HIV/AIDS: How to break the bad news

There are two answers to expect when you take an HIV test -- negative or positive. The biggest challenge, however, is how to receive the bad news. That is what healthcare providers are supposed to help patients with.
A medic counselling a client before an HIV test is done. / Internet photo.
A medic counselling a client before an HIV test is done. / Internet photo.

There are two answers to expect when you take an HIV test – negative or positive. The biggest challenge, however, is how to receive the bad news. That is what healthcare providers are supposed to help patients with.

Leonille, who is in her late 40s, is a nurse and counselor who has been working at the HIV clinic at King Faisal Hospital for 13 years. Married with four children, her job is not an ordinary one. It is her duty to prepare clients for all sorts of expectations when they come for HIV tests. She explains that there is always fear among everyone but proper preparation is meant to clear this tension.

“People come to the clinic for different reasons; some have messed up during sexual intercourse or have been involved in accidents, while others want to allay fears of their partners being infected. Everyone needs attention but how you provide it matters,” she explains.

Her first step is to welcome everyone into the clinic. In what is referred to as the pretest, patients are asked a number of things after a brief background check and then they too make inquiries.

How are you? Why have you decided to take the test? Are you married? Where do you work? Who do you stay with? Are you suffering from any illness currently? And then comes the most difficult of all; What would you do if you discovered you have HIV?

It is indeed, a challenging beginning for both men and women but the questions mean no harm, according to this healthcare provider.

“I ask you for just one simple reason - to prepare you for all sorts of outcomes. Good or bad, your brains should be ready when it comes to the next stage referred to as the post-test. This helps a lot in terms of imagination. As naïve as some can be, they get to learn about the disease even before breaking the ultimate news,” says Leonille.

Initiating the post-test phase

The post-test phase is the phase when individuals are informed about their HIV status. 

Leonille says all clients are affected by the bad news and it is only human to feel some sort of attachment to them.

“I feel pity of course, but I don’t have to show you that. HIV is manageable. I have met a number of people who feel it is the end of the world but it is not,” she adds.

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Leonille at the King Faisal Hospital HIV clinic. / Solomon Asaba.

Those found positive receive counselling before starting treatment, a period during which follow-up is very essential and for successful viral load suppression. The biggest call towards patients is to adhere to their medication.

But that is not always the case and it is common for people to interrupt drug uptake.

Leonille points out that some incidences include people on medication interrupting their doses claiming that they have received special spiritual healing.

“It is a big challenge. One time couples came back here and told us they got healed through prayer. You know patients have to report back every after three months to track progress, but with such news, the option is to further counsel them. That is what we exactly did and they got back on track,” she adds.

Fortunately, some discordant situations have been cited among married couples. For instance, at the King Faisal Hospital HIV clinic, 70 men and 54 women of those who access these services are discordant.

New hope in the ‘test-and-treat’ approach

Earlier, admission of antiretroviral drugs to HIV-positive patients was a totally different strategy as individuals had to wait for treatment until their CD4 cell count fell below the 500 threshold, but now the immediate test-and-treat method for anyone found positive is the recommended approach.

Recently study findings at the 21st International AIDS Conference in South Africa revealed that the test-and-treat was effective in reaching the global targets of combating HIV/AIDS.

A study in East Africa revealed that ‘test-and-treat’ for HIV within a larger multi-disease prevention campaign in rural Kenya and Uganda achieved 82 per cent viral suppression after two years and already exceeded UNAIDS targets for viral suppression after one year of activity.

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Leonille gets a blood sample during testing. / Solomon Asaba.

The UNAIDS 90-90-90 seeks to ensure that 90 per cent of people diagnosed with HIV, 90 per cent get treatment and 90 per cent of the treated people virally suppressed) equate to viral suppression in the entire population of people living with HIV.

The Search study achieved viral suppression of 77 per cent after its first year of activity, and 82 per cent after its second year, says Dr Maya Petersen of University of California Berkeley School of Public Health reported.

Data was collected at baseline and after 12 and 24 months of follow-up. Participants were tested for HIV and viral load was checked for those found to have the infection. The therapy consisted of a standardised regimen of efavirenz with tenofovir and emtricitabine or lamivudine. The intervention adopted a patient-centred approach to care. Viral load counselling was offered to all patients.

Scaling up the ‘test-and-treat’ locally

Recent statistics from the Rwanda Biomedical Centre show that the prevalence of HIV in the country stands at 3 per cent but it is believed that more efforts would slash this percentage further.

On July 1, Rwanda fully adopted the ‘test-and-treat’ strategy to be implemented in all medical centers. This strategy combined with other treatment intervention is doing a great job in reducing HIV.

Dr Placide Mugwaneza, the head of the HIV Prevention Unit at Rwanda Biomedical Centre, told Healthy Times that some specific strategies were put in place to ensure that high risk members of society have access to education on HIV.

“Health facility-based interventions are offered through education sessions and other communication materials. In addition, community-based interventions, including outreach education and peer education, are provided,” said Dr Mugwaneza.

Despite hope about the progress on the new vaccine, HIV is still a huge problem globally. By the end of 2015, 36.7 million people were living with the disease, according to the World Health Organisation. With the routes of transmission known such as being having unprotected sexual intercourse, infected blood contamination and use of unsterilised instruments, knowing ones status is crucial.

editorial@newtimes.co.rw

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THE ROLE OF VOLUNTARY COUNSELLING & TESTING IN PREVENTING HIV TRANSMISSION

Voluntary counselling and testing (VCT) programmes form an important component of both primary and secondary HIV prevention strategies. Early diagnosis of HIV infection has potentially significant individual and public health benefits.

Benefits of VCT programmes

VCT programmes have both individual and public health benefits. Those who test negative have their minds put at rest, can be encouraged to reduce their risk and can be referred to supplemental prevention services. Individuals who test positive can be referred to appropriate follow-up services and have their health monitored. Treatments, such as HAART, mean that VCT programmes and early diagnosis play an important role in accessing potentially life-saving care. Individuals who learn of their positive status are also likely to reduce risk-taking behaviours; thereby reducing the risk of onward transmission or becoming infected with other sexually transmitted infections (STIs).

Individual prevention strategies to reduce onward transmission of infection have obvious public health benefits. VCT programmes are cost-effective since late identification of infection is often associated with increased treatment costs and hospitalisation. Additionally, effective antiretroviral therapy reduces mother-to-child transmission and HIV viral load (which in turn reduces the risk of heterosexual transmission) . As a primary prevention tool VCT can be effective in helping people reduce their risk behaviours for HIV and other STIs.

Barriers

Stigma and the fear of testing positive are potential barriers to testing. Individuals are more likely to seek HIV testing when it is offered anonymously. Anonymity can be critical component for establishing trust and ensuring client demand for services, as has been shown in Uganda’s VCT programme. Policies that require mandatory testing or name reporting of HIV positive persons may also act as a barrier to test seeking. Clients are more likely to accept testing if the service providers have a “pro testing attitude” and stress the potential benefits for the individual such as peace of mind, treatment access and the welfare of partners and offspring.

Counselling

It has been demonstrated that counselling, as opposed to basic health information in the form of a culturally appropriate video, leads to a lower incidence of STIs and longer periods of HIV/STD risk reduction. There are different counselling strategies available that potentially increase the efficacy of VCT as a prevention intervention. Short-term, client-centred counselling has been shown to be more effective in reducing unsafe behaviours than brief, didactic counselling.

In some instances pre-test counselling may act as a barrier to testing, by making it difficult to access a test. The uptake of antenatal HIV testing has been significantly increased by the normalisation of the testing process. In most clinics HIV testing is now a normal part of the antenatal booking procedure, where it is offered with the routine antenatal blood tests. There is a pre-test discussion but no pre-test counselling is provided.

VCT for couples

The provision of VCT programmes targeted at couples can be a very effective tool in HIV prevention, especially when the client is offered a HIV test whilst seeking care or treatment for other reasons, e.g. Pregnancy. Many clients may be surprised by the offer and refuse on the spot or defer their refusal by asking for time to think. Absent partners can affect the decisions of VCT clients, causing them to refuse the test, or fail to return for the results and post-test counselling. The decision to begin treatment, to prevent mother-to-child transmission, may also be affected by a partner. Universal antenatal testing has reduced the undiagnosed fraction of prevalent HIV infection among African women attending these services. VCT for couples could provide a way to improve the testing opportunities for men.

Agencies

 

 

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