Quality HIV counselling for pregnant women
Counselling and HIV testing in antenatal situations differs from VCT at dedicated counselling and testing centres in that women have not consciously decided to come for testing. Indeed, they may know little or nothing about HIV, and may never have considered testing or its implications. It differs, too, in that counselling and testing in ANC situations should be linked to concrete interventions that potentially bring an almost immediate benefit to the woman and her infant. But many complex issues raise their heads. For example, how does one counsel women who are HIV positive but who risk being thrown out of their home if they reveal their status by not breastfeeding, for example? If counselling and voluntary testing is to be widely offered to pregnant women, it is almost inconceivable that the resources will be found to provide dedicated counsellors for pre- and post-test counselling for all women at all ANC sites. It is much more likely that the bulk of the extra burden of counselling will fall on regular ANC staff with a brief extra training in counselling for HIV. This indicator, based on observation of posttest counselling sessions, uses a checklist to create a score of quality that includes interpersonal skills, information gathering from the client, correct and complete information given to the client, discussion of therapy, infant feeding options, personal circumstances and partner notification, and other aspects of counselling. It is critical that interventions which focus on protecting infants from infection do not neglect the welfare of the mother. An especially important aspect of counselling for HIVpositive pregnant women is referral to care and support services through which the HIVinfected mother can improve her own health and well-being.
In a health facility survey at antenatal clinics providing counselling and voluntary HIV testing for pregnant women, between three and five post-test counselling sessions are observed per site. Counselling skills are scored against a standard checklist of items which constitute the minimum standards for quality post-test counselling in antenatal situations. The checklist is similar to that used in Voluntary Counselling and Testing Indicator 4, VCT centres with minimum conditions to provide quality service, but in addition includes issues specific to the antenatal situation such as discussion of the risks and mechanics of vertical transmission, the proper usage of anti-retroviral therapy together with its pros and cons, and issues surrounding breastfeeding and substitute feeding. Counsellors are also assessed on the discussions they generate about shared confidentiality, reproductive choice referral for contraception, and referral for HIV-related care and support for the infected mothers.
Geographic location: N/A
Pregnancy status: N/A
Time period: N/A
Type of orphan: N/A
Vulnerability status: N/A
This indicator shares the strengths and limitations of other indicators for the provision of counselling. Observational studies are timeconsuming, and performance of counsellors may deviate from their standard practice because of the presence of the observer. Confidentiality is a major issue in observational studies of post-test counselling, and the consent of the client must be sought before observation can take place. Experience has shown that counsellors themselves often refuse to be observed. An alternative to direct observation is that counselling sessions may be taped for later anonymous review. This may reduce reluctance to participate on the part of both the client and the counsellor, makes the review exercise more time efficient, and allows for checking of variation in scoring between reviewers. The measure looks only at post-test counselling sessions. It is recognised that the quality of pre-test counselling is especially important in the antenatal setting, since many women will not previously have considered an HIV test, or will have had little or no information about mother to child transmission of HIV and potential prevention methods. However, current practice in pre-test counselling varies widely, ranging from group sessions with videotaped information to individual sessions. It would therefore be difficult to propose a standardised assessment in this area. Test results and at least part of post-test counselling, on the other hand, must always involve a private interaction between a counsellor and a client or couple. Like all composite indicators, this indicator aggregates information which must also be reported separately for most effective programme management and planning.