HIV/AIDS and Voluntary Counseling and Testing (VCT) Ene Peter

HIV/AIDS AND VOLUNTARY COUNSELING AND TESTING (VCT), A CRITICAL

REVIEW

ENE PETER, JANET

Department of Human Kinetics and Health Education, Faculty of Education University of
Port Harcourt, Rivers State

Abstract
Voluntary Counseling and Testing (VCT) is an essential component of comprehensive AIDS
prevention and treatment programmes. VCT enables people to learn their HIV status in the most
informed and supportive way possible. Counseling is done before the test to educate them about
HIV infection and afterward to help them respond appropriately to the results. The study looks at
what various authorities have said or written about HIV/AIDS and counseling.

Introduction
Acquired Immune (Immuno) Deficiency Syndrome (AIDS) is a highly infectious disease of the
human immune system caused by Human Immuno Virus (HIV), (Sepkowitz, 2001). According to
the centre for Disease Control and Prevention (CDC), (2006), this condition progressively reduces
the effectiveness of the immune system and leaves the individual susceptible to opportunistic
infections and tumours. AIDS' first recognized case by the CDC Cohen, (2000) notes, occurred in
the USA (San Francisco) in 1981 and also in the early 1980's among a number of gay men in New
York (Avert, 2010). The CDC, (2006) states that HIV is transmitted through direct contact of
mucous membrane or blood stream with bodily fluid containing HIV, such as blood, semen,
vaginal fluid, preseminal fluid and breast fluid. This transmission can involve anal, vaginal or oral
sex, blood transfusion, contaminated hypodermic needles, exchange between mother and baby
during pregnancy, childbirth, breast feeding or other exposure to one of the bodily fluids. AIDS is
now a pandemic (Kailings, 2008). In 2007, it was estimated that 33.2 million people lived with
the disease worldwide, and that AIDS killed an estimated 2.1million people including 330,000
children and over three quarters of these deaths occurred in Sub-Saharan Africa (WHO, UNAIDS
Report, 2007). According to Wigley (2004) Voluntary Counseling and Testing (VCT) is an
essential component of comprehensive AIDS prevention and treatment programmes. VCT enables
people to learn their HIV status in the most informed and supportive way possible. Counseling is
done before the test to educate them about HIV infection, and afterward to help them respond
appropriately to the results. Wigley (2004) states further that VCT thus serves as an entry point to
services that promote health and risk reduction. Those who test negative receive prevention
counseling and those who test positive receive referrals to prevention, care, support and treatment
programs. VCT also encourages and provides support for disclosing one's HIV status to sexual
partners. Reports by UNGASS, (2010) show that Nigeria has an estimated 3.6 percent of its
population living with HIV and AIDS. Although HIV prevalence is much lower in Nigeria than in
other African countries such as South
 HIV/AIDS and Voluntary Counseling and Testing (VCT) Ene Peter

Africa and Zambia, the size of Nigeria's population (around 149 million) meant that by the end of
2009, there were almost 3 million people living with HIV (UNGASS Report, 2010).

HIV/AIDS
According to Basavanthappa (2008), Amadi (2002) and Lucas and Gilles (2003), AIDS, the
Acquired Immuno-Deficiency Syndrome (sometimes called "slim disease, Basavanthappa, 2008)
is a newly described, usually fatal illness caused by a retro-virus known as the Human
Immunodeficiency Virus (HIV) which breaks down the body's immune system leaving the victim
vulnerable, to a host of life threatening opportunistic infections, neurological disorders, or unusual
malignancies.

Origin
Infectious diseases had ceased to be a major problem in developed countries till a decade or two
ago but with the advent of AIDS in the early 80's, the situation changed dramatically. Retro-virus
and their cancer causing potential are not new to scientists. Reverse transcriptase was discovered
in 1970. However, up to mid 70s another infectious retrovirus was found in human beings. In

1980, the first human retrovirus HTLV-1 was isolated which causes a rare, highly malignant cancer
called adult and T-cell leukemia, that is endemic in parts of Japan, Africa and Caribbean islands
and spreading to other regions as well, two years later, HTLV-2 was found out. Both viruses cause
immune depressions and therefore, when AIDS cases were first discovered, the initial hypothesis
was that the cause of AIDS could be a close reactive of HTLV1, the hypothesis did not prove
correct, however, the search in this direction led to the discovery of HIV as the cause of AIDS
(Basavanthappa, 2008).

Epidemiology
HIV/AIDS knows no geographical, social, racial or cultural boundaries. Initially described in 1981
in USA, AIDS is now recognized throughout the world. Though, HIV has been spreading fast in
America, Europe, Australia and Africa, Asia appears to be the continent affected last and
fortunately by HIV infection. The reason for lesser spread in the Asian countries particular India
is not very clearly understood though there could be several causes. World Health Organization
(WHO, 1987)) estimates that between 5 and 10 million people are infected with HIV. AIDS is
spreading fast and is already a worldwide epidemic. By October 1987, the AIDS epidemic had
reached at least 128 countries and a total number of cases reported rose to 60,652. But this is only
the tip of the ice berg (Basavanthappa, 2008). Also, Basavanthappa (2008), elaborating further on
the epidemiology of HIV/AIDS states that although AIDS was first reported in USA in

1981, earlier cases were found by retrospective analysis to have occurred in 1978 in the USA and
in the late 1970s in equatorial Africa. Since the beginning of the epidemic in 1981, the prevalence
has increased exponentially with a doubling time of 6 to 12 months. Also, the vast majority of

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reported cases of AIDS have come from USA; AIDS is now seen in several countries throughout
the world. According to WHO estimates, about 1 to 2 million Africans may already be AIDS
carriers and that 50,000 are now suffering from the disease. However, Lucas and Gilles, (2003)
notes that HIV/AIDS has developed into a massive global pandemic. Sub-Saharan Africa is the
most severely affected region with prevalence rates among adults in some communities of the
order of 20-30%. As the epidemic evolves, foci of high prevalence are developing in Asia and
other regions.

Causative Organism
Two retroviruses have been identified as the aetiological agents of AIDS. Retrovirus is
characterized by coding its genetic material in RNA instead of in DIMA. Like other viruses,
retrovirus cannot replicate without taking over the biosynthetic apparatus of a cell. Retroviruses
are unique in their capacity to reverse ordinary flow of genetic information from DNA to RNA to
proteins. With the help of reverse transcriptase, viral RNA is converted into DNA which gets
integrated into genome of the host. Once getting established in the host genomes, the viral DNA
remains latent until it is activated to make new virus particles. (Other retroviruses have been
associated with immunodeficiency and can cause cancers in animals). Human immunodeficiency
virus, HIV-1 formerly called the lymphadenopathy - associated virus (LAV) or the human T-
lymphocyte virus type III was discovered in 1983. More recently, a new strain, HIV-2 was
discovered in West Africa. HIV binds specifically to C04 lymphocytes and eventually destroys
them. The virus also invades other cells and lies dormant in them for long periods (Basavanthappa,
2008 & Lucas and Gilles, 2003).

Mode of Transmission
Amadi, (2002), Lucas and Gilles (2003), and Basavanthappa, (2008) all agree that HIV/AIDS is
transmitted from person to person most frequently through sexual activity. The infection is not
transmitted through casual contact in the household, office or school nor during other normal social
activities. Biting of insects does not seem to play a role in the transmission of the infection.

Transmission occurs through the transfer of body fluids by four main routes:

Sexual Transmission
AIDS is first and foremost a sexually transmitted disease. Any vaginal, anal or oral sex can spread
AIDS.

Blood Contact
AIDS is also transmitted by contaminated blood transfusion of whole blood cells. Also,
contaminated instrument such as; any skin piercing (including injects, ear piercing, tattooing,

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acupuncture or scarification) can transmit the virus if the instruments used have not been sterilized
and have previously been used on infected person.

Prenatal Transmission
An AIDS infected mother can transmit the virus to her child during pregnancy (through the
placenta) or during birth.
Intravenous Drug Abusers
Drug addicts become infected by sharing unclean needles and other paraphernalia with infected
persons.

Clinical Features
The clinical features of HIV infection have been classified into three or four broad categories; in
the three categories all the features of the fourth category classification are still present. Notably,
AIDS strictly speaking refers only to the late stage of HIV infection. The categories are:

i. Initial acute infection characterized by mononucleosis - type illness and zero

conversion.
ii. Intermediate asymptomatic infection without clinical features and the AIDS - related
complex (ARC) characterized by fever, weight loss and persistent lymphadenopathy. iii.
Late infection; full blown AIDS characterized by opportunistic infections which include:

 Pneumocystic carinii pneumonia

 Disseminated cytomegalovirus (CMV) infection
 Central nervous system (CNS) toxoplasmosis.

 Oesophageal candidiasis Herpes virus infection

Secondary cancers o Kaposi sarcoma
Neurological disease o AIDS dementia complex

Management
Antiretroviral Chemotherapy
Treatment with Zidovudine, the first specific drug for the treatment of HIV/AIDS, gave clear but
limited benefits to patients with advanced disease and those who were immuno compromised.
Newer drugs, reverse transcriptase and protease inhibitors, used in combination significantly
reduce mortality and confer other clinical benefits, more substantial and more durable than
monotherapy with AZT (Zidovudine). It also significantly reduces the risk of vertical transmission
from an infected pregnant woman to her child.

1. Reverse transcriptase inhibitors include:

a. Nucleoside reverse transcriptase inhibitors (NRTIS) such as

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i. Zidovudine (AZT, ZDV)

ii. Didanosine (ddl)
iii. Zalcitabine (ddc) iv. Stavudine (d4T)

v. Lamivudine (3TC)
vi. Abacvir (ABC)
b. Non-nucleoside reverse transcriptase inhibitors (NNRTIS)
i. Nevirapine (NVP)
ii. Efavirenz (EFV)
iii. Delavirdine (DLV)

b. Protase inhibitors
• Saquinavir (SQV)
• Ritonavir (RTV)
• Indinavir (IDV)
• Nelfinavir (NEV)
• Amprenavir (APV)
• Lopinavir / iritonavir

Prevention and Control

According to Lucas and Gilles (2003), the most logical approach to the control of the infection
is to reduced transmission whilst providing human care for patients. The role of chemotherapy
in the control of the disease is expanding but it is limited in developing countries because of the
high cost of the drug and the complexity of the schedules as well as the demanding close
monitoring of the patients. The most important tool is through education directed at each of the
four modes of transmission.

This can be achieved through the following:

Health education
Promote community wide awareness of HIV/AIDS
Inform people on how to protect themselves against infection with emphasis on sexual
abstinence and monogamous relationships.

Promote safe sex including the use of male and female condoms.
Promote safer habits among illegal drug users.

Control sexually transmitted diseases.

Promote safe sexual habits
Ensure access to inexpensive condoms

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Prompt diagnosis and treatment of other sexually transmitted diseases.

Establish and manage surveillance programme

Promote voluntary counseling and testing

Collate and analyze data from sentinel sites and groups to determine trends

Identify high risk groups including commercial sex workers.

Prevent mother to child transmission

General prevention of HIV infections
Voluntary screening of pregnant women
Prevent unwanted pregnancy in infected person
Use antiretroviral therapy to protect the child and care for the mother.

Provide and manage the anti-retroviral therapy

a. Give high priority to treatment of pregnant women and her child.
b. Define feasible chemotherapeutic programme in view of the complexity of the schedules,
the need for close monitoring of patients including laboratory support, and the high cost
of drugs.

Concept of Voluntary Counseling and Testing (VCT)

VCT is when a person chooses to undergo HIV/AIDS counseling so that they can make an
informed decision about whether to be tested for HIV. Hornby, (2006) defines voluntary as "done
willingly, not because you are forced" In same vein, counsel is defined as "advice, especially
given by older people or experts; a piece of advice. Also, "to listen to and give support or
professional advice to somebody who needs help" (Hornby, 2006). Whereas testing is defined as
(2) "a medical examination to discover what is wrong with you or to check the condition of your
health" (Hornby, 2006). Counseling is a private conversation with a specially trained person
aimed at helping individuals to help themselves. Counseling encourages an individual to explore
possible solutions to their problems, and to consider the impact that certain decision may have
on their lives. HIV/AIDS counseling provided at VCT sites is free and confidential. This means
that the Counselor cannot tell anyone about the result without their permission. The individual
must receive face-to-face counseling before the test. This is known as pre-test counseling, and is
aimed at ensuring individuals make a well-informed decision about whether to have the HIV test
or not, and encourages exploration of the possible impact that having the test may have on their
lives. Once the test has been done, post-test counseling is done. This is the counseling during
which result is given to the individual. People who have good pre and post-test counseling are
able to cope better with their results, and are more likely to look after their health, and protect

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others from infection. The counseling that an individual may have once they already know their
result is known as on-going counseling. On-going counseling helps people to live positively with
HIV and provides them with support and guidance with regard to any problem that they may
face. Having the HIV antibody test is an individual's own personal decision. It is not forced on
people to have it done. Voluntary counseling and testing (VCT) is an essential component of
comprehensive AIDS prevention and treatment programs. VCT enables people to learn their HIV
status in the most informed and supportive way possible: with counseling both before the test to
educate them about HIV infection, and afterward to help them respond appropriately to the
results. VCT thus serves as an entry point to services that promote health and risk reduction, with
those who test negative receiving prevention counseling and those who test positive receiving
referrals to prevention, care, support and treatment programs. VCT also encourages and provides
support for disclosing one's HIV status to sexual partners. VCT stands for voluntary counseling
and testing (Wigley, FHI, 2004).

Goals of Voluntary Counseling and Testing (VCT)

• Generally, VCT aims at reducing spread of HIV; mitigating its impact; reducing fear &
anxiety associated with HIV testing; improving the length & quality of lives of those who
test positive by linking them to treatment, care & support services; and reducing HIV
stigma. Get information and counseling on how to live positively with the virus. This means
learning to accept the fact that the individual is HIV-infected, seeking emotional support,
eating a healthy diet, learning how to control the amount of stress in their lives, making
sure he or she does not become re-infected, and planning for the future.

• Learn to recognize the signs of opportunistic infections so individuals can get treated
promptly.

• Find out what resources are available within the community to help people manage their
HIV status.

• Find out about prophylactic drugs. These drugs do not cure HIV/AIDS, but can prevent the
individual from getting some opportunistic infections that are common with people living
with HIV/AIDS, for example, tuberculosis and some kinds of pneumonia.

• Access Nevirapine. This is a drug available at a number of hospitals and clinics that lessens
the chance of a pregnant mother passing the virus onto her baby.

• Get emotional support by seeking counseling and joining support groups.

• Make sure that they do not infect anyone else or get re-infected themselves.
• Learn how to manage the stress in their lives.

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VCT can motivate those who are not infected with HIV to stay HIV antibody negative, and to
accept those who are infected (Angaza Project Tazania, 2001).Angaza Project Tazania, (2001)
notes the following about voluntary counseling in HIV and AIDS.

Pre-Test Counseling:
This is the kind of counseling done before an individual decides whether they want to have the
HIV antibody test. Some of the issues the counselor will discuss with the individual are:

• Why the individual decided to come for counseling.

• What counseling is and the role of the counselor.
• The individual's personal history.
• Whether the individual has any health problems.
• What the individual's risk of being HIV infected is.
• What the individual knows about HIV/AIDS.

Information about HIV/AIDS, including the test procedure and what people who are HIV infected
can do to make sure that they stay as healthy as possible for as long as possible.

What alternative there are for solving their problems.

Which issues the individual wants to tackle first.
What impact the individual thinks a positive, indeterminate or negative result would have on the
individual's life and how he/she think he she would react to receiving them.

The advantages and disadvantages for having the test done.

What kind of support system the individual has including who he/she would be able to tell if tested
HIV antibody positive.

How the individual had coped with problems in the past.

Post Test Counseling:

This is the kind of counseling done after the test. During this session the counselor will:
• Give the test result.
• Let the individual express his/her feeling about being HIV antibody positive, negative or
indeterminate. Help to revisit the issues being raised during the pre test counseling session;
including any plans the individual might have made.

• Discuss any immediate problems and help to decide on a plan of action.

• Answer any questions asked by the individual and provide all useful information.
• Discuss positive living.
• Give positive information on what resources there are in community for help.

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Ongoing counseling is the kind of counseling that happens after the individual has received the
test result. The aims of ongoing counseling are to:

• Help the individual to manage the impact that HIV has on his/her own life, and thelives of
the people around him or her.

• Encourage them to take control of their health and take charge of their lives.
• Help the individual to accept his or her result and live positively with HIV/AIDS
• Explore the advantages and disadvantages of telling other people about their status.
• Assist individuals in tackling their problems • Provide emotional and psychological support

• Help to strengthen support system.

• Help to plan for the future.
• Explore issues around death and dying.
• Refer people to community resources.

HIV Antibody Test

ELISA
Some services use the ELISA HIV antibody test. A sample of blood will be taken from a vein in
the arm. This sample will be sent to the nearest laboratory where the ELISA test will be conducted.
The results take between one and three weeks.

• If the blood sample on which the ELISA test is conducted tests HIV antibody negative,
then, during post-test counseling session, the counselor will explain that the individual
tested antibody HIV negative. This means that there are no antibodies to HIV- in the
individual's blood. However, he or she may still be in the window period so the individual
will be advised to return for testing after a few months (three to six months).

• If the blood sample tests HIV antibody positive, a second blood test will be done on the
blood sample so that the result can be confirmed. If the second blood test tests HIV antibody
positive, then, during the post-test counseling session, the counselor will report the
individual tested HIV antibody positive. This means that the individual has antibodies to
HIV in his or her blood. The individual is therefore infected with HIV. The individual will
be advised to return for another test in a few months time. If the first ELISA test is positive,
but the second one is negative, the individual will be told that the result is indeterminate or
discordant. This means that the test is not sure if the individual is HIV positive or negative.

• The individual will be advised to come back in a few months time to be tested again.
Rapid HIV Test
Some HIV/AIDS counseling and testing sites use the Rapid HIV Test. If the test is a blood one,
the tip of the individual's finger will be pricked with a special kind of needle and a drop of blood

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squeezed out. Using a thin glass tube, the drop of blood will be put into a small window in the test
strip. Drops of special fluid will be added to this test window to help the blood move up the length
of the strip. The test result will be ready in 15 minutes.

• If the test shows that the individual is HIV antibody Positive, a second HIV rapid test will
be done. If the second test is also HIV antibody positive, the counselor will inform the
individual that he /she is HIV antibody positive. The individual is therefore infected with
HIV.

• If the individual is HIV antibody Negative, no further test will be done. This means that he
or she has no antibodies to HIV in his or her blood. The individual may be in the 'Window
Period', and is therefore advised to return for another test in a few weeks.

Some HIV testing sites may use the Rapid Saliva Test. This test tells if there are HIV antibodies
in the saliva and is just as quick and reliable as the others.

The Window Period

When HIV first gets into the body, the immune system recognizes it as harmful and makes special
disease fighting cells called antibodies. The body takes between 6 and 12 weeks to make these
antibodies. The HIV antibody test looks for these special cells and not for HIV itself. If an
individual has an HIV antibody test before his or her body has made these fighting cells, the test
will be HIV antibody negative, even though HIV is in the person's body. The time when an
individual has HIV in his / her body but the immune system has not made antibodies yet is known
as the window period. It is important to remember that if an individual has HIV in his / her body,
even if the individual has tested HIV antibody negative, he/she can still pass the virus onto
someone.else if they have unprotected sex. If the individual gets tested after 12 weeks, the test will
be HIV antibody positive.
This will mean that the individual has HIV.

References
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Avert International AIDS Charity. (2010). AIDS & HIV Information. AVERT.org
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Hornby, A.S. (Ed.). (2006). Oxford advanced learner's dictionary of current English (7th Ed.).
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Sepkowitz, K. A. (June 2001). AIDS--the first 20 years. New England Journal.344 (23): 176472.

UNGASS. (2010).UNGASS country progress report: Nigeria

http://www.unaids.orq/en/countriesresponses/countries Nigeria.asp.

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