In 2017, the Ministry of Health, following the World Health Organisation’s (WHO) newly released HIV and Aids treatment guidelines, recommended that all HIV-infected individuals are eligible for antiretroviral treatment at diagnosis, regardless of their disease stage and CD-4 cell count.
The guidelines for the HIV Test and Treat policy are aligned with the global 90-90-90 targets, whereby WHO and Unaids recommended that by 2020, 90 per cent of all people know their HIV status, 90 per cent of all HIV-infected individuals are on antiretroviral therapy, and 90 per cent of those on antiretroviral therapy have achieved viral load suppression.
If the Test and Treat policy is to be successful, focus should be placed on the role of HIV counsellors in medical facilities. These are usually the first point of contact between the health facility and a client who has voluntarily decided or has been persuaded to know their HIV status. While it is mandatory that proper and useful counselling must be provided before and after an HIV test, the reality is different.
On a hot morning last week, Hajara Namale, a 25-year-old radio presenter, walked into a private medical centre in Bunga, Makidye Division, Kampala District, with a friend. The two young women requested for an HIV test.
“The doctor on duty did not engage us in any conversation that might have passed for counselling,” Namale says, adding, “He just informed us that the test would cost Shs5,000 and, then, he brought out the testing equipment. My friend developed cold feet and walked out of the room.”
When Namale asked the doctor why he had not counselled them before bringing out the testing equipment, he informed her that by the time they came to the clinic, they knew what they wanted. “When I adamantly requested for a counsellor, he told me the clinic does not need counsellors but if the need arose, he would counsel me himself.”
According to the Uganda National Policy Guidelines for HIV Counselling and Testing (HCT), developed in 2005, in order to establish the sero status of an individual, there is need to carry out HIV counselling and testing.
The guidelines state: Mass education, while explaining the meaning of HIV-positive and HIV–negative results and the procedures at the HCT centre, should encourage the public to take advantage of HCT services as a necessity…HCT requires confidentiality.
As Namale was seated at the reception, with other patients, waiting for her results, the doctor suddenly appeared in the doorway and announced her results to the entire room. “I was shocked,” Namale says, continuing, “Everyone in the room knew my HIV status. I wonder if he would have done the same if I had tested HIV positive. He asked if I was married, and when I said I was not, he asked, ‘How do you do it? How do you manage to remain negative? If you are abstaining, then continue to doing so.’”
With the Policy Guidelines for HCT emphasising the need for confidentiality between the public and health workers, the behaviour of the doctor calls into question the training provided to HCT service providers. According to the same guidelines, the Ministry of Health and approved institutions have the mandate to train and provide comprehensive knowledge and skills to HCT service providers.
This reporter visited a private clinic in Ntinda, Nakawa Division, Kampala District, and after she was informed that an HIV test costs Shs10,000, in the absence of a counsellor, the doctor counselled her. He asked why she wanted to know her HIV status and what she would do with the results. He told the reporter that it was not right to make a decision based on the results. Instead, she should have already decided what to do with her life even before taking the HIV test.
In this confusion, the doctor finally concluded that the reporter was not in the right state of mind to take the HIV test. He advised her not to take the test, thus defeating the logic of the Test and Treat policy.
Who trains HCT service providers?
The Ministry of Health does not have a specific policy to guide recruiting of HCT counsellors. According to Dr Peter Mudiope, the coordinator of HIV prevention, there is no designated position for counsellors in the ministry’s structure.
“Counselling came about because of HIV. We only had social workers in our structure so it (counselling) is a poorly developed area within the health system because the assumption is that the general health workers – during their training – have been equipped with skills to handle clients.”
Currently, most of the people who pass for HIV counsellors in government health centres are actually general health workers, who are not professionally trained in counselling. The situation is worse in private medical facilities because the ministry has fallen back on its oversight role.
“There are a lot of issues concerning the quality of services in private practice,” Dr Mudiope says, adding, “There are doctors who connive with clients to give them false HIV results. Honestly, we are overwhelmed. The ministry is working on accrediting private facilities that can offer HCT. We shall even accredit people who should perform HIV tests on clients. We have been severely fought off (by doctors) in this area but we are in advanced stages. Right now, we are training auditors (who will do the accreditation).”
Test and Treat in jeopardy
In health centres that serve heavily populated communities, the HCT service providers are overwhelmed by the sheer number of clients.
At Kisenyi Health Centre IV, a group counselling session is held outside the labour ward. About 35 people are in attendance, sitting on benches and white plastic chairs. The counsellor talks about how the HIV virus is transmitted and what to do in case of an unintended unprotected sexual encounter.
Many of the people attending the session are middle-aged women. The few men in attendance look to be in their 40s and 50s. Some people in the group had already been tested and were waiting for their results. Others were waiting to take the test. Only one joint counselling session is offered. Those who came after the counsellor had concluded the session did not get any counselling. Soon, a nurse behind a screen began calling out people to pick up their results. Everyone who got the result walked away immediately. They had calm expressions on their faces; no elation or shock. There was no after-test counseling provided unless one specifically approached the overwhelmed counsellor.
Dr Mudiope admits that over the years, the Ministry of Health has been overwhelmed by HIV to the extent that support partners have been making efforts to bring counsellors on board. “Most counsellors in government facilities are not on the payroll. They are facilitated by our different support partners. But, the (available) counsellors have done a wonderful job because the health workers could not respond to the burden of the HIV epidemic.”
At Kisenyi Health Centre IV, although the counsellor assured people that their results would be out in 15 minutes, the results came back after two hours. Some walked away before getting their results.
Dr Stephen Watiti of Community Health Alliance Uganda and a peer counsellor living with HIV concurs that there is a dearth of professionally trained HIV counsellors. “Most of the counsellors in medical facilities have some knowledge of HIV and counseling. Some of them are people living with HIV who have been integrated in the system to counsel new patients. But really, none of us is professional. We just train on the job.”
The way forward
Currently, the ministry is revising the policy guidelines for HCT. However, in the new structure there is no position for HIV counsellors. Instead, modules on counselling are being developed to train health workers who are already in government health facilities.
“That is the problem we are facing,” Dr Mudiope says, adding, “It is still the same overwhelmed health worker who will be trained in couselling. This will bring in the issue of fatigue and bad attitude in the health worker, which will compromise the quality of services they offer.”
However, he defends the ministry’s position arguing that there is nothing new about HIV that creates a need for counselling, and that is why counselling sessions are being shortened.
“With the evolution of the epidemic, you can no longer scare somebody with Aids. It is very hard to counsel people, especially the youth, because they never saw how bad the disease was before antiretroviral therapy was developed. Nowadays, if you tell someone they are HIV negative, they express surprise. Besides, young doctors never saw the Aids conditions that we grappled with in Mulago hospital in the late 1990s and early 2000s. So how can they counsel people?”
He adds that to facilitate the Test and Treat Policy, the ministry of health is adopting a method of persuasion. “When you come to a health centre and you are in the target (high-risk) populations, the doctor will ask whether you are willing to take an HIV test. We cannot test everybody because of the finances involved.
Currently, there are 1,300,000 million HIV-infected people in Uganda and of these, 1,050,000 in care (on antiretroviral therapy). So, we are targeting 250,000 people.”
With this outlook, health workers now consider HIV to be on the same level as other diseases, such as hypertension. Counsellors are only giving out basic information – not counselling – that encompasses the need to adhere to drug regimens and monitor viral load. This information is mainly offered to HIV-infected people.
However, according to the HIV Situation Report for February 2017, Uganda has 230 new HIV infections per day, while every day, 76 people die of HIV related causes. The national HIV prevalence rate is 7.3 per cent. This statistics, especially those indicating new infections per day, clearly highlight the fact that while health workers may be suffering from Aids fatigue, there is a continuous need for information among the population.
Counsellors and health workers should be ready and willing to provide this information to their clients in a conducive environment that encourages them to take the HIV test to know their sero status.
What others say...
I have so far tested 10 times, in both private and public health facilities. I was never counselled before and after the tests in both facilities; I was just told to stay safe. Over time, I have realised that health workers in private facilities care more about the people who are going to be tested, than their counterparts in public hospitals. I believe this is because the former receive a better pay.
Lucy Namaganda, Hair stylist
I have tested five times but every time I go for the test, no one offers me counselling. It is only after the test that I am told to continue being safe, as the nurse is giving me the results.
Hanifa Namatovu, Electrician
I have so far tested three times, in different public health facilities. In all situations, I was counseled; however, the counseling placed more emphasis on the fact that the needle would not hurt me, than on the disease. I was counseled both before and after I did the test.
Sandy Amos, Casual labourer
In 2016, I got a wound and when I went to the hospital, I was tested without my consent. The nurse just gave me the results as I was leaving. No one asked if I wanted to do the test or not. When I finally decided to take the test on my own initiative, I went to a different hospital. The counsellor first asked why I wanted to do the test. Afterwards, I was sensitised about HIV, how it affects the body and others, and the measures I can take to remain safe.
Nathan Jeffrey, Businessman