Access to voluntary counseling and testing for HIV in developing countries.

The counseling that precedes and follows testing of subjects for HIV has become, quite unexpectedly, a focal point for assessment of the ethical propriety, availability, and appropriateness of health services during the AIDS epidemic. It can be anticipated that in the worst affected regions, Voluntary Confidential Counseling and Testing (VCCT) will be an integral component of "...access to comprehensive, essential, quality health care" which is WHO's goal of "Health for All" in the next century. The role, purpose, location, and methods of VCCT, which were reviewed at the previous Global Strategies Conference in 1997, are summarized. Currently understood objectives of VCCT include acceptance of the test, provision of care for HIV-infected individuals (particularly pregnant women), prevention of HIV transmission, and psychosocial support. Many countries in Africa are gradually instituting VCCT as part of their Primary Health Care package. For example "...access to care, counselling and support" for HIV/AIDS and STDs is one of the top 10 national priorities in South Africa. However, closer examination in the country reveals personnel and skill shortages, inability of half the primary health care (PHC) clinics to provide antenatal services, and HIV testing being offered in only 56%. Condom availability is generally good, but termination of pregnancy is undertaken in a bare 27% of hospitals. In other regions of Africa, VCCT is also deficient in many respects: medical services are often unavailable, support is absent, availability is restricted and there are few trained counselors. Consequently, workloads are heavy. Requirements for effective counseling will be listed. The global determinants of inequities in accessing VCCT, such as the GNP and the crushing debt burden borne by poor countries, are discussed. A third of women worldwide receive no antenatal care, and just 60% of the roughly 133 million annual births throughout the world are attended by trained health personnel. Even when VCCT services are available, they are often not acceptable. The overwhelming majority of African women appear to accept HIV testing, but only a proportion (59-61% in recent intervention trials) return for the results. Obstacles to be overcome for provision of VCCT services are identified. Evidence for a positive impact of VCCT services includes facilitated decision-making, acceptance and coping with HIV, improved family and community acceptance, increased condom use, and reduced gonorrhea rates and HIV transmission.