September 27, 2010
ADMINISTRATIVE ORDER
No. 2010 – 0028
POLICIES AND GUIDELINES IN THE CONDUCT OF HUMAN
IMMUNODEFICIENCY VIRUS (HIV) COUSELING AND TESTING IN COMMUNITY AND HEALTH
FACILITY SETTINGS
I. INTRODUCTION
AND RATIONALE
The
Philippines still maintains less than one (1) percent prevalence rate of HIV
infection. Preventive interventions must be undertaken by the country in order
to maintain its low prevalence status, and the Department of Health and other
concerned agencies are focusing their efforts thereon.
Pursuant
to the 4th Medium Term Plan (2005 – 2010), HIV counseling and
testing is one of the preventive interventions used to reach the most at risk
population. The at–risk and vulnerable populations for HIV infection include
people in prostitutions, men having sex with men, people who inject drugs, and
migrant workers. HIV counseling and testing is being advocated to the most at
risk population because through this intervention, the same are given the
opportunity to known their HIV status and at the same time are provided with
information on risk reduction strategies and location of facilities to treat
HIV positive individual.
Since
counseling is anchored on HIV testing, efficient post–test counseling can
appropriately manage the negative consequences of client’s knowing their HIV
status especially if the client tested positive for HIV. On the other hand,
poor quality counseling which may inadequately address client issues may result
in suicide, depression and other psychological consequences in persons tested
positive for HIV.
Furthermore,
the importance of implementing quality counseling anchored on HIV testing as
mandated by Republic Act No. 8504, “AIDS Prevention and Control Act of 1988,”
will not only benefit the individual being tested but will also scale up
preventive interventions so as to slow down or halt the spread of HIV. Hence,
there is a need to provide a standard in the conduct of HIV counseling and
testing.
II. OBJECTIVES
General
Objective
To
provide policies and guidelines in the conduct of HIV counseling and testing
(HCT) at community and health facility settings.
Specific
Objectives
1. To identify the required components of HIV counseling
and testing and set the protocol for these components;
2. To set the standards/requirements for an HIV
counseling and testing facility; and
3. To define the roles and responsibilities of DOH and
other stakeholders in the implementation of these guidelines.
III. SCOPE AND
COVERAGE
This
guideline covers all Sexually Transmitted Infection (STI) and HIV service
providers, coordinators and managers of HIV clinics and/or testing
laboratories, all facilities offering HIV testing for diagnostic purposes,
surveillance and research, and blood safety purposes.
IV. DEFINITION
OF TERMS
1. Blood
Service Facility (BSF) – any unit,
office or institution providing any of the blood transfusion services and which
can be a blood center, blood bank, blood collection unit or blood station.
2. Confirmatory
test/testing – refers to the test
performed on samples that have tested reactive to the screening test to find
out if the results were true positive or not.
3. DOH
Retained Hospitals – hospitals that
remain under the management and supervision of the Department even after the
devolution.
4. Fourth
AIDS Medium Term Plan – the
five–years plan containing the country’s action and response towards
maintaining the low HIV prevalence status of the Philippine and preventing the
spread of HIV infection.
5. Informed
written consent – refers to the
voluntary written agreement of a person allowing him/herself to undergo or be
subjected to a procedure based on full information.
6. Overseas
Filipino Workers (OFW) clinics –
these are clinics that conduct pre – employment medical examinations for
Filipinos bound for abroad.
7. Pre–donation
counseling – a process in blood donor
selection wherein donors are informed about health conditions or risk behavior
that would make them unsuitable to donate blood. The donor’s informed consent
to blood donation and to the blood testing is obtained during counseling.
8. Reactive
sample – the blood sample from the
patient/client has antibodies that reached to the HIV antigen or vice versa in
the screening test. However, the presence of reactive sample does not totally
confirm that the person has HIV infection.
9. Screening
test – refers to the initial
serological test performed to determine the presence of antibody and/or antigen
against HIV1 and HIV2.
10. Social Hygiene Clinics – these are clinics of the local government unit that
are usually part of the municipal/city health office providing reproductive
health service including management of STI.
11. Treatment hub
– a hospital facility with an organized HIV/AIDS Core Team (HACT) providing
prevention, treatment care and support services to People Living with HIV
(PLHIV) including but not limited to HIV counseling and testing, clinical
management, patient monitoring and other care and support services. ARV
treatment can only be accessed through these facilities. Refer to ANNEX II for
the list of treatment hubs.
12. HIV Counseling and Testing (HCT) – also called Voluntary Counseling and Testing (VCT),
is a counseling process that enables a client make an informed choice about
being tested for HIV. The counseling process has two components, the pre and
post HIV test counseling.
a. Pre–HIV
test counseling – a process that
prepares the client for the HIV test. Pre –HIV test counseling explains the
implications of knowing that one is or is not infected with HIV, facilitates
discussion about ways to cope with knowing one’s HIV status, to enable an
individual to practice strategy to reduce future risk behaviors. It can be
Client initiated (CICT) or provider initiated HIV counseling and testing
(PICT), both process is voluntary and enables client to make informed decision
about being tested for HIV infection.
b. Post HIV
test counseling – process conducted
by a trained personnel to assist the client understand and cope with the HIV
test result and be able to identify options for future plans including
physical, mental, social, reproductive and other personal concerns.
13. HCT facility
– any health facility equipped in providing services on HIV counseling and
testing recognized by DOH. It can be free–standing or incorporated into
existing health–care services.
V. GENERAL
GUIDELINES
1. All HCT facilities shall observe the principles of
counseling, informed consent and confidentiality at all times. (Refer to Annex
I for Minimum Information provided during Pre–test Counseling).
2. All HCT facilities shall be duly licensed and comply
with the standards set by the Department of Health for an HIV Testing Center.
3. All Social Hygiene Clinics (SHC) shall offer to most
at risk and vulnerable clients HIV counseling and testing services or referral
at regular intervals.
4. All DOH–licensed OFW clinics shall provide pre–HIV and
post–HIV test counseling to all their clients for HIV testing as mandated by Republic
Act No. 8504, “AIDS Prevention and Control Act of 1998.”Provision for
counseling shall be part of the accreditation requirements of OFW clinics.
5. Blood service facilities (BSF) shall include it its
pre–donation counseling an assessment of risk behavior among all its potential
blood donors. All individuals seen at BSF with high risk behavior among all its
potential blood donors. All individuals seen at BSF with high risk behavior
shall be deferred and shall be referred to a HCT facility for counseling and
HIV testing.
6. All identified treatment hubs (See Annex II) and DOH–retained
hospitals shall set– up and provide HIV counseling and testing as part of HIV
AIDS Core Team (HACT) services and as potential referral facilities for LGU and
NGO based HIV counseling and testing facilities.
7. Private and LGU hospitals shall be encouraged to set
up within their systems provisions of HIV counseling and testing services for
walk in clients. The said services shall be closely linked to the HACT of the
hospital.
8. All persons who underwent HCT shall be provided with
their test results with post – test counseling, except for testing done during
blood donation, surveillance and research purposes. No other person shall be
provided with the result other than the person tested except in circumstances
allowed by R.A. 8504 or similar guidelines.
VI. SPECIFIC
GUIDELINES
1. Conduct of
Pre–HIV Test Counseling
a. Client–Initiated
Counseling and Testing
(1) All clients who want to be tested for HIV shall be
provided with pre–HIV test counseling in a space where privacy could be
observed and confidentiality ensured.
(2) Pre–HIV test counseling shall either be conducted in
individual or group settings. Client shall be strongly encouraged to bring
their confidants during the pre– and post–HIV test counseling.
(3) The same counselor is highly recommended to conduct
both pre– and post– test counseling and, if needed, follow–up sessions for a
client.
(4) Adult clients shall be counseled in a setting that is
safe and secure for both counselor and client.
(5) Pre– and post–HIV test counseling of children shall
take into consideration the maturity of the client and, when necessary,
responsible parents or a legal guardian, including any registered social
worker, shall be involved.
(6) Counselors shall ensure that clients understand the
information printed on the consent form. All necessary and correct information
that clients need to make decisions for themselves shall be provided.
(7) Counselors shall strongly encourage follow–up counseling
sessions and ensure that clients utilize referral networks that are in place
and functional.
(8) All Counselors shall have basic knowledge on voluntary
blood donation and incorporate facts on blood donation when appropriate.
b. Provider–Initiated
Counseling and Testing
(1) As part of medical management, HIV testing shall be
offered by health care provider to ALL the following:
(a)
Clients assessed
for STI in an STI clinic or elsewhere;
(b)
Pregnant women
with one or more of the following HIV risks:
· Multiple sex
partners,
· Persons who
inject drugs (PWID),
· History of STI,
including a diagnosis of syphilis
· Husband or
partner has multiple sex partners, history of STI or is a known PWID
(c)
People accessing
community – based services designed for males having sex with males, people in
prostitution and those who inject drugs;
(d)
Diagnosed TB
patients, as discussed in A.O. 2008 – 0022, otherwise known as “Policies
and Guideline in the Collaborative approach of TB and HIV Prevention and
Control.”
(e)
Patients showing
signs and symptoms consistent with HIV–related diseases or AIDS seen by the
attending physician.
(f)
Parents/Guardians
of all children born to HIV infected mothers (or those with possible exposure).
(2) Basic conditions on confidentiality, informed consent,
and counseling shall be adhered to.
(3) Pre–HIV test counseling shall be limited to basic
information – giving that would help the patient decide whether to accept HIV
testing (See Annex I).
(4) Post–HIV test counseling services shall be provided to
all clients tested by trained personnel (See Annex III).
(5) Counselors providing post–test counseling services
shall emphasize prevention for those that tested negative and, medical and
psychosocial support to those that tested positive.
(6) The capacities for pre and post HIV test counseling
including the capacity to provide medical and psychosocial support shall be
enhanced and the referral networks between and among these providers shall be
functional.
2. Conduct of
HIV Testing
Only
registered medical technologist with HIV proficiency training shall perform the
HIV test using Food and Drug Administration (FDA) registered test kits. Other
screening tests may be performed including but not limited to Enzyme
Immunoassay (EIA), Particle Agglutination (PA) and Rapid Assay (RA). Reactive
samples from clients/patients shall be brought to the STD/AIDS Central
Cooperative Laboratory (SACCL) at the San Lazaro Hospital for confirmatory
testing (Refer to Annex IV for the Current HIV Diagnostic Testing Algorithm).
For reactive blood units (not person) from blood banks, samples shall be
referred to the Research Institute for Tropical Medicine (RITM) for
confirmatory testing.
3. Release
and Reporting of Test Result
Samples
reactive to screening test shall not be reported directly to the
client/patient. All reactive samples shall be referred for confirmatory
testing. The reference laboratories namely SACCL and RITM shall not release the
result of the confirmatory test directly to the patient/client under any
circumstance but must send the result to the referring HIV testing facility.
This is to ensure that the release of the HIV test shall be accompanied by
post–test counseling especially if the result is positive. SACCL and RITM are
required to report the confirmed positive samples to the National Epidemiology
Center (NEC).
It
is the responsibility of the BSF to ensure that donors have been screened
properly and pre–donation counseling has been provided to all potential blood
donors in order to prevent the occurrence of reactive and positive samples by
eliminating those individual with high risk behaviors. For confirmed positive
blood units, tracing the donor and informing him/her of the result is not
recommended. Providing result to a free HIV test can put the blood supply at
risk as high risk individuals within the window period may avail of this free
services. Information campaign on HIV services available and stigma reduction
activities will be intensified by CHD in areas where positive blood units are
identified.
4. Conduct of
Post–HIV test Counseling
Post–HIV
test counseling shall be provided together with the release of the test result
whether the test is negative or positive. It shall be done in an enclosed space
where counseling can be done in privacy. It is recommended that the trained
counselor who performed the pre–test counseling shall also provide the post –
test counseling. Refer to Annex III for the list of information that should be
disclosed to the clients/patients during post–test counseling.
5. Special
Concerns on Post HIV Test Counseling: Infant Feeding
HIV–Infected
pregnant women shall also be given information on the risk and benefits of
exclusive breastfeeding, exclusive replacement feeding and guidance in
selecting the most suitable option in their circumstances. (The entire spectrum
of preventing mother to child transmission of HIV is described under A.O. No.
2009 – 0016).
VII. REQUIREMENTS
FOR AN HIV COUNSELING AND TESTING FACILITY
1. Human
Resources
a. Physician, allied medical/social welfare personnel
trained in conducting pre–test and post–test counseling for HIV by DOH or any
of its recognized organizations.
b. Registered Medical Technologist with training on HIV
proficiency testing
2. HIV test
kits
a. Only FDA
registered test kit or other available screening test (EIA/PA/RA) shall be used
in HIV testing;
b. For HCT
facilities with no HIV testing capacity, there shall be an explicit linkage to
any DOH–accredited HIV laboratory for HIV testing.
c. Space – an
enclosed room or devoted section/space where counseling can be done in privacy.
d. Annual
certification of satisfactory performance in the National External Quality
Assurance Programme of NRL–SACCL or its designate.
VIII. ROLES AND
RESPONSIBILITIES
1. National
Center for Disease Prevention and Control
a. Advocate the setting up of HCT facilities to the local
government units (LGU)/hospitals/health facilities as a preventive intervention
in reaching the most risk population.
b. Conduct awareness campaign on HIV and AIDS in the
workplace including the availability of HIV counseling services either by the
DOH–licensed HIV laboratory staff and/or HIV AIDS Core Team.
IX. FUNDING
The
Infectious Disease Office of the NCDPC shall allocate budget for the
implementation of these policies and guidelines including but not limited to
fund for the augmentation of HIV test kits and funds for training. Other DOH
Offices including CHD and DOH– retained hospitals shall support financially, as
part of their annual budget, the implementation of these policies and
guidelines.
X. REPEALING
CLAUSE
Provisions
in previous issuances that are inconsistent and contrary to this Administrative
Order are hereby rescinded and repealed.
XI. EFFECTIVITY
This
Administrative Order shall take effect immediately.
ENRIQUE T. ONA, MD,
FPCS, FACS
Secretary of Health
ANNEX I
MINIMUM INFORMATION
PROVIDED DURING PRE–TEST COUNSELING
(Adapted from Guidance
on Provider–Initiated HIV Testing and Counseling in Health Facilities, WHO–UNAIDS
2007)
1. The reason why
HIV testing and counseling is being recommended;
2. The clinical and
prevention benefits of testing and potential risks, such as discrimination,
abandonment or violence.
3. The services that
are available in the case of either and HIV–negative or an HIV–positive test result,
including whether anti–retroviral treatment is available;
4. The fact that the
test result will be treated confidentially and will not be shared with anyone
other than health care providers directly involved in providing services to the
patient;
5. The fact that the
patient has the right to decline the test and that testing will be performed
unless the patient exercises that right;
6. 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;
7. In the event of
an HIV–positive test result, encouragement of disclosure to other persons who
may be at risk of exposure to HIV;
8. An opportunity to
ask the health care provider questions;
9. Patients should
also be made aware of relevant laws in jurisdictions that mandate the
disclosure of HIV status to sexual and/or drug injecting partners.
Other
information/topics that should be included during Pre–HIV test counseling
(client– initiated)
1.
Risk assessment
and risk reduction strategies
2.
Promotion and
facilitation of behavior change
3.
Ways of coping
positive results
4.
Exploration of
potential support for family or friends
Additional
information for women who are or may become pregnant
1. The risk of
transmitting HIV to the infant;
2. Measure that can
be taken to reduce mother–to–child transmission, including anti–retroviral
prophylaxis and infant feeding counseling;
3. The benefits to
infants of early diagnosis of HIV
Annex II
List of Treatment Hubs
in the Philippines
A. Luzon
1.
San Lazaro
Hospital
2.
Research
Institute for Tropical Medicine
3.
Philippine
General Hosptial
4.
Ilocos Training
and Regional Medical Center
5.
Baguio General
Hospital and Medical Center
6.
Bicol Regional
Training and Teaching Hospital
7.
Cagayan Valley
Medical Center
8.
Jose B. Lingad
Memorial Regional Hospital
B. Visayas
1. Vicente Sotto
Memorial Medical Center
2. Western Visayas
Medical Center
3. Corazon Locsin
Montelibano Memorial Regional Hospital
C.
Mindanao
1. Davao Medical Center
2. Zamboanga City Medical Center
Annex III
MINIMUM INFORMATION
GIVEN DURING POST–TEST COUNSELING
(Adapted from Guidance
on Provider–initiated HIV Testing and Counseling in Health Facilities, WHO–UNAIDS
2007)
Post–test counseling
for HIV–negative persons
Counseling for individuals
with HIV–negative test results should include the following minimum
information:
1. An explanation of
the test result, including information about the window period for the
appearance of HIV–antibodies and a recommendation to a re–test in case of a
recent exposure;
2. Basic education
on method to prevent HIV transmission;
3. Education on
condoms and guidance on their use.
4. The health care
provider and the patient should then jointly assess whether the patient needs
referral to more extensive post–test counseling session or additional
prevention support, for example, through community–based services and VCT
facilities with CICT capacity.
Post–test counseling
for HIV–positive persons
The focus of post–test counseling
for people with HIV–positive results is psychosocial support to cope with the
emotional impact of the test result, facilitate access to treatment, care and
prevention services, prevention of transmission and disclosure to sexual and
injecting partners. Health care providers should:
1. Inform the
patient of the result simply and clearly, and give the patient time to consider
it;
2. Ensure that the
patient understands the result;
3. Allow the patient
to ask questions;
4. Help the patient
to cope with emotions arising from the test result;
5. 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;
6. 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;
7. Provide
information on how to prevent transmission of HIV, including provision of male
and female condoms and guidance on their use;
8. Provide
information on other relevant preventive health measures such as good
nutrition, use of cotrimoxazole and TB;
9. Discuss possible
disclosure of the result, when and how this may happen and to whom;
10. Encourage and offer referral for testing and
counseling of partners and children;
11. Assess the risk of violence or suicide and discuss
possible steps to ensure the physical safety of patients, particularly women;
12. Arrange for a specific date and time for follow up
visits or referrals for treatment, counseling, support and other services as
appropriate (TB screening and treatment, antenatal care, access to sterile
needles and syringes).
ANNEX IV–A
CURRENT HIV DIAGNOSTIC
TESTIGN ALGORITHM FOR ADULTS AND INFANTS ≥18 MONTHS OLD
a. HIV test kits
with ≥99% specificity are used for the first screening process.
b. Samples that
turned out to be non–reactive on the first screening test are considered
seronegative and the client is given a negative rest report. No further testing
is required.
c. Samples found
sero–reactive by all HIV screening test will be sent to the referral laboratory
(SACCL) for confirmatory testing.
d. Sero–reactive samples
will be tested on SACCL with 2 different test formats (PA and EIA Ag/Ab). If
one or both of the tests on parallel examinations is positive then Western Blot
test will be performed on the sample. If both tests are negative then a
negative test report will be released.
e. Samples that are
positive on Western blot will be reported as positive and those that are
negative will be reported as negative. If the result is intermediate, repeat
follow up testing may be required (3,6 and 12 months). If the results remain
indeterminate after 1 year, the person is considered to be HIV antibody
negative. The client is given a negative test report.
f. Client should be
advised to come back to the HIV counseling and testing (VCT) facility after an
estimated turn–around time.
g. The client is
given HIV test report after conducting post–test counseling.
ANNEX IV–B
CURRENT HIV DIAGNOSTIC
TESTING ALGORITHM FOR INFANTS <18 MONTHS OLD
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