It is hard to know what to do in Myanmar / Burma with the new PITC Provider Initiated Testing and Counselling guidelines from WHO.

These guidelines are not evidence-informed. There is one reference to India in the footnotes. None from Burma, Thailand, or Cambodia. None from anywhere else in Asia.

The document gives guidance for countries with generalized epidemics. But the word 'generalized' of course never appears in any government-approved WHO literature on Burma / Myanmar. Even though the country has a generalised epidemic.

You can see the executive summary below or download the document from http://www.who.int/entity/hiv/who_pitc_guidelines.pdf or he can email you a copy.

[him] moderator

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Executive Summary: Guidance On Provider-Initiated HIV Testing And Counselling In
Health Facilities  

UNAIDS/WHO
30 May 2007  

http://www.aegis.org/news/unaids/2007/UN070515.html

1. INTRODUCTION

This document responds to growing need at country level for basic operational
guidance on provider-initiated HIV testing and counselling in health facilities.
It is intended for a wide audience including policy-makers, HIV/AIDS programme
planners and coordinators, health-care providers, non-governmental organizations
providing HIV/AIDS services and civil society groups. Surveys in sub-Saharan Africa
have shown that a median of just 12% of men and 10% of women had been tested for
HIV and received the results. Greater knowledge of HIV status is critical to
expanding access to HIV treatment, care and support in a timely manner, and offers
people living with HIV an opportunity to receive information and tools to prevent
HIV transmission to others. Increased access to HIV testing and counselling is
essential in working towards universal access to HIV prevention, treatment, care
and support as endorsed by G8 leaders in 2005 and the UN General Assembly in 2006.
 
WHO and UNAIDS strongly support the continued scale up of client-initiated HIV
testing and counselling, but recognize the need for additional, innovative and
varied approaches. Health facilities represent a key point of contact with people
with HIV who are in need of HIV prevention, treatment, care and support. Evidence
from both industrialized and resource-constrained settings suggests that many
opportunities to diagnose and counsel individuals at health facilities are being
missed and that provider-initiated HIV testing and counselling facilitates diagnosis
and access to HIV-related services. Concerns about the potential coercion of
patients and adverse outcomes of disclosure underscore the importance of adequate
training and supervision for health care providers and the need for close monitoring
and evaluation of provider-initiated HIV testing and counselling programmes.  

The document recommends an "opt-out" approach to provider-initiated HIV testing
and counselling in heath facilities, including simplified pre-test information,
consistent with WHO policy options developed in 2003 and with the 2004 UNAIDS/WHO
Policy Statement on HIV Testing. With this approach, an HIV test is recommended
1) for all patients, irrespective of epidemic setting, whose clinical presentation
might result from underlying HIV infection; 2) as a standard part of medical care
for all patients attending health facilities in generalized HIV epidemics; and 3)
more selectively in concentrated and low-level epidemics. Individuals must
specifically decline the HIV test if they do not want it to be performed. Additional
discussion of the right to decline HIV testing, of the risks and benefits of HIV
testing and disclosure, and about social support available may be required for
groups especially vulnerable to adverse consequences upon disclosure of an HIV
test result. An "opt-in" approach to informed consent may merit consideration for
highly vulnerable populations.  

Provider-initiated HIV testing and counselling should be accompanied by a recommended
package of HIV-related prevention, treatment, care and support services described
in Section 5 and implemented within the framework of a national plan to achieve
universal access to antiretroviral therapy for all who need it. Simultaneous with
implementation of provider-initiated HIV testing and counselling, efforts must be
made to ensure that a supportive social, policy and legal framework is in place
to maximize positive outcomes and minimize potential harms to patients. Adaptation
of this guidance at country level will require an assessment of the local
epidemiology as well as the risks and benefits of provider-initiated HIV testing and
counselling, including an appraisal of available resources, prevailing standards
of HIV prevention, treatment, care and support, and the adequacy of social and
legal protections available. Implementation of providerinitiated HIV testing and
counselling should be undertaken in consultation with key stakeholders, including
civil society groups and people living with HIV/AIDS.  

When recommending HIV testing and counselling, service providers should always
aim to do what is in the best interests of the individual patient. This requires
giving individuals sufficient information to make an informed and voluntary
decision to be tested, maintaining patient confidentiality, performing post-test
counselling and making referrals to appropriate services. Endorsement of
provider-initiated HIV testing and counselling by WHO and UNAIDS is not an endorsement
of coercive or mandatory HIV testing. WHO and UNAIDS do not support mandatory or
compulsory testing of individuals on public health grounds.  

2. RECOMMENDATIONS  

Guidance on provider-initiated HIV testing and counselling in this document is
categorized according to the following HIV epidemic types:  

1. Low-level HIV epidemics  

Although HIV may have existed for many years, it has never spread to substantial
levels in any sub-population. Recorded infection is largely confined to individuals
with higher risk behaviour: e.g. sex workers, drug injectors, men having sex with
other men. Numerical proxy: HIV prevalence has not consistently exceeded 5% in
any defined sub-population.  

2. Concentrated HIV epidemics  

HIV has spread rapidly in a defined sub-population, but is not well-established
in the general population. This epidemic state suggests active networks of risk
within the sub-population. The future course of the epidemic is determined by the
frequency and nature of links between highly infected sub-populations and the
general population. Numerical proxy: HIV prevalence is consistently over 5% in at
least one defined subpopulation but is below 1% in pregnant women in urban areas.
 
3. Generalized HIV epidemics  

HIV is firmly established in the general population. Although sub-populations at
high risk may contribute disproportionately to the spread of HIV, sexual networking
in the general population is sufficient to sustain an epidemic independent of
sub-populations at higher risk of infection. Numerical proxy: HIV prevalence is
consistently over 1% in pregnant women.  

* Recommendations for all epidemic types  

In all types of HIV epidemics, health care providers should recommend HIV testing
and counselling as part of the standard of care to:  

- all adults, adolescents or children who present to health facilities with signs,
symptoms or medical conditions that c

ould indicate HIV infection. These include,
but are not necessarily limited to, tuberculosis and other conditions specified
in the WHO HIV clinical staging system.  

- infants born to HIV-positive women as a routine component of the follow-up care
for these children.  

- children presenting with suboptimal growth or malnutrition in generalized
epidemics, and under certain circumstances in other settings such as when malnourished
children do not respond to appropriate nutritional therapy.  

- men seeking circumcision as an HIV prevention intervention.  

* Recommendations for generalized epidemics  

In generalized epidemics where an enabling environment is in place and adequate
resources are available, including a recommended package of HIV prevention,
treatment and care, health care providers should recommend HIV testing and counselling
to all adults and adolescents seen in all health facilities. This applies to
medical and surgical services, public and private facilities, inpatient and outpatient
settings and mobile or outreach medical services. HIV testing and counselling
should be recommended by the health care provider as part of the normal standard
of care provided to the patient, regardless of whether the patient shows signs
and symptoms of underlying HIV infection or the patient's reason for presenting
to the health facility.  

Resource and capacity constraints may require a phased implementation of
provider-initiated HIV testing and counselling. The following should be considered
priorities for the implementation of provider-initiated HIV testing and counselling
in generalized epidemic settings:  

- Medical inpatient and outpatient facilities, including tuberculosis clinics.  

- Antenatal, childbirth and postpartum health services.  

- Health services for most-at-risk populations.  

- Services for younger children (under 10 years of age).  

- Surgical services.  

- Services for adolescents.  

- Reproductive health services, including family planning.  

* Options for concentrated and low-level HIV epidemics Health care providers should
not recommend HIV testing and counselling to all persons attending all health
facilities in settings with low-level and concentrated epidemics, since most people
will have a low risk of exposure to HIV. In such settings, the priority should be
to ensure that HIV testing and counselling is recommended to all adults, adolescents
and children who present to health facilities with signs and symptoms suggestive
of underlying HIV infection, including tuberculosis, and to children known to
have been exposed perinatally to HIV. If data show that HIV prevalence in patients
with tuberculosis is very low, the recommendation of HIV testing and counselling
to these patients may not remain a priority.  

Decisions about whether and how to implement provider-initiated HIV testing and
counselling in selected health facilities in low-level and concentrated epidemics
should be guided by an assessment of the epidemiological and social context.
Consideration may be given to the implementation of provider-initiated HIV testing
and counselling in the following health facilities or services:  

- STI services  

- Health services for most-at-risk populations  

- Antenatal, childbirth and postpartum services  

- Tuberculosis services.  

3. ENABLING ENVIRONMENT  

Provider-initiated HIV testing and counselling should be accompanied by a recommended
package of HIV-related prevention, treatment, care and support services shown in
Section 5. Although not all the services need necessarily be available in the
same facility as where the HIV test is performed, they should be available through
local referral. Although access to antiretroviral therapy should not be an absolute
prerequisite for the implementation of provider-initiated HIV testing and
counselling, there should at least be a reasonable expectation that it will become
available within the framework of a national plan to achieve universal access to
antiretroviral therapy for all who need it.  

Antiretroviral prophylaxis and infant feeding counselling are important interventions
for the prevention of mother-to-child transmission. These interventions must be
available as part of the standard of care for pregnant women who are diagnosed
HIV-positive through provider-initiated HIV testing and counselling.  

At the same time as provider-initiated HIV testing and counselling is implemented,
equal efforts must be made to ensure that a supportive social, policy and legal
framework is in place to maximize positive outcomes and minimize potential harms
to patients. This includes:  

* Community preparedness and social mobilization  

* Adequate resources and infrastructure  

* Health care provider training  

* Health care provider codes of conduct and methods of redress for patients  

* A strong monitoring and evaluation system.  

Optimal delivery of provider-initiated HIV testing and counselling in the long
term requires that laws and policies against discrimination on the basis of HIV
status, risk behaviour and gender are in place, monitored and enforced. Because
UNAIDS and WHO encourage voluntary disclosure of HIV status and ethical partner
notification and counselling, national policies and ethical codes should also be
developed to authorize partner notification in clearly defined circumstances.
Governments may also need to develop and implement clear legal and policy frameworks
that stipulate 1) the specific age and/or circumstances in which minors may consent
to HIV testing for themselves or for others, and 2) how the assent of and consent
for adolescents should best be assessed and obtained.  

4. PRE-TEST INFORMATION AND INFORMED CONSENT  

Depending on local conditions, pre-test information can be provided in the form
of individual information sessions or in group health information talks. Informed
consent should always be given individually, in private, in the presence of a
health care provider. When recommending HIV testing and counselling to a patient,
the health care provider should at a minimum provide the patient with the following
information:  

* The reasons why HIV testing and counselling is being recommended  

* The clinical and prevention benefits of HIV testing and the potential risks,
such as discrimination, abandonment or violence  

* The services that are available in the case of either an HIV-negative or an
HIV-positive test result, including whether antiretroviral treatment is available
 
* The fact that the test result will be treated confidentially and will not be
shared with anyone other than heath care providers directly involved in providing
services to the patient  

* The fact that the patient has the right to decline the test and that testing
will be performed unless the patient exercises that right  

* The fact that declining an HIV test will not affect the patient's access to
services that do not depend upon knowledge of HIV status  

* In the event of an HIV-positive test result, encouragement of disclosure to
other persons who may be at risk of exposure to HIV  

* An opportunity to ask the health care provider questions.  

Patients sh

ould also be made aware of relevant laws in jurisdictions that mandate
the disclosure of HIV status to sexual and/or drug injecting partners.  

Verbal communication is normally adequate for the purpose of obtaining informed
consent. Jurisdictions that require consent to be given in writing are encouraged
to review this policy. Some patient groups may be more susceptible to coercion to
be tested and to adverse outcomes of disclosure of HIV status such as discrimination,
violence, abandonment or incarceration. In such cases, providing additional
information beyond the minimum requirements defined in this document may be appropriate
to ensure informed consent.  

Pre-test information for women who are or may become pregnant should also include:
 
* The risks of transmitting HIV to the infant  

* Measures that can be taken to reduce mother-to-child transmission, including
antiretroviral prophylaxis and infant feeding counselling  

* The benefits to infants of early diagnosis of HIV.  

Special considerations apply in the case of children and adolescents who are below
the legal age of majority (usually 18 years of age). As minors, children cannot
legally provide informed consent. However, they have the right to be involved in
all decisions affecting their lives and to make their views known according to
their level of development. Every attempt should be made to inform and involve
the child and to obtain her/his assent. Informed consent from the child's parent
or guardian is required. More detailed discussion of consent for children and
adolescents is considered in Section 6.1.3.  

Declining an HIV test should not result in reduced quality or denial of services
that do not depend on knowledge of HIV status.  

5. POST-TEST COUNSELLING  

Post-test counselling is an integral component of the HIV testing process. All
individuals undergoing HIV testing must be counselled when their test results are
given, regardless of the test result. Counselling for those whose test result is
HIV-negative should include the following minimum information:  

* An explanation of the test result, including information about the window period
for the appearance of HIV-antibodies and a recommendation to re-test in case of
a recent exposure  

* Basic advice on methods to prevent HIV transmission  

* Provision of male and female condoms and guidance on their use.  

The health care provider and the patient should then jointly assess whether the
patient needs referral to more extensive post-test counselling session or additional
prevention support. In the case of individuals whose test result is HIV-positive,
the health care provider should:  

* Inform the patient of the result simply and clearly, and give the patient time
to consider it  

* Ensure that the patient understands the result  

* Allow the patient to ask questions  

* Help the patient cope with emotions arising from the test result  

* Discuss any immediate concerns and assist the patient to determine who in her/his
social network may be available and acceptable to offer immediate support  

* Describe follow-up services that are available in the health facility and in
the community, with special attention to the available treatment, PMTCT, and care
and support services  

* Provide information on how to prevent transmission of HIV, including provision
of male and female condoms and guidance on their use  

* Provide information on other relevant preventive health measures such as good
nutrition, use of co-trimoxazole and, in malarious areas, insecticide-treated bed
nets  

* Discuss possible disclosure of the result, when and how this may happen and to
whom  

* Encourage and offer referral for testing and counselling of partners and children.
 
* Assess the risk of violence or suicide and discuss possible steps to ensure the
physical safety of patients, particularly women, who are diagnosed HIV-positive

* Arrange a specific date and time for follow-up visits or referrals for treatment,
care, counselling, support and other services as appropriate (e.g. tuberculosis
screening and treatment, prophylaxis for opportunistic infections, STI treatment,
family planning, antenatal care, opioid substitution therapy, and access to sterile
needles and syringes).  

Post-test counselling for pregnant women whose test result is HIV-positive should
also address the following:  

* Childbirth plans  

* Use of antiretroviral drugs for the patient's own health, when indicated and
available, and to prevent mother-to-child transmission  

* Adequate maternal nutrition, including iron and folic acid  

* Infant feeding options and support to carry out the mother's infant feeding
choice  

* HIV testing for the infant and the follow-up that will be necessary  

* Partner testing.  

6. FREQUENCY OF TESTING  

Recommendations about re-testing will depend on the continued risks taken by the
patient, the availability of human and financial resources and HIV incidence in
the setting. Re-testing every 6-12 months may be beneficial for individuals at
higher risk of HIV exposure.  

HIV-negative women should be tested as early as possible in each new pregnancy.
Repeat testing late in pregnancy should also be recommended to HIV-negative women
in generalized epidemic settings.  

7. HIV TESTING TECHNOLOGIES  

The advantages of using rapid HIV tests for provider-initiated HIV testing and
counselling - particularly for health facilities where laboratory services are
weak - include visibility of the test and quick turn-around, increasing confidence
in results and avoidance of clerical errors. Rapid HIV testing can occur outside
laboratory settings, does not require specialized equipment and can be carried
out in primary health facilities.  

ELISA tests may be preferable in settings where large numbers of tests need to be
performed, where immediate provision of test results is less important (such as
for hospital inpatients) and in reference laboratories. However, ELISA tests
require specialized laboratory equipment and staff. Decisions on whether to use
HIV rapid tests or ELISA for provider-initiated HIV testing and counselling should
take into account factors such as the setting in which testing is proposed; cost
and availability of the test kits, reagents and equipment; available staff,
resources and infrastructure; the number of samples to be tested; sample collection
and transport and the ability of individuals to return for results.  

Virological testing, while more complex and expensive, is recommended for diagnosing
HIV in children less than 18 months old.  

8. PROGRAMMATIC CONSIDERATIONS  

Decisions on how best to implement provider-initiated HIV testing and counselling
will depend upon an assessment of the situation in a particular country, including
local epidemiology; the available infrastructure, financial and human resources;
the available standard of HIV prevention, treatment, care and support, and the
existing social, policy and legal frameworks for protection against adverse
consequences of HIV testing, such as HIV-related discrimination and violence. Where
there are high levels of stigma and discrimination
and/or low capacity of health
care providers to implement provider-initiated HIV testing and counselling under
the conditions of informed consent, confidentiality and counselling, adequate
resources should be devoted to addressing these issues prior to implementation.
Decisions around implementation should be made in consultation with all relevant
stakeholders, including civil society groups and people living with HIV/AIDS.  

9. MONITORING AND EVALUATION  

Monitoring and evaluation are essential to implementation of provider-initiated
HIV testing and counselling but may need to be supplemented by focused evaluations
on specific aspects of programming. Regular evaluations of health care provider
performance and patient satisfaction (including testing processes, pre-test
information, consent process and post-test counselling) can help improve the
effectiveness, acceptability and quality of HIV testing and counselling services.