Provider-Initiated HIV Testing and Counselling In Sub- Saharan Africa: The Role of Lay Health Workers

Editorial

The introduction of Highly Active Anti-retroviral Therapy (HAART) to reduce the viral load and prevent HIV transmission led to a range of intervention strategies to increase HIV screening in population (for example, provider-initiated HIV testing and counselling). The World Health Organization (WHO), the Joint United Nations Programme on HIV/AIDS (UNAIDS) and the Centre for Disease Control (CDC) recommends provider-initiated HIV testing and counselling for adolescents and adults aged 13 years and above (including pregnant women) in communities, where HIV prevalence is high [1]. Provider-initiated HIV testing and counselling (PITC) refers to a routine offer of HIV testing and counselling for all patients who visit a health facility, regardless of the presenting complains, and without a separate written consent. However, informed consent must be obtained from the parent or guardian if the person is less than 18 years [1].

In most African communities with high HIV prevalence, a large proportion of people living with HIV do not know they are infected, and they miss the opportunity to commence available treatment, and also play a significant role in the transmission of the disease. The PITC strategy presents an important opportunity to offer preventive health care to patients – an essential principle of primary care [1,2]. Evidence from sub-Saharan Africa (a continent with the highest burden of HIV) indicates that PITC is acceptable and feasible, and has increased the number of patients who tested for HIV and those who commenced treatment for the disease compared to voluntary counselling and testing (VCT) [3-7]. Similarly, a recent systematic review found that PITC increased HIV testing and the number of people who used condoms following its implementation compared to VCT [8].

Despite the benefits of PITC, its full implementation is still limited in many health facilities in Sub-Saharan Africa [9]. Plausible reasons for the incomplete implementation of this strategy may be due to shortages of health care workers in many communities and the inadequate training of health personnel [10,11]. To improve health care delivery (including HIV screening services) in communities amidst these challenges, WHO recommends task sharing, which is the rational reallocation of tasks between cadres of health workers with higher training and other cadres with basic training, including trained lay health workers. A lay health worker is any person who performs health-related functions and has been trained to deliver specific services, but has received no formal professional or paraprofessional certificate or tertiary education degree [12]. Evidence suggests that task sharing not only increases the efficiency and effectiveness of all available health workers, but also improves health outcomes in communities. For many years, task sharing has been implemented within the health sector, but this has not been broadened to involve HIV counselling and testing (HCT). Recent studies indicate that using lay health workers can increase HIV testing services, improve client satisfaction, and can provide supportive health services to disadvantaged population [5,12].

Lay health workers provide an important support to the health system framework in Sub-Saharan African, particularly in remote and disadvantaged communities. In these areas, lay health workers provide primary and secondary disease prevention strategies to patients on a range of health problems, including HIV screening services [13- 15]. Similarly, various national HIV policies in many Sub-Saharan African countries (16 out of 25 countries studied) allow trained lay health workers to perform rapid HIV testing and provide other health linkages for supportive care [12]. Given the circumstances, the use of trained lay health workers in the implementation of PITC in Sub- Sharan African can increase HCT, and is likely to improve timely treatment and care for people who are infected with the virus.

Additionally, programme managers need to take into account a number of key considerations when incorporating lay health workers into the PITC strategy. First, a lay health worker should be appropriately selected and should be suited to the health service/community. The lay health worker should demonstrate professionalism and should also be skilled in dealing with sensitive issues as well as respect confidentiality [12]. Secondly, opportunities for training, mentoring and continuing support should be available to lay health workers. Quality assurance indicators should be measured regularly, and revised when necessary. Finally, even though the use of lay health workers may reduce the overall programme cost, the use of lay workers in HIV programmes should not be seen as a strategy to cut cost, but to maximise the available human resources and to increase access to HIV care. Thus, lay workers should receive appropriate payment and/or adequate reward [12].

In conclusion, despite the availability of a range of measures to increase HCT in the Sub-Saharan African continent, many people who are infected still do not know their HIV status, and play a major role in contributing to the burden of HIV in the region. Lay health workers play an important role in the health care delivery system in communities in Sub-Saharan African. Appropriate implementation of the PITC strategy that incorporate trained lay health workers – shown to be successful in other health programmes – can increase HCT in Africa, and subsequently, reduce the disease burden in population.

References

1. World Health Organization /Joint United Nation Programme on HIV/AIDS, Guidance on provider-initiated HIV testing and counselling in health facilities 2007, World Health Organization: Geneva.
2. Marks G, N Crepaz, R.S Janssen, Estimating sexual transmission of HIV from persons aware and unaware that they are infected with the virus in the USA. Aids, 2006; 20: 1447-1450.
3. Creek TL, Ntumy Raphael, Seipone Khumo, Smith Monica, Mogodi Mpho, Smit Molly, et al., Successful introduction of routine opt-out HIV testing in antenatal care in Botswana. JAIDS Journal of Acquired Immune Deficiency Syndromes, 2007; 45: 102-107.
4. Ijadunola K, Abiona Titilayo, Balogun Joseph, A Aderounmu, Provider-initiated (Opt-out) HIV testing and counselling in a group of university students in Ile-Ife, Nigeria. The European Journal of Contraception and Reproductive Health Care, 2011; 16: 387-396.
5. Leon N, Naidoo Pren, Mathews Catherine, Lewin Simon, C Lombard, The impact of provider-initiated (opt-out) HIV testing and counseling of patients with sexually transmitted infection in Cape Town, South Africa: a controlled trial. Implement Sci, 2010; 5: 5-8
6. Wanyenze RK, Nawavvu Cecilia, Namale Alice S, Mayanja Bernard, Bunnell Rebecca, Abang Betty, et al., Acceptability of routine HIV counselling and testing, and HIV seroprevalence in Ugandan hospitals. Bulletin of the World Health Organization, 2008; 86: 302-309.
7. Kankasa C, Carter Rosalind J, Briggs Nancy, Bulterys Marc, Chama Eslone, Cooper Ellen R, et al., Routine offering of HIV testing to hospitalized pediatric patients at university teaching hospital, Lusaka, Zambia: acceptability and feasibility. JAIDS Journal of Acquired Immune Deficiency Syndromes, 2009; 51: 202-208.
8. Kennedy CE, Fonner Virginia A, Sweat Michael D, Okero, F Amolo, Baggaley Rachel K.R. O Reilly, Provider-initiated HIV testing and counseling in low-and middle-income countries: a systematic review. AIDS and Behavior, 2013; 17: 1571-1590.
9. Bassett IV, RP Walensky, Integrating HIV screening into routine health care in resource-limited settings. Clinical Infectious Diseases, 2010; 50: S77-S84.
10. Mills EJ, Kanters Steve, Hagopian Amy, Bansback Nick, Nachega Jean, Alberton Mark, et al., The financial cost of doctors emigrating from sub-Saharan Africa: human capital analysis. BMJ, 2011; 343.
11. Machayo JA, VN Keraro, Brain drain among health professionals in Kenya: A case of poor working conditions?-A critical review of the causes and effects.
12. World Health Organization, WHO recommends HIV testing by lay providers 2015, World Health Organization Geneva, Switzerland.
13. Lewin S, Babigumira SM, Bosch-Capblanch X, Aja G, Van Wyk B, Glenton C, et al., Lay health workers in primary and community health care: A systematic review of trials. Geneva: World Health Organization, 2006.
14. Byamah MB, Nadja G, Smith P Lucy, Simon Wandiembe, D Schellenbeg, Roles and effectiveness of lay community health workers in the prevention of mental, neurological and substance use disorders in low and middle income countries: a systematic review. BMC health services research, 2013; 13: 412.
15. Schneider H, U Lehmann, Lay health workers and HIV programmes: implications for health systems. AIDS care, 2010; 22: 60-67.