serological tests for the detection of HIV antibodies have been commercially available since 1985. The most often used screening tests, EIA or ELISA are highly sensitive and specific. However, the reactivity of these tests has to be confirmed by additional tests such as Western Blot or IFA. Non-reactive additional (Western Blot or IFA) test results render initially reactive EIA tests negative, reactive tests support them, while an undefined Western Blot test result requires further examinations. Due to the extreme seriousness of positive HIV test results, it is recommended that test results are confirmed on another blood sample from the same person, to exclude possible errors when marking the samples and writing the results. The majority of HIV-infected individuals develop antibodies that can only be identified 1 to 3 months after the time of infection. Sometimes this interval is extended to six months and rarely to more than 6 months. There are other tests that can be used for the detection of HIV infection before before seroconversion. These tests involve circulating P24 antigen and PCR, whereby viral nucleic acid sequences are detected. Since the window period between the earliest possible detection of the virus and its seroconversion is short (less than 2 weeks), diagnosing HIV infection using these tests is rare. They are, however, very important for HIV diagnostics with babies born to HIV positive mothers, as HIV antibodies of infected mothers are passively transmitted to their babies. Therefore, EIA tests carried out on these babies can prove to be false positive, even until they reach 15 months of age. Determination of the absolute number or percentage of T-helper cells (CD4+) is most often used to assess the seriousness of the infection and as an aid to clinicians to determine the therapy. 2. Voluntary and Confidential Counselling and Testing for HIV

Voluntary and Confidential Counselling and HIV Testing (VCCT) are the key components of the programme for the prevention and repression of HIV infection. VCCT is an accomplished preventive strategy, which is an integral part of the HIV prevention programme in most countries. VCCT enables people to get information about HIV: how HIV is transmitted, how to recognise personal behavioural risks that could lead to HIV infection, how to practice safe sex, where to get tested for HIV and, depending on the result, how to take steps to avoid getting infected or infecting others. Within the HIV/AIDS protection programme framework, counselling before testing, the testing itself, HIV test results, and the post-test counselling can help people change their behaviour and to a large extent reduce the risk of HIV transmission. Wider access to VCCT could also be advantageous for the wider understanding of HIV/AIDS and eliminating or reducing stigmatisation and discrimination of those infected with HIV. It should be emphasised that access to VCCT is recognised as a key strategy in the response to HIV/AIDS in low and intermediately developed countries, as well as in highly-developed countries with modern health care systems. Many countries are gradually introducing VCCT as an integral part of the health protection system. In the USA, where it is estimated that 25% of HIV positive people are unaware of their HIV status, centres for the control and prevention of the disease have acknowledged VCCT as a basic strategic plan for HIV prevention in the period 2001 to 2005. The plan envisaged an increase in the number of institutions that would routinely offer VCCT in health institutions (for example: clinics for sexually transmitted infections, clinics for treatment of dependency diseases, family planning clinics, first aid posts, health centres) as well as outside of those (such as in community services, general assistance programmes, etc.). Even though there are high-quality services for VCCT in low and intermediately developed countries, the majority of them are concentrated in the main urban areas. This means that VCCT is currently not accessible to a large majority of people who would have benefited from it. Expansion of VCCT services was the basis of a UN strategic plan for HIV/AIDS prevention from 2001 to 2005 and the goals of UNGASS towards reduction for HIV/AIDS, especially among youths and children. In environments where there are no voluntary, confidential counselling and HIV testing services, counselling needs to be established, and where such services exist, people need to be encouraged to use them. 3. HIV Pre-Test counselling

3.1. Basic information about HIV pre-test counselling HIV pre-test counselling includes • Obtaining prior consent from the client to perform HIV-testing, • Evaluation of HIV infection risk (was the individual in exposed to risk?), • Giving basic information about HIV testing, • Determining arguments for and against HIV testing for a particular individual at that time, • Determining if valid epidemiological or clinical reasons exist for a referral to HIV testing, • Information about testing procedures, including information on how the test is done, how the test results are given, the need for HIV post-test counselling, regardless of the test outcome, • Confidentiality and explanation of the procedures involved in the protection of confidentiality for testing and results, • Discussion about the period after the HIV testing, how the client will react to a positive or negative result, • Discussion about possible clinical and social services accessible to HIV infected individuals, • Discussion about special needs of particular groups (homo- and bi-sexual individuals, intravenous drug users, sex workers), • Checking knowledge of condom use, including a practical demonstration for both genders. More detailed information about separate counselling segments in HIV pre-test counselling and the protocol for counselling are given in the next chapters.

3.2. Evaluation of HIV infection risk Assessment of HIV infection risk is an important part of the process of pre-test counselling, as many people ask for testing on HIV antibodies even though they were not at risk. Psychological tension that can arise from waiting on results often can be lessened through talking about possible risks that the person being tested was exposed to in the past. Actual findings on the status of HIV antibodies itself seem to have little impact on the change in people's behaviour, while counselling about safe sex or safe drug use is more efficient. For this reason, the actual discussion about risk assessment with the client can be a very valuable way to provide the client with the right information about safe sex and safe drug use, depending on the person’s needs. The opportunity to assess past risks and offer useful advice to concerned individuals depends upon an overall understanding of information about the transmission of HIV. High-risk behaviours, unprotected sexual acts and the use of shared devices for drug injection will perhaps not be easily admitted to. Therefore, the counsellor has to offer non-judgemental support and enable the client to realistically assess his own risks. Women are perhaps more at ease talking to about risky behaviour (such as unprotected sex with men), while it is much more difficult talking about or examining risks that men face. All these can be obstacles that prevent a precise determination of risk, even in an environment that is full of support and confidence. Women can have a hard time discovering that anal sexual acts are a possible risk, due to taboos associated with this kind of sex.

3.3. Basic information about HIV testing See also chapters 1.4. HIV diagnostics and 6., Testing for HIV. 3.3.1. HIV antibody testing This most commonly used test for the presence of HIV basically tests the presence of HIV antibodies. The production of antibodies is the response of the immune system to infections. Antibodies normally emerge in the blood several weeks after HIV infection. The test for HIV antibodies detects the presence of HIV antibodies in the blood. It is easier and more economical to find HIV antibodies than to search for the actual virus. If the test on HIV antibodies is positive, it confirms the existence of HIV infection. This is not a test for AIDS.

3.3.2. Window period HIV antibodies are not produced in sufficient quantities needed for detection on the day of or the day after infection. Therefore, it is not possible to discover if the individual was infected immediately after the possible risky behaviour. Approximately two to three months is required for antibodies to be produced in sufficient quantities for them to be detected with standard tests. The time between infection and the appearance of detectable antibodies is called the window period. In that window period people infected with HIV do not have HIV antibodies in their blood, but do have a high level of HIV virus in the blood, in the bodily fluids of sexual organs and in breast milk. In fact, people with HIV are more infectious during the window period, before their own immune system manages to control the virus to some extent. Accordingly, during this period, HIV can be transmitted to another person even if his or her test on HIV antibodies is negative. It is generally recommended to wait for 3 months after the risky behaviour before carrying out the test, which has to be repeated after 6 months to make sure that a negative test result was in fact true. Where unusual risky behaviour is concerned, or if there is a reason to believe that infection could have happened, there should be no delay in asking for advice. 3.3.3. What does a positive test result to HIV antibodies mean? A positive result means that the body has produced antibodies against HIV. It does not indicate whether the infected person will remain healthy, develop concurrent diseases or develop AIDS; rather, it means that this person most probably has an HIV infection. Researchers have shown that the virus can be found in almost everyone carrying HIV antibodies (except in newborns of HIV positive mothers, who can have the mother's antibodies in their blood without the presence of the virus). This signifies that a person with a positive test result has to practice safe sex with their sexual partners. Intravenous drug addicts must not share needles and syringes with others. Taking precautionary measures prevents others from receiving an HIV infection from the infected person, and will prevent him/her from getting any other infection from another person. It is possible that other infections stimulate the development of AIDS in a person infected with HIV. Persons that test positive to HIV antibodies will have more tests carried out to show them and their physicians the extent of damage that HIV has caused to their immunological system. The physicians will want to talk to them about currently available options for HIV treatment. 3.3.4. What does a negative test result mean? A negative test result means that HIV antibodies were not found in the blood of the tested person. A negative test result means that the person probably does not have an HIV infection. However, after HIV infection, 3 months can pass before the antibodies are produced in detectable amounts, in accordance with the previously explained window period. During this period, the test result can be negative even if the person has an HIV infection and is infectious. As previously stated, infectivity in the window period is at its highest, before the antibodies are produced in a detectable concentration. For all these reasons, a negative test result (for a test performed in the window period) has to be repeated . in order to be sure of the result. If there is a high possibility that the person was exposed to HIV during the month prior to the visit to the physician, the physician may want to discuss the possibility of early treatment, or some other type of testing such as P24 antigen test, unless it was already carried out. A small number of people, perhaps in the order of one in a hundred infected people, need more than 2 months to form antibodies, but it is very unusual for this to be 6 or more months. A very small percentage of people with HIV infection (one in a thousand) never form antibodies. Obviously, a negative test result is not a guarantee of future tests. Consequently, regardless of the test results, the person has to practice safe sex and avoid sharing needles and devices for drug injections with others.

3.4. Arguments for and against testing

3.4.1. Medical reasons for testing Recent achievements in therapy for HIV infection have strongly changed the balance of medical opinion to the advantage of identifying HIV positive people before they develop AIDS. Starting antiretroviral therapy (combined therapy) while the immune system is still relatively strong can increase the chances that this kind of therapy keeps the infected person healthy for a long time. New therapeutic methods are being used according to the viral load, which is a determination of the HIV level in the blood. In infected people, the HIV level gradually increases and as the HIV level rises, the immune system becomes weaker. This makes the body unable to fight many diseases and the infected person can die from an opportunistic infection. A viral load test can quickly show if anti-HIV medications are working. Combined antiretroviral therapy is the most efficient in individuals who, after the beginning of therapy, showcased a high drop in viral load. The larger the drop of viral load, the higher the chance that the viral load will stay low for a longer period of time, enabling the person to remain healthy for a longer time. There are two reasons that some people had a larger drop in viral load at the beginning of therapy: • They used the most potent medication combination (HAART), • They had a lower viral load at the beginning of the therapy. The second reason strongly suggests that early treatment is favourable. It is important to note that accessible medication combinations have to be increased (on a day-by-day basis). A short delay of the treatment will, perhaps, not be damaging if the infected person is offered more potent medications between 6 months to a year. In any case, while many investigators and people with HIV are very optimistic about new kinds of treatment, this is only the beginning, and many lessons about the most efficient way to use these medications still have to be learned. Because of continuing scientific advancements, we can expect much better treatments in the following years. On the other hand, people who are not tested do not know if they are infected or not. Hence, HIV infection can progress in their bodies. They will not know if they are infected or not until they become ill. If HIV testing had been done earlier, they could have benefited from therapy to maintain health for a longer period. In our country, the majority of those hospitalised with AIDS related diseases did not know about their HIV status until they developed AIDS. If somebody is currently ill and a physician experienced in HIV infection thinks that HIV testing is useful for making a diagnosis, the potential value in establishing the patient's HIV status for treatment purposes lends a hand in making a decision in favour for HIV testing.

3.4.2. Arguments against testing Can the person come to terms with a positive test result? During HIV pre-test counselling, it is essential to talk to the client about the potential of a positive test result. Being told of a HIV positive test result can cause great distress for the client. Health wise, this stress is damaging on its own. This should be carefully considered. Some people may even become suicidal after receiving a positive test result. Despite the prospect of advancements in that direction, there is no comprehensive medication against HIV infection. There is a danger that a patient rushes into treatment, having the feeling that he is doing something effective against HIV infection, just to discover later that perhaps waiting would have been the better option. For example, people who start therapy with AZT will most probably delay the development of AIDS for just one year. Perhaps they would have gained more if they had waited to begin therapy with 2 or 3 medications. Unfortunately, patients who were only taking AZT have reduced treatment options with other medications, because of the early treatment and developed resistance. We have no knowledge if the same can happen with people who start with the current medication regimen. The chances can be better in the following years, so the desire for early treatment has to be carefully considered. The client has to be prepared for the therapy regimen against HIV infection, which requires discipline and a lot of motivation and additional energy because of the amount and frequency of medication administration and associated side effects. The client has to be informed of all the treatment options before he has a HIV test done. Be aware that somebody may be satisfied with the currently available options as well as with not knowing his/her HIV status. 3.5. Making the decision to have the HIV test Time is needed to allow consideration of all the questions connected to HIV testing. The person should be given a week or 2 to think about and decide on whether he/she wants to have HIV testing done or not. This is a very important decision, so there should be no rush about making it. Perhaps in addition, the client will find it useful to speak, confidentially or anonymously, a trained counsellor from the Centre for Prevention of AIDS and STI or AIDS Counselling Centre by phone. 4. VCCT in Particular Situations

4.1. VCCT after possible recent exposure to HIV infection During the past several years, it has become evident that therapy with antiretroviral medications during the initial weeks of infection can have a significant influence on the course of HIV infection. 4.1.1. Within 24 to 48 hours after exposure to HIV infection In countries with a developed health care system, the individuals that were possibly exposed to HIV within the last 24 to 48 hours are offered post exposure prophylaxis (PEP), which can completely block HIV infection if started right after the exposure to HIV. The treatment lasts for 1 month and does not have to last for longer since the aim of this treatment is to prevent the virus from entering cells in the body. The infection will be either stopped or established during this period. In some countries, the Health Ministry gives recommendations that PEP must be offered to health workers exposed to injuries with a needle prick. In this instance, PEP is started within 1 hour of exposure to the injury. Studies with individuals exposed to HIV infection through injuries with the prick of a needle have shown that PEP started 24 hours after the exposure reduces the possibility of infection by 80%. Clinics do not automatically offer this therapy to everybody who thinks that he/she is at risk of HIV infection. In order to determine if somebody is at a high risk of infection, it is necessary to obtain answers to the following questions concerning the route of exposure to the virus (the questions can be formulated in the following way): • Does your partner know if he/she is HIV positive? • Does your partner belong to a high-risk group? • Did ejaculation occur in your body? • Was the sexual act violent or traumatic, such as an act of rape? • Where does your partner come from (from a city region with high prevalence of HIV, from a small city with low prevalence)? • If you shared a needle, did you inject a large amount of blood into your veins? • Do you know the HIV status and viral load of the patient and the amount of blood or other bodily fluids that were injected, and where these were injected? • Are you prepared to undergo a therapy that will last for 4 weeks and accords to a strictly established protocol that can cause unpleasant side effects? It is essential that this therapy starts no later than 24 to 48 hours after exposure to the risk to allow the maximal chances of success. Naturally, it may happen that you were not infected even though you did not take the medication therapy. However, if it were determined later on that you were not exposed to HIV, using the medications just in case will not harm you in any fashion.

4.1.2. More than 48 hours after exposure to HIV infection In case of exposure to HIV infection more than 24 to 48 hours before asking for medical help and discovery of signs of HIV infection, many physicians recommend a 3 to 4 antiretroviral medication combination in order to prevent the spread of HIV. The interference in virus replication at this stage of infection can enable elimination of HIV from the body after a few weeks of therapy, or it may reduce the infection to an extremely low level for the rest of that person’s life. HIV P24 antigen tests can discover HIV infection in the 2 to 3 weeks after infection. If one of the antibody/antigen tests is positive but the confirmation tests on antibodies are negative, a P24 test or viral load test can be done. Viral load testing detects the presence of genetic material before the production of antibodies. Some clinics also perform an HIV genomic test for the detection of proviral DNA. The advantages of testing for HIV DNA or HIV RNA shortly after the onset of the suspected infection are that the period of diagnostic uncertainty is shortened and therapy can start earlier if needed. There are other methods for distinguishing recent HIV infection from infection which occurred a long time ago. At present, it is recommended that therapy administered during primary infection must continue without limitations. Some people can develop symptoms during this infection stage before the appearance of the antibodies in the blood. These symptoms include: • Prolonged fever (4 -14 days) and muscle pain, • Rash appearing as red spots on the body, • Sore throat, • Ulcerations on mouth and genitals, • Diarrhoea, • Heavy headaches, and • Photophobia. Other symptoms, such as paralysis, meningitis or opportunistic infections appearing as the consequence of weakening of immune response are infrequent. Symptoms of seroconversion can occur in 80% of the infected individuals, but the seriousness of symptoms varies. Some people report mild symptoms, like flue, within 30 to 60 days after exposure to HIV, while others develop a sufficiently serious disease to require hospitalisation. The longer the disease lasts and the more serious it is, the more likely it is that AIDS will develop during the next 5 years. These symptoms can also be caused by other infections such as flu, infections of glands and tonsils, and a serious herpes attack. If the client thinks that he/she was exposed to HIV during the past few weeks and has some of the symptoms, this treatment is an option that should be considered. However, it is still not known if this treatment will have any long-term effect. If the client wants to start this kind of treatment, he/she has to go immediately to the AIDS Counselling Centre. There is no need to wait for a doctor's referral, as a doctor perhaps may not understand the need for urgent treatment or the scientific basis for medication at this stage of infection.

4.2. VCCT after sexual abuse or rape VCCT can be conducted if the client is concerned about HIV infection because of sexual abuse or rape. If the client plans to file charges against the attacker and there is a possibility that the attacker infected the client with HIV, it is advisable to contact a solicitor as soon as possible after the attack. A solicitor can advise the client to have a HIV test done straight away, so that if the later test indicates HIV infection, the client will have a greater chance to prove that at the time of the attack he/she did not have infection. 4.3. VCCT relating to the choice of sexual relationships between permanent partners If a person is in a stable relationship, knowing his/her HIV status can be important in the decision of the kind of sexual activities that person can have with his permanent sexual partner. Many people prefer not to use condoms with permanent partners, but the only way to make such a decision and feel safe, is to have both partners undergo an HIV antibodies tests at the same time. This will help them to agree on the sexual activities that each of them will have with other partners and to be assured that unprotected sex among them will remain safe. Partners must also agree that if one of them uses a needle (to inject a drug), they must not share it with the others. If the client intends to have the test done with his partner, it is advisable to wait at least 3 months from the last occasion when one of them had unprotected sex with some other person. After all, during the 3 months after the infection the chance of emergence of antibodies is at its highest (even though the majority of people will produce antibodies within 2 months after the infection). This is the ideal scenario. Many people think that they can start having unprotected sex with their permanent partner without both being tested first. One study from Australia showed that close to 50% of gay men spent less than 3 months with their partners before they had unprotected sex for the first time. This can be an informed decision for them if they believe that neither of the partners had a risk of HIV infection in the past; or, they perhaps stopped using condoms without thinking about the implications, or believe that if infection is possible, it occurs straight away. In these situations, it is necessary to wait at least 3 months after the last act of unprotected sex. Depending on the results for both partners, the following possibilities are: - If both partners have negative test results and neither of them had unprotected sex with any other person(s) at least 3 (or 6, respectively) months before the testing, they can continue to perform unprotected sex and be assured that there is no risk from HIV transmission between them. - If both partners have negative test results, but at least one of them had unprotected sex with another person in the past 3 months (or 6, respectively), the risk of transmission still exists, as one person had unprotected sex less than 3 months ago and perhaps has not yet developed antibodies. If this is the case, the person that had unprotected sex will have to repeat the test 3 months after the last occasion when he/she had unprotected sex with another partner. If the test result remains negative, it is recommended that this test is repeated 6 months after the last act of unprotected sex. - If the partner who had unprotected sex with another person obtains a positive test result, the other partner must then wait at least 3 months after the last occasion when they had unprotected sex before having the test done, and have this repeated 6 months later. While waiting for the test results, they must use condoms. It has to be emphasised that the partner who until that point is perhaps not infected with HIV has no reason to reject the use of condoms. - If both partners are HIV positive, it must be explained to them that unprotected sexual acts can lead to HIV re-infections (not only an increase in virus concentration, but also the introduction of new, altered virus forms) which leads to attacks on the immune system and can lead to progression of infection and a more rapid development of AIDS. Therefore, the use of condoms for every sexual act is still recommended in such situations. Infection progression can be particularly more pronounced in women, since women are more prone to HIV infection and HIV re- infections than men, because of anatomical and physiological characteristics. It is obvious that these situations can be very complicated and stressful for both partners, possibly leading to uncertainty about their relationship. In situations such as those described, it is possible that all negative feelings concerning sexual acts outside of their permanent relationship will be more pronounced, and grievances from previous conflicts can surface again. The counsellor’s support is especially important here. If the partners are being tested together, the question arises as to how that will reflect upon their relationship, that is, how they would feel if one of them has a positive test result and the other a negative one. Not only will one partner have to face living with HIV, but both partners will have to cope with the fact that this will reflect on their relationship. Sometimes people cope well with this and continue to perform safe sex and learn new ways to support each other. Sometimes the pressure is too much and the relationship ends. The other possibility is that both may have positive test results. This can be very hard; especially if there is a suspicion that one partner infected the other. Unfortunately, most advice about safe sex and HIV testing ignores the emotional context in which unprotected sex and the decisions about HIV testing take place. The majority of relationships will get shattered to some degree from the lack of trust by and the uncertainty of one or both partners. The majority of people believe that they are able to put aside these kinds of feelings, but human behaviour consistently shows that this is very hard for many. In relationships with uneven personal power (for example, gender or age differences), some individuals can easily feel forced into performing unprotected sex and/or HIV testing without personal assessment. No words of wisdom can be offered to avoid such situations, as every relationship has its own problems, but one of the most valuable resources in helping to make the best possible decisions is the counselling service available in Counselling Centres. It would be very useful for both partners to come to a counsellor together if they consider testing before stopping with using condoms. When testing is done to enable partners to stop using condoms, explicit agreement on whether it is permissible for any of them to have sex with other partners, as well as on the type of sex allowed with other partners, is required. Partners have to agree as to what they consider safe sex and must adhere to their commitments.

4.4. VCCT during pregnancy If one of the partners believes that he/she might be in risk of becoming infected with HIV and the pair are considering having a baby, it is wise that both are tested for HIV. HIV can be transmitted from mother to child in 14% to 20% of pregnancies on average. This rate is increased up to 30% if the mother breastfeeds her baby. However, if the pregnant woman is aware of her HIV status, performing essential diagnostics and therapeutic procedures in a timely fashion, before, during and after the birth, can significantly reduce this risk - to below 10% (even below 2%). Unfortunately, because of inadequate approaches to VCCT for pregnant women, until 2005 almost all HIV positive mothers in our country have learned about their HIV positive status only after it was determined in their children and, therefore, were unable to receive timely treatment. If HIV infection is detected during the pregnancy, the pregnant woman has to have the options for the prevention of HIV transmission to her child explained to her, along with all risks for the baby that are connected with baby’s future HIV status. The mother is the one that decides to continue the pregnancy or not. In the majority of developed countries (also in our country from 2005, as part of the strategy against HIV), pregnant women are offered tests on HIV antibodies as part of routine prenatal care. Numerous tests are performed to ensure that mothers and their babies receive the best possible care. An HIV test is one of them. If a pregnant woman does not want this test done, she must tell this to her physician when he asks her about it - otherwise it will be performed together with the other routine tests for health assessment of the mother and her baby. Pregnant women have the right to refuse this test and also the right to hear all of the arguments in favour of and against the testing. This will help her to make a decision around the baby's birth. It is most effective if HIV testing is done in the first trimester of the pregnancy. Until 2005, HIV testing was only recommended for pregnant women that were considered to be exposed to a high risk of HIV infection. Until the new strategy is completely implemented, an HIV test may not be routinely offered to pregnant women as part of their prenatal care and counselling. Pregnant women can specifically ask for this test. The test is never performed without consent, obtained in advance, from the pregnant woman.

4.4.1. What if a pregnant woman has a positive HIV test result? If it is determined that a pregnant woman is HIV positive, she can transmit HIV to her baby during the pregnancy or labour, or through breastfeeding. It is obvious that HIV infection affects the health of a pregnant woman as well. However, currently there are very effective treatments that can reduce the risk of HIV transmission from the mother to her baby. Without treatment, the chances of HIV transmission are 1 in 7, but with new diagnostics and therapy, the risk is reduced to less than one in a hundred. Tests that measure the amount of virus in the blood of a pregnant woman and the status of her immune system (the ability of an organism to fight against serious infections) have to be performed. Based on the results of these tests, the physician will offer different medication combinations. Some physicians will recommend a caesarean section rather than a natural birth, as this further reduces the risk of HIV transmission to the baby. New mothers are advised not to breastfeed their babies (if they are able to provide the newborns with an adequate replacement for mother's milk), as HIV can also be transmitted to the baby through breast milk. Even if the HIV positive status of a pregnant woman is found late (in the second or third trimesters, when the option of pregnancy termination is not possible), it is an indication to start with diagnostics and therapeutic procedures, as it is generally accepted that in most cases HIV infection is transmitted to the baby during labour. After an HIV positive mother’s baby is born, numerous tests and treatments will be performed on the baby, to ascertain whether HIV infection occurred or not. This entails many additional visits to the hospital. The treatment for a baby lasts 6 months. After 6 months of treatment, it is usually possible to discover if the baby is infected or not. However, the final confirmation of a baby's HIV status is only possible after the baby is 18 months of age. Before that time, the baby can have retained his/her mother's antibodies, which disappear when the baby's own immune system becomes developed. If the virus is transmitted to the baby, it has to be noted that babies are very sensitive to HIV infection. It is known that about a fourth of children born with HIV develop serious diseases connected with AIDS or die during the first year of life.

4.4.2. Announcing HIV positive test results to pregnant women An HIV positive test result is probably an enormous shock for a pregnant woman. One possibility is that the baby's father is also HIV positive and the pregnant woman has to decide what and when to tell the baby's father. She can be angry if she suspects that he transmitted HIV to her or fear that she may have transmitted HIV to him. The situation is even more delicate if the father of the child is HIV negative. The pregnant woman can be afraid of what people will think if they find out that she is HIV positive. For this reason, it is essential that she talks to a physician, counsellor or midwife, who needs to know about the HIV positive result. The physician and other people in charge of caring for the pregnant woman are not allowed to tell anybody about her HIV positive status without her consent, but the information will be recorded on her medical record chart in the clinic.

4.4.3. What if a pregnant woman has a HIV negative test result? If the test for HIV has a negative result, it means that there are no HIV antibodies found in the blood of a pregnant woman at that time. In the majority of cases that means that there is no HIV-related risk for this pregnant woman and her baby. If the HIV infection occurred within less than 2 to 3 months prior, there has been insufficient time for antibodies to develop. If the client believes that she was recently at risk of HIV infection, she should talk to a counsellor from an AIDS Counselling Centre and then decide when the best time to have a HIV test is.

4.5. VCCT outreach work For better accessibility to VCCT, especially for groups sensitive to HIV infection, such as commercial sex workers, intravenous drug addicts, men who have sex with men, or groups not readily accessible such as the Roma people, VCCT can be organised outside the counselling centre(s), at locations close to where the target group lives or works. This activity can be organised as "drop-in centres", using special rooms with a secured confidential and pleasant atmosphere for the client or in a mobile, specially- equipped medical unit. With regard to the conditions for counselling and testing, so called speedy counselling (see chapter 12, Minimum Counselling Protocol) and quick testing are practised. If the result of a quick test for HIV is positive, the client is told the preliminary, positive result, with the recommendation to have blood taken at the same time for an ELISA test, which is done in the laboratory. The results of an ELISA test will be given to the client and HIV post-test counselling is performed in the next 24 hours. It is essential to pay particular attention during HIV pre-test counselling to the possibility of a combination of risks that can often be found in especially sensitive groups for HIV infection (for example, commercial sex workers and intravenous drug users).

4.5.1. The advantages of VCCT outreach work The advantages of VCCT outreach work are numerous: • Easier accessibility to VCCT for a large number of people that are at special risk of HIV, • The opportunity to carry out VCCT continuously through the network of regular outreach activities, • Establishment of trust in the field between counsellors and clients, • Higher reliability of data, • Possibility of quick intervention - education, further diagnostics and therapy, • The opportunity to influence behaviour - more meetings after completing first VCCT, • The opportunity to contact others from the environment - same age group/peers, sex worker's clients, • The opportunity to establish a system that connects clients with other government and non-governmental support organisations.

4.5.2. The disadvantages of VCCT outreach work Besides the listed advantages, VCCT outreach also has disadvantages and limitations: • Uncomfortable working conditions, • The use of only one type of test - quick test, • Limited time for counselling and testing, • The fear of discovering HIV status by people from their environment, for example, by "co-workers" of sex workers, • The loss or prohibition of work in the case of a positive result for a CSW, and • The increase in expenses for work due to organisation of fieldwork and procurement of mobile equipment.

4.6. Understanding safe sex and security measures in drug use A test for HIV is not the same as HIV prevention. Since the introduction of HIV testing, unfortunately, some have started to believe that having a positive test result is essential and sufficient in itself to ensure that an individual will start to practice safe sex. Worldwide studies have shown that there is no clear and universal connection between knowledge of HIV status and safe sexual behaviour. What is known is that the only thing that connects HIV testing and the adoption of safe sex is the quality of counselling before and after testing, and not the test result on its own. On the contrary, such misunderstanding of the purpose of HIV testing carries the risk of diverting the attention from the vital need for current safe sex education for all. A good counsellor can help. He/she uses the occasion to counsel about safe sex and safe drug use in the context of testing on anti-HIV antibodies. Questions that can be raised include: • Does a negative test result mean that an individual can freely continue having unprotected sex with a partner, believing that a negative result for one partner confirms that both partners in the relationship are not infected? • Does the person that is requesting the test mistakenly believe that sex with a prostitute using condoms is in essence more risky? • What precautionary measures did the individual use in the past? • What kinds of obstacles exist that prevent these precautionary measures from being practiced in the future?

Safe behaviour is necessary and the counsellor must insist on its adoption. The counsellor has to advise and support the individual in many different stages. Some will be at the very beginning of adoption of safe behaviour, while others will only need support. 5. VCCT and People Under 18

The majority of counsellors do not discuss the issues concerning counselling of minors. This is always recommended, whether the minor came to the counselling centre alone or accompanied by parents or friends, and regardless of his/her age. However, when testing minors for HIV, a large number of issues need to be considered, as numerous dilemmas emerge. If we try to consider all circumstances, advantages and deficiencies concerning HIV testing of minors, it is always necessary to assess what is gained by giving testing services (naturally always accompanied by counselling) and if this is in the best interest of the minor. With responsible assessment of the maturity, psychological state and the degree of vulnerability of the minor, the counsellor can, alone or in consultation with other counsellors, make a decision about the importance of a complete VCCT process. Having this in mind a decision is made about the need for testing. According to Health Protection Act, a child who has reached the age of 15 and who is capable of making a judgement and can her/himself give consent for proposed medical measures. In any case, the minor has to be involved in making a decision for the proposed medical measure according to his/her maturity and judgemental capability.

5.1. Counselling and testing of those between ages 16 and 18 In accordance with the above, it is recommended that clients who are not yet 18, but are between 16 and 18 years of age (older teenagers) can obtain counselling and testing without notifying their parents, unless the counsellor decides otherwise. During HIV pre-test counselling, it is advisable to make an agreement with the client that one parent (or guardian) will be notified and from that point on included into the counselling process and care if the HIV test result is positive.

5.2. Counselling and testing of those under 16 Those under 16 years of age can be counselled and tested for HIV without the consent of parents/guardians if two counsellors assess that this is in the best interest of the child. During the counselling and testing of a minor, it is important to have written documentations and notes about the actual course of counselling. The involvement of more counsellors in the entire VCCT process has many advantages, both for the objectivity and impartiality of the first (primary) counsellor and for possible unforeseen events.

5.3. Specific aspects of youth VCCT All people, including youths, have the right to know their HIV status. However, in the counselling and testing of youths some specific aspects of young people must be addressed as they could influence and direct both the counselling and testing processes. a. Do not underestimate the sensibility to HIV of young people. Young people are very sensitive to HIV, especially young intravenous drug users and those selling sexual services, that is, sex workers. Young people have to be encouraged to use the services of VCCT centres. Even if they do not want to be tested straight away, they should be invited to come back when they are ready. b. First visit to VCCT can be the only visit. The advantages of counselling must be utilised, since it may be that this could be the only chance for you to talk to this client about safer sex and to give him/her information he/she did not know and which is important for the reduction of risky behaviour. Make sure that he/she receives educational material, in case he/she does not come back, and referral to some other services (peer support) where they can receive more information and additional support. If possible, the young person should be offered an escort. c.Promoting the importance of finding out about HIV status. All those living with HIV need support in order to live more healthy and positively. Support from family and close friends can be of the utmost importance for young people. However, they can obtain this support only if they determine their HIV status. The counsellor must help them to understand the advantages of knowing their HIV status. However, do not forget that discovery of HIV status in some instances where the client does not have support from anybody is not recommended (for example, in the case of domestic violence). d. Take advantage of HIV negative results. A HIV negative test result gives an excellent opportunity for a discussion about reducing risky behaviour. Preventive education and counselling for risk reduction can help young people to consider their options and implement risk reduction. 6. Testing for HIV

See also chapters 1.4., HIV diagnostics, and 3.3., Basic information about HIV Testing.

6.1. Where to go for HIV testing The largest numbers of institutions where HIV testing can be performed in Serbia are in Belgrade and other larger cities. In Belgrade and in larger centres in Serbia there are also Institutes and Funds for Health Protection where adequate advice can be obtained for HIV pre- and post-test periods, regardless of the test outcome. However, there are only a few institutions and centres (counselling centres) where complete, adequate, confidential counselling before and after testing can be obtained; where the counsellors in this field have completed appropriate education; and have internal and external supervision and organised permanent ongoing education for all counsellors. (Examples of good centres for VCCT in our country are the Centre for the Prevention of AIDS and STIs and the Institute for the Protection of Student Health, Belgrade.)

6.1.1. The role and place of primary health protection in VCCT a. Family physicians In addition to referrals for HIV testing, general practitioners can offer counselling, but many family practice physicians would rather refer clients to one of the Counselling Centres for AIDS or a Clinic for Infectious Disease than perform counselling themselves. Many family practice physicians are not able to give counselling before and after testing for HIV, as they lack the time and education. If the client talks about HIV with family physicians, it will most probably be recorded in their medical records; the confidentiality of this information may be an issue. b. Physicians in Youth Counselling Centres Youth Counselling Centres formed in a large number of health centres throughout Serbia include physicians, medical workers and collaborators educated for work in voluntary and confidential counselling for HIV. They can perform quality counselling and refer the client for testing to a counselling centre or a Centre for VCCT with which they have established collaboration.

6.1.2. Choosing an institute for VCCT The client does not have to be referred to the counselling centre by his family physician and does not have to go to the closest counselling centre. The client can choose the AIDS Counselling Centre where he/she wants to have VCCT carried out her/himself. Usually, when the client comes to the counselling centre with the intent of having a HIV test done, he/she will be given the opportunity to have testing done anonymously or by using his full personal information. In both cases, this data are confidential. The physician, counsellor, asks questions about the sexual activities of the client and other forms of behaviour that can eventually lead to HIV transmission. This is also completely confidential. The physician can perhaps recommend checking for other sexually transmitted infections. If the client had unprotected sex, the chances are higher that he/she has another common sexually transmitted infection, as these are more easily transmitted than HIV. These other infections are in most cases easier to treat

6.2. When to perform HIV testing When using a common HIV antibody test, bear in mind that HIV antibodies in the majority of cases can be discovered in individuals that were infected with HIV about 2 to 3 months after infection (depending on the test type), and that less than 2% of the population need a longer period of time for the antibodies to develop. It is not known why some people need a longer time to produce antibodies. For this reason, the test must be performed at least 2 to 3 months after possible exposure to the virus and repeated after 6 months. Tests to determine the actual virus can detect the presence of the virus and therefore the infection after only 2 weeks after possible infection. These tests are not performed on a routine basis.

6.3. How is HIV testing done? HIV tests can be performed in different ways. The most common method is to take a small amount of blood from the vein in the arm. The blood is sent to the laboratory where it is subjected to the procedure that enables trained laboratory staff to detect rather quickly if the sample contains HIV antibodies. If the serum shows a negative reaction at first testing, it is certain that HIV antibodies are not present in the blood and that the client may not be infected. If the serum shows a positive reaction in the testing procedure, the test is repeated using the same blood sample and the same method. If the repeated test result is positive, the confirmation test is then performed using another, more sensitive diagnostic method (most often Western Blot, in the Clinic for Infectious and Tropical Diseases of the Clinical Hospital Centre of Serbia) whereby a positive HIV test can be confirmed. The counsellor in the counselling centre is given the HIV positive test result before the confirmation test is performed so that he can further explain to the client the procedure and confirmation testing. The test result is always given to the client in person, regardless of whether the test result is positive or negative. Test results cannot be given over the phone or sent by post. During the handing of the test results, regardless of the test outcome, the counsellor again talks in person to the client.

6.4. How long is the wait for HIV test results? The HIV tests are done in one to a few days, depending on the Institution where the test is performed.

6.5. Can the HIV test determine when the infection occurred? Common testing for anti-HIV antibodies does not give any information as to when the infection occurred, unless a prior negative test result exists. There are other tests, which can determine the age of HIV infection.

6.6. Testing at home The sale of any kind of equipment for HIV testing for home or personal use is not recommended. In the majority of countries with developed health care systems, such testing is illegal and will remain so. HIV testing must be done by qualified medical professionals and every test must be accompanied by counselling.

6.7. Validity of HIV testing The test validity correctly classifies the subjects as infected (or ill) and healthy. The anticipated test value - considered by many as the accuracy - also depends on how common or rare HIV is among the tested population. The precision of each test is usually described in terms of "sensitivity" or "specificity".

6.7.1. Sensitivity of HIV tests The sensitivity is the test ability to mark infected individuals as positively infected. A basic ELISA test for HIV can be very sensitive, which means that if HIV antibodies are present, the ELISA will detect them. Performing this test on a large number of samples is also economical, making it very convenient for initial screening for HIV infection. Commercial tests usually cover a series of antibodies, including both HIV-1 and HIV-2. The latest recommendation from the WHO is that ELISA tests are not used unless they can detect 100% of known positive samples on a referent plate of 203 HIV-1 and/or 60 HIV- 2 samples.

The main limitation of antibody test sensitivity is that for a short period the body “leads” itself to elevate an immune response to any kind of infection since it binds the existing antibodies to the reagents. In addition, during the first few weeks after infection, the antibodies can be at a low level in the blood and perhaps cannot bind as well as the antibodies produced later on can, therefore remaining undetectable during the so-called window period. These limitations are partially resolved with the use of improved antibodies in HIV ELISA tests. Modern, current generation tests for the detection of HIV antibodies in infected people will mainly give positive results after 6 weeks from the moment of infection, despite the fact that the existence of a possible window period of up to 3 months (in some exceptional cases even more) still remains.

6.7.2. Specificity The specificity of a test is connected with the number that shows that seronegative blood samples are accurately identified as negative. The WHO does not recommend the use of tests whose specificity is less than 95% when tested on the African serum plate, but in practice the majority of commercial tests are much better. An example is the test specified as "98.8% specific". That means that 1.2% of the samples - or 12 samples in a thousand - will turn out to be positive when tested, while they are not actually positive. This test has to be used alongside other tests that utilise various antigens in order to obtain confirmation. This second test does not have to be more specific (but it helps if it is), so that the chances of a double false-positive result are reduced to negligible levels. The most common way to achieve this is to use a Western Blot test or an IFA test.

6.8. False positive and false negative HIV test results 6.8.1. False positive HIV test results There are two reasons for false positive results: cross-reaction of antibodies and human error. It should be noted that this kind of result occurs very rarely. Sometimes antibodies can be present without there being an HIV infection, resulting in a HIV positive test result. In the early years of HIV testing, this kind of false positive result occurred more often. Some diseases can induce false positive results. Nowadays this is very rare since various means (tests) are used for testing. Cross- reactivity can occur with one type of test but not with the others, so the laboratories that perform testing commonly use 2 or 3 various test types in order to confirm positive results. However, in every laboratory there is room for human error. This is the reason why blood taken is usually divided into two parts, so that, if one test has a positive result, the confirmation test can be done on the other sample. This eliminates the chance of positive results being a consequence of a laboratory error. 6.8.2. Undefined or weak positive results of HIV tests An undefined result is one that shows a weak positive reaction, due to unknown antibody cross-reactions or a technical error, or because of the presence of low levels of HIV antibodies. In the latter case, weak positive results can occur immediately after the infection, as the virus is composed of various proteins and antibodies can be formed on any of them. In the case of HIV, some blood proteins become easier and quicker to detect than the others. If the antibodies were detected on only one protein and not on the whole protein spectrum, the result will be weak positive. 6.8.3. Diseases that cause false positive or false negative HIV test results Are there any diseases that can cause a false positive result in HIV testing? In a small number of cases there are. Hepatitis B vaccination and vaccination against influenza can possibly and temporarily cause false results. An immunoglobulin infusion can also give false positive results. There are no data that infection with influenza can cause false positive results. False positive results are also observed in a small number of patients with lupus, cystic fibrosis, chronic liver diseases and with dialysis patients. Can a disease cause a false negative result? A person with severe immunodeficiency (probably one with pronounced HIV infection to start with) may not be able to produce antibodies. In this situation symptoms and signs of AIDS will most probably be seen if the patient’s immunodeficiency is connected with HIV. Otherwise, a disease does not cause a negative result.

6.9. PCR test or HIV viral load test

PCR is testing with a polymerase chain reaction. This is a test type that detects genetic HIV material. It is possible to detect the presence of a virus in the body even if it is not replicated. This is a very sensitive test, where problems can arise due to its sensitivity to contamination. PCR testing methods are being developed so that false results are becoming very rare. PCR is usually used to detect HIV infection in children born to HIV positive mothers. The usual ELISA test is not appropriate for these children, as HIV antibodies found in babies during their first months of life originate from their mothers. This test is not used as a routine HIV test on adults.

6.10. HIV genome test HIV genetic test detects proviral DNA. Even though false readings can appear, the test can be used to identify primary HIV infection.

6.11. P24 antigen test P24 is a HIV antigen that can be detected in serum about 2 to 3 weeks after HIV infection and approximately one week before HIV antibodies can be detected. P24 is expensive and is not used routinely. However, due to the inclusion of the P24 antigen into the "fourth generation" of ELISA tests for HIV antibodies, these tests are becoming more common. 7. Confidentiality

When we talk about voluntary and confidential counselling and HIV testing, confidentiality is the component that underpins this kind of work, forming a part of the discussion between the counsellor and the client. Confidentiality is an integral part of counselling and the majority of experts believe that special emphasis on it is not required. In defining confidentiality and the confidential discussion during counselling, it is necessary to choose the terminology carefully and never replace the term "confidential" with the term "secret" as far as talks between the client and the counsellor are concerned, as secrecy is most frequently connected with some activities that are not allowed or not accepted and can lead to discrimination.

7.1. Confidentiality in an AIDS Counselling Centre (Centre for Prevention of AIDS and STIs) Every counselling centre or Centre for the Prevention of AIDS and STIs, has to set protocols (or regulations) to work by, and has to adhere to the basic principles of VCCT, which include anonymity, confidentiality and voluntarism. These centres represent the most competent, confidential parts of health services where HIV infection is concerned.

7.2. Notifying family physician/physician of choice about HIV status If the client is infected with HIV, it is desirable to notify his/her family physician. The client can do this but is not obliged to. This depends on his/her relationship with the family physician and their mutual trust. If the client is HIV positive and has symptoms of a disease, then a recommendation will be given to have him/her notify his/her family physician. This is recommended for medical reasons, as it could avoid a potentially dangerous delay in diagnosis and appropriate therapy. The client should be completely reassured that physicians are fully aware of the importance of confidentiality and that they are sufficiently well informed to know that a positive test result does not mean that the patient has AIDS. Currently, in Serbia, all HIV-infected individuals and individuals diagnosed with AIDS are treated with antiretroviral therapy in an outpatient clinic at the Centre for HIV/AIDS at the Institute of Infectious and Tropical Diseases of the Clinical Hospital Centre of Serbia. For all other health care services they visit their family or hospital physician.

7.3. Notifying other hospital physicians about the patient's HIV status If the client is referred to other hospital wards, the specialists will probably be told about their test results. This information will most likely be recorded in the hospital documentation, which is less confidential than that of the counselling centres. The test results can therefore be accessed by any physician or nurse, or by anyone who sees the medical chart. Even though the client knows that a HIV positive result is not the same as having AIDS, he needs to try to talk to the physicians about it. 7.4. Who to share HIV positive test result with It is important for everyone, including those who are HIV positive, to have someone with whom they can talk openly, someone they can really trust. Consideration should be given to who can be trusted before obtaining the test results. A positive test result is always a shock and the initial reaction is to rush into sharing this information with people you would not normally tell if serious thought had been given to the situation. You can always tell someone later, but once told it cannot be untold. The impact on interpersonal relationships must be considered when the decision is made to tell someone. It is not necessary for an employer or co-workers to know; they don’t even need to know that a HIV test has been carried out. Just finding out that a worker or colleague has been tested for HIV can cause some people to behave badly due to their lack of knowledge or from personal biases. 8. VCCT for Particularly Sensitive Groups

8.1. Specific questions for gay men during VCCT VCCT within the MSM population has a particular burden to overcome. Due to extensive stigmatisation towards this sexual orientation, there are difficulties for gay men with talking openly during VCCT counselling, as are there difficulties for the counsellors, who need to overcome the culturally established taboos and biases. However, well-trained VCCT counsellors are able to create an atmosphere of confidence and understanding for the client, as these are prerequisites for VCCT. In anticipation of often experienced stigmatisation and discrimination, gay or bisexual men do not readily ask for health care services, they do not turn to AIDS counselling, or if they do, they hide their sexual orientation. Fortunately, positive experiences of AIDS counselling have found their way through MSM peer channels. In turn, this has resulted in an increase in requests for HIV testing among the MSM population. Occasions in which somebody goes through HIV testing just because it might be a prerequisite for starting having unprotected sex in a particular relationship aren’t very rare. Obtaining this kind of consent must be based on the assumption between partners that there should be no unprotected sex outside the relationship, as well as understanding about what is acceptable sexual behaviour outside the relationship and what is not. For example, one partner might have concerns about the safety of oral sex, while the other does not. Since this kind of disagreement can cause excessive tension in their relationship, both partners need help in expressing their attitudes, a very important part of HIV pre- and post-test counselling. Counselling the partners can also be a confidentiality issue where HIV testing is concerned. For example, one partner may not have told the other certain aspects of his sexual history. Both partners should be encouraged to have joint counselling after negative or positive test results. In this way assurances are given that both partners have understood the implications of the test results on their relationship. For some gay and bisexual men, especially the ones who are at the beginning of sexual activity, it would be useful to emphasise that tests on HIV antibodies should not be considered a part of the standard monitoring in the same way as blood tests for syphilis and hepatitis B are. Having a pattern of routine testing on HIV antibodies can be psychologically damaging for some gay men, as it may show them that HIV infection is associated with gay men and can subconsciously give them a feeling of being powerless. For other gay men, a pattern of repeated testing whereby a negative test result is obtained after having had unsafe sex might mean that safe sex is only practiced for a short while before returning to having unsafe sex. When they again obtain a HIV negative test result, they may pay less attention to safe sex and consider themselves as mysteriously immune to HIV infection, or believe that it is just a matter of time before they are infected since they have difficulty in adhering to safe sex. In such situations, testing may not always provide a solution to the question of how they can protect themselves in the future. It is a good idea to include specialised support or counselling groups for gay men who want to make their sexual behaviour less risky in the future. Gay men will have all the arguments for and against HIV testing explained to them and will be well informed about HIV infection, but may refrain from having the test for a long time before they make the decision that it is essential to know their HIV status. For many of them the need to know will prevail over wanting to ignore HIV status. This may be a consequence of entering into a relationship with a HIV positive or HIV negative person in which the attraction to having unprotected sex must be considered. The decision to have HIV testing done might also be a consequence of new information about the treatment of asymptomatic HIV infections or discomfort in general health. Under these circumstances, the counsellor needs to recognise that disbelief can, paradoxically, turn into a feeling of security and that a well-informed individual will probably suffer from shock when he is given a positive diagnosis just as much as someone who is given a positive diagnosis without having previous knowledge of such information.

8.2. Specific questions for women during VCCT Women can have difficulty in understanding the risks they face. Many women will participate in risky behaviour (unprotected sex with men), but they are often not in a position to assess the risk of HIV. Women in this country who live with HIV/AIDS come from different backgrounds. The majority are not aware of the high-risk behaviour of their male partner, for example, having sex with other men or injecting drugs. Just because a woman did not have a partner that belonged to any of these categories does not mean that she is not at risk. Perhaps she is unaware of any past risky behaviour, or her partner can deny having behaved risky. It is very important not to avoid any discussion about the possibility of a positive test result for women who counsellors determine may have been at some risk. Examine strategies for safe sex together with the client. Does she currently have a strategy? Is she able to distinguish between good and bad past experiences? Are there any additional difficulties, such as contraception problems (oral contraception) or abuse and violent behaviour of their male partners? There is very little discussion around female homosexual relationships during "routine" visits to the physician. Therefore, there is an opportunity during VCCT counselling to offer support and encourage discussion with women who engage in sexual acts with other women. It is necessary to emphasise practical examples and concrete protective measures, which are rarely given in the existing literature written in our language (for example the use of personal condoms during the exchange of sex toys, the use of barriers, /female condom, soaked cellophane, etc.). Carefully check the female client’s reasons for HIV testing. Some women request testing as they have come to know that their male partners have engaged in risky behaviour (for example infidelity). In the event of a negative test result, it is important to assess to what extent the tested woman is ready to accept the information about future, safe sexual behaviour. Some women want to have children. This is possible but it does not have to be associated with the request for HIV testing. All women in their reproductive years (of any sexual orientation) need to obtain information about HIV during pregnancy. This must include all the information about the risk of HIV transmission from mother to child, options that can reduce transmission risk and considerations about the choices of labour. If a woman asks for HIV antibodies testing in order to find out her status before becoming pregnant, it is important that the potential father also considers HIV testing. More and more women are being tested in pregnancy. It is important to understand the needs of women during this period and not to force women to have the test done. See also chapter 4.4., VCCT during pregnancy. 8.3. Specific questions for drug users during VCCT Just because the client has in the past or is currently injecting drugs does not automatically mean that he was at risk of becoming infected with HIV. The first step is to specifically assess any risky behaviour with the client before making any conclusions about risks connected with drugs or sex. It is important to reinforce the strategies the client already uses concerning safe sex and safe drug use. It is easier to build upon the existing strategies than to make a complete new strategy. Is the client too drugged or drunk to be able to comprehend the information? Would it be better to move the counselling to another day? Carefully check the client’s reasons for having HIV testing done. Do they have external pressures or is this a personal, free choice? Pressure can come from a partner or family members. This pressure can be most pronounced in hospital or prison settings. Even though it is important that drug users obtain the same information about employment, insurance, mortgage and international travel, it is important to bear in mind that drug injection in itself can be an exclusion factor for many activities, whether or not the HIV test was done. In addition, more and more employers are excluding drug users at the employment selection stage, whether or not they inject drugs. Does the client use drugs regularly? How much influence can a positive test result have on his drug use? Has the client started a therapy programme recently or started to take drugs more carefully? In this case, it would be the best to let the client stabilise in the new regime before HIV testing.

Has the client recently joined a detoxification or rehabilitation programme? It would perhaps be best to let the client adjust to the new programme before HIV testing. The reasons for the client's desire to have the test done should be checked - was he/she encouraged in a rehabilitation centre? If so, why? For many people, the information given during the counselling before testing can be confusing and complex, findings that are heightened through anxiety and factors connected to drugs and alcohol. It is often useful to reinforce verbal information by writing them dawn of drawing them and by proposing that the client write them down himself, or by using a leaflet. The client should be asked about the person he plans to confide in while waiting for HIV results. Many people exaggerate and open themselves up too much in anticipation of a negative result. This can have serious consequences around confidentiality if the HIV test result is positive. 9. HIV Post-Test Counselling

Counselling after HIV testing must include providing notification of the test results, offering support in the client’s understanding and acceptance of the test result, reconsidering prevention and treatment aspects, and scheduling a further session or talk when the excitement or shock caused by receiving the test result has been stabilised.

9.1. Announcing a HIV positive test result There are no easy answers and best ways to proceed when announcing bad news. This also goes for announcing a HIV positive test result to the client. Each individual will have different initial reactions. The majority of clients will accept the information about their HIV positive test result with disbelief, or feelings of anger, fear, sadness or panic. Almost everyone who receives a HIV positive test result will experience immediate shock and, at first, will not be able to talk to the physician (counsellor) who is giving them the results. The clients should be left to let the results sink in and their consequent reactions should not be suppressed. There should be no delay in the announcement of the test result. Tell the patient straight up that the HIV test result is positive. At the same time, it is necessary to leave some room for expressing the hope that the result might be a false positive one and that the test must be repeated. During announcement of the result, listen carefully to the client and make it clear that you are there to offer any support needed. During the first consult, it is important to make sure the client tells you which person he/she trusts and from whom he/she can get support. The client should be informed about the possibilities and the achievements in HIV/AIDS therapy. Almost everyone who receives a HIV diagnosis will experience immediate shock, making it more difficult for the client to deal with the complicated information and topics such as progression of the disease. You need to check if the client knows who to go to right away to arrange the start of appropriate therapy. It is important to schedule a next visit of the client soon afterwards, as well as to schedule other future meetings. It may help to give the client some written material. If the client came with someone else (partner, friend, relative, parent...), check if the client also wants the counsellor to talk to that person.

9.2. Announcing a HIV negative test result Bear in mind that in the initial burst of relief after receiving a negative HIV test result, the client may not understand all that is being said afterwards. Therefore, it is always a good idea to schedule in at least one more meeting, if possible.

The counsellor should make sure that the client is aware that a HIV negative test result is not a guarantee for the future. It does not mean that the client will automatically adopt safe sex practices or safe drug use. The counsellor must play a vital role here in bringing the client’s attention to all the risks associated with his/her behaviour learned from him/her during the HIV pre-test counselling.

9.3. Notifying a partner about the outcome of HIV testing Notifying the partner is a very important part of voluntary and confidential counselling and HIV testing. The need to notify the partner originates from the fact that early diagnosis and treatment of HIV infection can reduce morbidity and mortality. It can also reduce the possibility of highly risky behaviour. Counselling and testing for HIV antibodies should be routine practice for sexual partners and those sharing needles and syringes with HIV-positive patients, even though the counsellor must use his influence to convince the clients to reduce their risks from HIV infection by performing safe sex and safe behaviour during drug injection. It is desirable for the HIV infected client to inform his/her partner(s) in person about the test results, letting them know about their personal HIV status. The health care provider (physician, counsellor) and the client must agree that in the event the client is infected with HIV, the client will inform his/her partner(s) about their personal HIV status. An agreement can be reached that the counsellor (health care worker) informs the partner, bearing in mind all ethical and legal issues that need to be addressed. Possible advantages of partner notification: • To warn the people about the possible risks they may be unaware of. For example, many women are not aware that they are under considerable risk of HIV infection (if their male sexual partner practices risky sexual behaviour). Following contacts can warn them about risks they cannot easily ignore. • More economical use of the resources, i.e., a less comprehensive range of public education campaigns amongst a population with a low prevalence of HIV. • Epidemiologically useful research of the spread of HIV and data collection about transmission paths. • Medical advantages: bring people under medical monitoring much earlier than otherwise. Possible limitations: • Breach in counselling confidentiality around HIV testing and diverting attention from the needs of individuals who have tested HIV positive to that person’s partner(s). • It would probably be seen as a substitute for a much more aggressive campaign of public education, in the same way as HIV testing was seen that way. • It is only efficient in a sexual network with obviously low rates of partner exchange and not effective among sex workers and homosexual men and women. • It influences the individual's rights not to know that they are infected with HIV. • Could invoke a feeling of atonement by those who consider themselves at low risk, whether heterosexuals or monogamous gay men. Notifying partners is a challenge for any health care system. The attitude toward those at risk of HIV infection, social values, capability of communication and degree of trust that the client has in the system, present key elements for the success of any partner notification programme. 9.4. HIV and AIDS treatment possibilities Every counselling session that accompanies a positive diagnosis gives the opportunity to point towards new achievements in the treatment of HIV infection, whether or not the client asks for such information. Newly diagnosed persons will be referred to the Institute for Infectious and Tropical Diseases of the Clinical Hospital Centre of Serbia, for further monitoring and treatment. In practice, there will be a difference for each client in the speed in which the test results of, for example, viral load or CD4-cels count (number of CD4 lymphocytes) are being given after diagnosis. In the initial months immediately following a positive HIV test result, this information has a crucial bearing on the discussion that the counsellor and the physician will have with the person who has been diagnosed with HIV.

9.4.1. Diagnostics during treatment of HIV and AIDS Determination of the CD4 lymphocyte level and the concentration of the viral load present key parameters for the start of the administration and the type and combination of retroviral therapy. If the viral load is low (below 10.000 copies per ml), many physicians will believe that the treatment is not urgent! If the number of CD4 lymphocytes falls below 200 to 250, they will recommend an immediate start of the antiretroviral therapy. If the number of CD4 lymphocytes is very low (below 50), many physicians will insist that antiretroviral therapy should begin whether the viral load is high or not, because of the very high risk of the development of symptoms connected with AIDS. Antiretroviral therapy can prevent further destruction of the immune system.

9.4.2. Is it better to wait until more effective treatments are developed? It is important to know that HIV infection therapy standards will most probably continue to be improved in the coming years. Every month that passes brings more information on how to best use the available medications. The fact is that people who delay the start of the therapy may have better treatment options in the next six months or year as long as they continue to have regular monitoring of their viral load and CD4 count. This information must be emphasised to those recently diagnosed as a reminder that, perhaps, they should not decide quickly on starting therapy. They may have a strong desire to do something after discovering that they are infected, but this has to be mitigated, and they should be made to understand that chances of successful treatment will continue to improve, provided that viral load and CD4 count are monitored and that timely reactions will follow. 10. HIV Counselling Process (Instructions for the Counsellors)

First contact between counsellor and client (general principles): • Greet the client and introduce yourself • Emphasise that the entire counselling and testing process is confidential (it is very important that the client understands this) • Explain the counselling and testing process Reminders for the counsellor during HIV pre-test counselling: • Greet the client • Question the client about his reasons for getting tested • Carefully, discreetly and with encouragement examine the risk history:

- Risky sex - personal and partner's - Intravenous drug use, personal and partner's - Blood (blood products), transplantation - Possible not-sterile procedures - tattooing, injections, scarring - Additional risk

• Examine the window period and the time passed since the last risk of exposure • Examine how well informed the person is about HIV and AIDS • Examine the client’s understanding of the HIV test and its implications:

- Marriage - sexual partner(s) - Pregnancy - Relationships (do the parents or sexual partner(s) know about the testing?) - Work, school - Stigmatisation - Available social support - Emotional capability

• Explain all that is known about HIV testing and the procedures involved • Talk about the values of HIV testing:

- If the result is negative, explain what that means (confirm that there are no HIV antibodies, remove suspense) - If the test is positive, explain what that means

Reminders for the counsellor during HIV post-test counselling: • Do not beat around the bush; be direct when you notify the test result whatever the outcome: - When the test result is negative, discuss the window period and potential risk reductions - When the test result is positive, use simple language when explaining the results and give the client enough time to accept the outcome and react to it at a comfortable pace - Explain the existence of HIV antibodies and the need to perform confirmatory testing, about the possibility of cross-reactivity, their personal protection, protecting their partner(s); help them to come up with a plan which includes their loved ones (treatment); provide emotional support - Discuss who should know if the result is positive, and how to tell them (try to invite that person to counselling to explain the situation) - Try to establish a strategy for solving or coping with future problems, short-term and long-term strategies - Talk about future prevention.

• Safe sex and the use of condoms • The use of clean needles • Options for management of personal risks Assessment: • Ask the client what the reason for his/her visit was (what worries him/her) • Ask who else knows • Ask who their personal influences are • Let the client let their emotions out Intervention: • Work together • Identify initial and subsequent priorities • Identify options for current solutions of the problem and those possible at a later date • Emphasise prevention • Identify a suitable support system • Encourage the client to face the problem Summary: • Summarise what has happened and what has to be done about it • Emphasise to the client that your door is always open to him/her • Verify and clarify that the client completely understands the situation • Schedule the next visit • Greet the client with the words "Until next time"

Basic Skills in Counselling • Active listening (thinking out loud, nodding your head) • Stimulate conversation ("Yes, please continue....") • Understanding ("This must be hard to accept...") • Confirmation ("I understand that this is not easy for you...") • Efficient investigation ("Please tell me exactly what you know...") • Identification with the client ("I see that you are very worried...") • Appreciation of the client’s feelings (listen carefully while the client speaks) • Paraphrasing ("That means that you are saying ...") • Repetition of positive qualities ("You are lucky that you have a girlfriend...") • Challenging ("Is that what you really want to do...") • Emphasising ("Can I emphasise the following...") • Structuring ("There are three main questions you have to face...") • Summarising ("Let us summarise, there are questions that need to be answered...")

Discussion during the counselling is: • Specific • Focused • Purposeful Consequently, the counselling should: • Clarify and face the problem • Offer information • Enable the ability to make choices about realistic alternatives • Stimulate motivation and decision making Common characteristics and the requirements of the counselling: • Timing • Acceptance and appreciation • Accessibility • Consistency and accuracy • Tactfulness • Confidentiality 11. VCCT Evaluation

Worldwide, the largest number of analyses of counselling and testing for HIV is trying to assess the effect of VCCT on the client’s behaviour, with evaluations before and after intervention. Very few studies initiate questions on how well the VCCT service being offered works, how the clients and providers evaluate the services or what the economic benefit of such services might be. In order to increase the quality level of VCCT, it is essential to have permanent and comprehensive evaluations of VCCT work, to progress towards improvements relating to the needs of the clients and to align with new discoveries and technologies. For any evaluation to give results useful to improve the VCCT programme, it may be wise to begin with the programme’s goals. Bearing this in mind, two main areas have to be evaluated: 1. Service provision - How would you rate the voluntary and confidential counselling and HIV testing? 2. Programme effectiveness - What is the outcome of the programme, including the long-lasting impacts on the population using the services of voluntary and confidential counselling and HIV testing? After establishing the VCCT goals, it is necessary to define clear indicators for the monitoring and evaluation of VCCT services.

11.1. Evaluation of VCCT service provision An important source of information for evaluating the services provided is the interview with the client about his/her satisfaction with the programme. The other aspects of VCCT services that need to be evaluated are the adequacy of the counselling protocol, qualifications of the VCCT personnel and the evaluation of accessibility of the client services.

11.2. Adequacy of the protocols for HIV counselling HIV counselling and testing protocols may differ, depending on the aims and framework of the programme. Evaluations are essential to be able to see if the services are in accordance with previously set protocols and how satisfied clients are with the services provided. Regular monitoring of counselling work is very important for quality assurance of the services provided and to prevent excessive counsellor exhaustion (burnout syndrome). Questions that should enable a proper response to the framework for counselling competence in protocol administration include: • How well do counsellors administer counselling protocol? • Do the clients believe that confidentiality is secure during the procedure? • Have adequate evaluations of risk been carried out? • Has adequate information about all risks of HIV transmission been provided? • Were all risk reduction possibilities revealed? • Was the meaning of the HIV test explained? • Was the HIV test result adequately explained to the client? • Was adequate psychological support offered to the client, especially those whose tests came back positive? • Was the client adequately directed toward further medical treatment? • How long was the wait for the counsellor during visits to VCCT? • How was the waiting structured? The analysis of the responses to these questions will enable the quality of the VCCT services provided to be improved.

11.3. Adequacy of the protocols for HIV testing The protocol for HIV testing has to provide maximum reliability and validity in accordance with local conditions, i.e., availability of adequate testing materials. Testing protocols have to be in accordance with the recommendations from UNAIDS and the World Health Organisation. The testing protocol evaluation must provide answers to the following questions: • How consistently is the protocol applied? • How valid is the HIV test concerning its specificity and sensitivity? • How long do clients have to wait for test results and does this waiting time suit the clients? • How much does the testing protocol cost? • Is the testing protocol aligned with local conditions?

11.4. Indicators for successful VCCT evaluation

1. Process indicators (based on provided services):

• Percentage of people who know about the existence of VCCT, • Number of people who were counselled and tested, • Percentage of those who were counselled, tested and who came to get their test results, • Percentage of people whose result was positive, who were referred to other institutions for further treatment, care and support, • Percentage of people who were counselled and tested and who informed their partners. 2. Efficiency indicators: • Percentage of clients who received VCCT, who changed their risky behaviour connected with the possibility of HIV infection and other STIs, • Assessment of trend movement of HIV and STIs in populations where VCCT operates, • Reduction of stigmatisation and discrimination against people living with HIV/AIDS, • The increase in community support for people living with HIV/AIDS. 3. Indicators of long-term effects of VCCT: • Changes in incidence and prevalence of HIV in a population where VCCT operates, • Decrease in HIV infection transmission from mother to child with pregnant women who participated in the programme, • Change in social attitude towards HIV/AIDS where the programme is realised.

In order to secure permanent quality and improvements to the programme, the evaluation of VCCT services must be a continuous process integrated into the service from its inception. Evaluation must be focused on key aspects of the services, such as the use of the service, competence of the counselling protocol and HIV testing and their applications, the quality of work by personnel and general accessibility to the services. Long-term results that pertain to the changes in behaviour, reduction of stigmatism and discrimination and the increase of community support also have to be evaluated occasionally. 12. Minimum Counselling Protocol

In situations in which we want to perform voluntary and confidential counselling and HIV testing and where we have little time to spend per client (campaigns with large responses, such as Worlds AIDS Day actions, fieldwork, evening counselling and testing events) we resort to the application of the minimum counselling protocol, which we call "quick counselling". The minimum counselling protocol contains two components: • - components of HIV PRE-TEST COUNSELLING, and • - components of HIV POST-TEST COUNSELLING

I. Protocol component: HIV PRE-TEST COUNSELLING Time in minutes 1. Introduction and explanation of the counselling process 1 -2 2. Assessing the client's self-awareness about the risks 2-3 3. Investigation into the specifics of most recent risky behaviour 2-3 4. Repetition of previous experiences about risk reduction 1-2 5. Summary of eventual existence of risk 1-2

Total time 7-12 II. Protocol component: HIV POST-TEST COUNSELLING Time in minutes 6. Provide and give the test result 3 (10/15) 7. Identify sources of support and provide additional reliance 1-2 8. Negotiate a plan about risk reduction 2-3 9. Enable follow-up meetings on an as-needed basis 1 Total time 7-15/20

12.1. HIV pre-test counselling in 7 to 12 minutes

12.1.1. Introduction and explanation of the counselling process (1-2 minutes) In order to establish a good initial interrelationship with the client, the counsellor must have a positive attitude, showing true concern and empathy towards the client, express understanding of client's risky behaviour and that he believes in the possibility that the client will initiate the process of risk reduction. Support and confidence will give a positive setting for further counselling. The counsellor has to relate to the client in a professional way, with respect and understanding that some questions (for example, sexual issues and drug use) may be of a sensitive nature for the client and a painful topic to discuss. The content and purpose of counselling must be clear to the client

Protocol Content Hello, I am (it is obligatoryto shake Introduce yourself to the client’s hand). Today we will talk about your concerns and/or fears the client about HIV or STIs, or (especially with pregnant women) if there are reasons to be worried about HIV infection. My role as your counsellor is to work Explain your role together with you to identify potential or actual STI or HIV risks, and together we can investigate issues connected with these risks. Consideration We will talk twice. This time for about 10 minutes and then ______(in a of testing few hours, or again the next afternoon process - depending on the work protocol). At that time we will have post-test counselling and you will be given your results (that is of course if you want to have the test done). Consideration The test result could be positive or of testing negative. Though you could be worried when waiting for the test results, I process would like to let you know that the test is completely thorough and final if it returns negative; if it is positive, it will be a preliminary test result as it is necessary to carry out a second test for confirmation. Accentuate the session content Today we will talk about your potential Examination of and/or actual STI and HIV risks and HIV/STI risks about how, at this moment, you are able to try to reduce this risk. Consideration of Before we continue, do you have any current questions questions or concerns that you would and concerns like to talk about right now?

12.1.2. Assessing client's self-awareness about the risk (2-3 minutes) Engaging the client in initial investigation about his/her risky HIV-related behaviour. The counsellor tries to focus the client's attention upon his/her behaviour and the corresponding risk of contracting HIV/STIs. The counsellor’s approach in these session components will change based on the questions that the clients ask about HIV risks: 1. Increase self-awareness; 2. Consider discrepancies (when beliefs and acts are in disagreement) and ambivalence (mixed feelings) concerning risk reduction; 3. Increased self- efficiency (belief in one’s self or readiness to do something). In this part, the counsellor tries to use the client's concerns around HIV to encourage him/her to consider questions with regard to HIV. The purpose of this is to focus the client's attention upon his/her risky behaviour, increase his/her degree of concern about such behaviour and to increase self- awareness about the risks. Increasing client's self-awareness about the risks Protocol Content Identify the Have you come on your own or by reason for client's referral? Why do you think that you arrival might be HIV positive? Focus the client's Are you familiar with the term "safe attention to risky sex", and how do you understand it? behaviour Are you practicing safe sex? Assess the degree What kind of behaviour made you of client's concern think about connecting it with the risk of HIV transmission? When you had unprotected sex (or some other risk), did you think that you were exposing yourself to danger from HIV? Talk about the client's Have you been tested for HIV before? history HIV testing and If yes: What did you experience? Did behavioural changes the counselling or test result influence in regard to the your behaviour or feelings towards result HIV?

12.1.3. Investigation into the specifics of the client’s most recent risk incident (2-3 minutes) Facilitate the client's understanding of the issue and circumstances that contributed to his/her risky behaviour. The counsellor must have an open approach to this part of the session. The counsellor’s approach will promote the client's eagerness and will encourage him/her to examine his/her behaviour. The examination of risky behaviour has to be specific. Extensive discussion about the most recent risky behaviour can help the client explain how it happened. What seemed at the beginning as a “combination of unusual events", coincidence or an unusual incident starts to build a picture of actual circumstances which contributed to the client's decision to behave in such an extremely risky manner. The counsellor must be aware that emotions, recent events, use of psychoactive substances, loss of self-esteem or self-respect, among other characteristics, can in many ways influence a particular risky incident or a form of risky behaviour. For these reasons it is necessary "to do lacework" while examining the client's either one-off or persistently risky behaviour, using this information to reveal the contributing factors to the kind of behaviour. Examination of specifics in most recent risky incident

Protocol Content Examine who, where, It would be good to talk about the risk that prompted you to come here today. what, how and when, Alternatively: It would be good to talk in connection with about the last time you had an unprotected sexual act. Alternatively: Is this situation that you just told me of ... unusual for you or has it happened before? With whom did this happen? How well do you know/did you know the person(s) with whom it happened? Assess the Did you talk about the HIV/STI risk with your partner(s) and was there anyone communication among you who has already been about HIV/STI with tested? Did you have any concerns the partners about having sex with this person? Is there a possibility that this person has HIV or an STI? Identify the What do you think prevented you from circumstances that protecting yourself at that time? Were contributed to the you drinking or taking drugs? risky behaviour Identify the Were there or is there anything in your vulnerability and life that could increase your risky triggers of the behaviour? incident/behavioural patterns

Evaluate the pattern of Would you behave in such a way if you risky behaviour (for knew that this person has HIV? Would example, it happens knowing about it change anything? regularly, occasionally, or is a very unusual incident) Identify and consider I see that you are worried about HIV, the examples when but that you, despite that, continue to beliefs and behaviour have unprotected sex (or state some are at odds or when other risk if any). Help me understand feelings are mixed in this. regard to risk reduction

12.1.4. Identifying the client's constructive attempts for risk reduction, exploring behavioural change limits through understanding and support (1-2 minutes) The counsellor has to explore every change initiated by the client in order to reduce his/her risk of HIV infection. This enables the counsellor to give additional support and empowers the client. The counsellor has to detect all of the client's intentions, communication and activities related to the reduction of risk of HIV infection. The counsellor has to, gently and sensitively, discuss the challenges that the client faces or notices. It is important to understand that change in behaviour is a complex, hard and challenging process. During this part of the session, the counsellor has to clarify any false information that the client may have. Renew previous experiences with risk reduction Protocol Content Identification of What is presently the biggest the obstacles for obstacle in your attempts to reduce risk reduction the risk of HIV infection? Explore Do drugs or alcohol influence you to triggers/situations have highly risky sex? that increase the If yes: It is good for us to talk about it. probability of high Was there any period of time in your risk behaviour life (depression, unemployment, recent break of a relationship) when you found it difficult to perform safe sex, when you thought that it was not necessary to protect yourself? Examine the Do you talk with your partners/friends communication or with anybody else about concerns between the client relating to HIV/STIs? When you talk and their about HIV/STI risk reduction how does friends/partners the discussion go? How do you feel about the risk when discussing this?

12.1.5. Summarising the client's risky behaviour through identification of his/her risky behaviour patterns and observing specific vulnerabilities and triggers of risky behaviour (1-2 minutes) The purpose of this component is to enable the client to understand the complexity of factors, which may influence his/her risky behaviour. The counsellor has to be sympathetic and non-judgemental, which will contribute to improved collaboration between the counsellor and the client and help the client to understand his/her unsafe behaviour. This component provides the basis for development of a risk reduction plan. The counsellor will refer to more important issues in this summary while giving test results and mentioning risk reduction components. Combining risky incidents with risk pattern

Protocol Content Summarise the This is how I understand your situation information that you concerning risk of HIV/STIs received from the (summarise key topics discussed with client the client). Is that how you see it? Are there any other topics you would like to discuss here? Place the client's risky There are a few issues that influence behaviour in a wider your risky behaviour (state specific context of their life topics connected with the behaviour, communication, substance abuse...) You will be able to protect yourself if... (list circumstances that could help the client to reduce risk). Make a record of each Let us examine how frequently these pattern of risky risky situations occur. What issues do behaviour. Identify key you think would most likely lead to a triggers/vulnerabilities risk of HIV or STI infection? State your concern I believe that if we did not bring up and the urgency in these issues, there would be a regard to the client's possibility that the risky behaviour risk would continue and there would be a high probability of HIV infection. Inform the client that If you want to and if you agree with he/she will then go to the testing, you may now go to the the laboratory for laboratory to give blood for the testing. Prepare the analysis. We will see each other in 3 client so he/she will hours (or state the time needed for have to come back the test to be done), when the test is to you and develop finished, and will further develop a the plan for the plan together. reduction of risk. Especially for pregnant women: Can you give me your contact telephone number, or an address.... Don’t forget: The counsellor should tell the client that with this the first counselling session is finished and ask the client to think about the issues that were discussed during the visit. The counsellor should repeat that, upon the client's return, he/she will be given the test results and that they will develop a plan for risk reduction together. Apply clear instructions as to where and when you will meet again.

12.2. HIV post-test counselling in 7-15/25 minutes

12.2.1. Providing and giving test results (2-10/20 minutes)

12.2.1. A. Giving clear and accurate HIV negative test result (2-10 minutes) The counsellor must describe the initial test results in simple terms and avoid using technical vocabulary. The client may experience huge relief if he/she gets a negative test result. The counsellor must carefully examine the feelings and beliefs that the client has in connection with his/her negative test result, especially in the context of the risky behaviour that the client described in pre-test counselling. At the same time, the counsellor must be discrete and focus the discussion towards an acknowledgement by the client that he/she needs to change behaviour in order to continue being HIV negative, emphasising the important fact that a negative test result does not mean that the client's sexual or needle sharing partner(s) is/are not infected. Giving negative test results Protocol Content Greet the client upon Welcome! Please, sit down. their return Give results clearly "Your test result is negative, which and simply means that HIV antibodies have not been found". Explain the meaning of This means that before 2 to 3 months the test once more before this test you were not infected with HIV. Consider the test results in relation to What does this test mean to you? the most recent exposure to HIV risk

There is a small possibility that recent risky behaviour (in the past 2 to 3 months) could result in the client being infected and that this infection did not actually show in this first test result. If there was recent exposure to risk there is also a chance that the client was infected during this exposure. For that reason, the counsellor should recommend a repeat test, which will correlate in accordance with the date of the last exposure to the HIV risk. 12.2.1B. Giving preliminary positive test results (10/20 minutes or longer) The counsellor must give preliminary positive test results using simple language, which openly reflects the probability that the client is infected with HIV, avoiding technical vocabulary. When choosing the way to transfer the meaning of the preliminary test results, the counsellor has to bear in mind the discussion on the client's risky behaviour during the pre-test counselling. The counsellor has to explain that the information given by the client at the beginning of the session, especially the risk assessment, can influence the client’s and counsellor’s understanding of the results. This can prompt the client to offer additional details in connection with the risk that he did not want to discuss before. The counsellor has to remind the client and explain to him that this test result is preliminary and that it has to be repeated with a more specific test, which will disprove or confirm the preliminary test. Giving positive results of preliminary testing

Protocol Content Greet the client upon Welcome! Please, sit down. his arrival Give preliminary Your preliminary test result is results clearly, simply positive. What this means is that you and without beating are probably infected (most probably around the bush infected usually means: the client is infected). Repeat the However, when positive, the meaning of the preliminary result has to be repeated, preliminary test as I have mentioned to you in pre- test counselling. Only after a repeated (so-called confirmatory) testing can we tell for sure if someone is infected with HIV or not. Give the client time to We have sufficient time at our understand the disposal to talk about the meaning meaning of the result of this result and about anything else you want to talk about. Assess how the patient is taking the What does this preliminary test mean preliminary result to you? Emphasise the It is very important that you get importance of additional testing done. In case of any additional problems that you may have with a testing return visit, you can call me at this number... If you would like, you could also give me a telephone number or address to contact you....

12.2.2. Identification of a support system and person(s) to help increase the client's chances of reducing risk and to implement a risk reduction plan (1-2 minutes) The priority of this counselling component is that the client identifies a particular person, partner, friend or relative, with whom he/she can talk about the test results, about his/her HIV status, about the situation he/she is in and about his/her plan for risk reduction, and who can be informed about the implementation of said plan. The client must fully trust that person, he must feel safe with that person and he must be able to confide in that person. It is completely understandable that the trusted person will often be the same person with whom the client is trying to initiate the plan for changing behaviour. Identification of support sources and risk reduction plan Protocol Content Emphasise the What plans do you have now upon importance of talking to leaving our counselling centre? Can a friend or relative we make a plan concerning where (who the client trusts) you’ll go from here? Do you want to about the test results, call somebody... intentions and the It is important to have a person that contents of the plan you trust. Identify the person Does anybody know that you are here that the client is today? Can you talk to this person comfortable with about everything? Who do you usually and feel free to talk to when you’re faced with present the plan challenges? It is important that you share your plan for changes in behaviour with someone. Who do you trust? Show your faith in This is the plan that you made the client’s yourself. This is a good plan and I capability to honestly believe that, though it is a complete the risk challenge, you can do it. reduction plan Schedule the next visit!

12.2.3. Development of specific, concrete and gradual plans for reduction of risk of HIV infection (2-3 minutes) This step can be achieved during the first visit but it is more frequently done during the following visits. This step presupposes the existence of a risk reduction plan and presents one of the most important counselling components. The counsellor should help the client to identify the behaviour that corresponds to the described risk and motivate the client to start investing in change. The counsellor must encourage the client to give some further thought to his initial reaction to risk reduction.

The risk reduction plan should be specific enough to describe the who, where, what, how and when of risk reduction. The plan has to be concrete and must contain detailed actions necessary for the client to implement and complete the risk reduction plan. Finally, the plan has to be gradual, directed towards one aspect of risky behaviour or one particular factor which contributes to the risky behaviour. The counsellor must avoid supporting a risk reduction plan that is unreasonable, unrealistic or extremely radical where changes in the client's life are concerned. General phrases such as "from today, I’ll always use condom", “I’ll stay monogamous forever" or "I’ll refrain from having sex" do not meet the criteria for a suitable risk reduction plan. The counsellor must ensure that the client agrees with the plan and be dedicated to its fulfilment. In fact, there is a series of steps in risk reduction and it is essential that encouragement and support are provided.

To negotiate a risk reduction plan

Protocol Content Examination of the What do you recognise as being the behaviour which the most realistic of your desires to client will be the most reduce the risk of HIV infection? If the interested in/ready to client uses words as "Always" or change "Never" when describing changes of behaviour, say: It is excellent that you really want to eliminate the risk. Since changes only happen through small steps, though, what would be your first step towards the achievement of this goal? Identify reasonable, Now that you have identified challenging steps something that you want to do, when towards HIV risk and how do you think this will reduction. Divide the happen? activities geared towards the risk reduction into specific and concrete steps Identify the support What can make it difficult for you to and obstacles for the take this step? What can make it risk reduction easier? Who can support you in this attempt? How will you proceed if something pops up in the way of plan? Recognise the With your decision to try this plan and challenges and reduce your risks, you have done support for something really very useful for behavioural change yourself.

If, during the session the counsellor or the client identify the need to ask for professional services (for example, therapy, support groups, mental health counselling, etc.), then the counsellor has to be ready to give the client names and telephone numbers for these services. The counsellors are especially important in this area as the consulting services that the client receives can contribute to or empower the process of risk reduction. Identification of support sources - Providing additional reliance

Protocol Content Consider the topics Your plan looks very good. But there that have a long are several important topics that history or are serious contribute to the risk, which we need and that contribute to to consider through professional help the risk (drugs, or assistance. alcohol) Assess the client's Have you ever asked for counselling readiness to seek or did you go to group therapy? Here professional help. are the names of contacts and the Provide respective telephone numbers of the services consultations you need to call in order to obtain the (naturally, if they exist help for topics (name them) that we and if you have the talked about. When do you think you opportunity) can call them or go there?

12.2.4. Enable follow-up visits on an as-needed basis (1 minute) When a client with a HIV negative result is concerned, the counsellor has to initiate and support the client's behavioural risk reduction plan.

In the case of a client with a positive preliminary result, the counsellor must make sure that the client comes back for a repeat test and obtain a confirmation test result.

Obtaining a reminder for follow up visits

Protocol Content Identify the ways for Do you have a diary or calendar? the client to remember Your next visit is on (Day/Date/Time). the further events Let me check if you know how to Repeat the client's and contact me in case you would like to counsellor’s contact talk to me. information Is this the best way to keep in touch? Greet each other (stand up, handshake) and (and this is COMPULSORY) say: See you soon!

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. About the Authors:

Dr Dragan llić, MD, specialist in epidemiology. Institute for the Protection of Student Health, Belgrade. Associate investigator at the Centre of Multidisciplinary Studies of Belgrade University. Vice-president of the Inter-Departmental Board for AIDS of the Serbian Academy of Science and Art Director of JAZAS (Yugoslav Association against AIDS). President of the Expert Group for Youth Development and Health and the Subgroup for the Prevention of HIV/AIDS Among Youth, Ministry of Health, Republic of Serbia. MSc in the field of HIV/AIDS prevention. Has been working for the past 17 years on the prevention of HIV/AIDS in our country, which has involved direct work with those living with HIV/AIDS. He has completed education and international training on "Voluntary and Confidential Counselling and Testing": 1. Training Programme on Voluntary Confidential Counselling and Testing for HIV/AIDS, organised by UNICEF New York, September 2002, Belgrade, Yugoslavia; 2. Advanced Training Programme on Voluntary Confidential Counselling and Testing for HIV/AIDS organised by CAFOD, London, January 2004, Belgrade, Serbia and Montenegro; 3. Training programme for work with individuals living with HIV/AIDS, organised by CAFOD, trainer Jim Simmons, London, May 2006, Belgrade, Serbia.

Dr Mila Paunić, MD, specialist in epidemiology. Institute for the Protection of Student Health, Belgrade. Counsellor at the Centre for Prevention of AIDS and STIs within the Institute for the Protection of Student Health. Trainer of VCCT counsellors and VCCT trainers. Member of the Subgroup for the Prevention of HIV/AIDS and Sexually Transmitted Infections of the Expert Group for Youth Development and Health, Health Ministry, Republic of Serbia. Coordinator and consultant of UNICEF pilot project "Health Education through Live Skills" for secondary schools pupils in two municipalities in Serbia (school year 2006/07). Vice-president of the Executive Board, JAZAS (Yugoslav Association against AIDS). MSc in the field of HIV/AIDS prevention. Working for the past 17 years in education and on prevention of HIV/AIDS in the Counselling Centre for AIDS, Student Outpatient’s Clinic. Working directly in "Voluntary and Confidential Counselling and Testing", offering support to individuals living with HIV/AIDS. Completed education and international training for "Voluntary and Confidential Counselling and Testing": 1. Training Programme for Voluntary Confidential Counselling and Testing for HIV/AIDS, organised by UNICEF New York, September 2002, Belgrade, Yugoslavia; 2. Advanced Training Programme for Voluntary Confidential Counselling and Testing for HIV/AIDS organised by CAFOD, London, January 2004, Belgrade, Serbia and Montenegro; 3. Training programme for work with individuals living with HIV/AIDS, organised by CAFOD, trainer Jim Simmons, London, May 2006, Belgrade, Serbia. EXCERPTS FROM THE REVIEW

The review of this Handbook was written by Prof Dr Slavenka Janković, specialist in epidemiology, professor at the Institute of Epidemiology, Medical Faculty, of Belgrade University. Member of the First National Committee in the Fight against AIDS.

Assessment by application

The manuscript completely satisfies its application purposes. It is written as a Handbook, accessible to every counsellor and to those in need of HIV testing with counselling. It is anticipated that this Handbook will significantly contribute to the prevention and elimination of HIV/AIDS in our country.

Conclusion

I propose that the book "Voluntary and Confidential Counselling and HIV Testing" be accepted as the national guide for the practical work services for voluntary and confidential counselling and HIV testing. It should be accessible to all health workers, especially to physicians who work in counselling centres in family practices and to individuals faced with the dilemmas of HIV testing, whom to turn to for help, what the testing means, etc.

Prof Dr Slavenka Janković, Belgrade, 2004

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