HTS Guidelines

ZIMBABWE
National Guidelines on
HIV Testing and Counselling
May 2014
Second Edition
Foreword
Zimbabwe National Guidelines on HIV Testing and Counselling
The Ministry of Health and Child Care remains committed and focused on halting the
spread of HIV and AIDS in line with the Millennium Development Goals as well as the
Universal Access targets for HIV prevention, care and treatment services. The primary
target for HIV Testing and Counselling (HTC) is that by 2015 85% of the people of
our sexual active adults know their HIV status. HTC remains a critical entry point to
HIV prevention, treatment, care and support services. Person who have been tested
and counselled are more likely to take responsibility for reducing the spread of HIV
and related morbidity and mortality. Encouraging more people to know their HIV
status will indeed lead to early diagnosis and access to care, treatment and support
for both those tested HIV positive and negative. However, it is currently estimated
that about half of the people living with HIV globally do not know their HIV status.
Those who get tested for HIV often test too late. Poor linkages from HIV Testing and
Counselling to care, including failure to access ART services timely, means that many
people start treatment when they are already significantly immunocompromised
resulting in poor health outcomes and continual spread of HIV infection.
The 2010-2011 ZDHS has shown continued decline in adult HIV prevalence rate from
18% to 15% between 2005 and 2011. Modelling has also shown a decline in the
incidence rate. The drop in the incidence rate can be attributed to, among other
things, the increasing number of people getting tested and knowing their status with
the effect of taking a more proactive and responsible behaviour that contributes to a
reduction in the spread of HIV. However, in the same ZDHS report only 57% of
women and 36% of men had been tested for HIV and received their results, while
only 45% of young women and 24% of young men, aged 15-24 years, who had
sexual intercourse in the preceding 12 months had tested for HIV and received their
results in the same period. There is therefore need to increase access and scale up
HIV Testing and Counselling services so as to achieve our goal as well as universal
i
access to ART services. The need to come up with innovative approaches, like
community based HIV testing and counselling services, in line with the 2013 WHO
Consolidated Guidelines to reach as many people as possible who know their HIV status
and appropriately linked to prevention, treatment and care cannot be overemphasized.
It is the Ministry of Health and Child Cares expectation that these guidelines will provide
national standards that must be adhered to in the provision of high quality client and
provider initiated HIV testing and counselling services in Zimbabwe.
Brigadier General (Dr) G Gwinji

Permanent Secretary of Health and Child Care
ii
Acknowledgements
These guidelines represent a strong collective effort from different people and
organizations.
The Ministry of Health and Child Care would like to thank the AIDS and TB Programme
for coordinating the committee that drafted the HIV Testing and Counselling guidelines.
Special acknowledgement and appreciation go to the teams from various organizations,

which included UNICEF, Ministry of Primary and Secondary Education, Ministry of
Health and Child Care, Zvitambo, Shine, Population Services International Zimbabwe,
Director of Health Services Harare, Medical Laboratory and Clinical Scientists Council,
National Microbiology Reference laboratory, Zimbabwe Quality Assurance Programme,
Zimbabwe Lawyers for Human Rights, Elizabeth Glazier Paediatric Foundation, CDC
Zimbabwe, CONTACT, CONNECT, CHAI, PANGEA, ZNNP+ and AFRICAID.
Special gratitude goes to Ms Getrude Ncube (MOHCC), Mrs Beatrice Dupwa (MOHCC),
and Mrs S.C. Gwashure (MOHCC) for providing oversight, strategic direction and
significant technical input.
World Health Organisation (WHO) Zimbabwe Country Office is acknowledged for

financial assistance and technical support through Dr Christine Chakanyuka (National
Programme Officer, HIV/TB). Special thanks are due to Dr Buhle Ncube (HIV Prevention
Focal Point, WHO Inter-country Support Team for East and Southern Africa,
WHO/AFRO) for her invaluable technical expertise in updating and compiling these
harmonised HTC guidelines.
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Table of Contents
Foreword..........................................................................................................................i
Acknowledgements........................................................................................................iii
List of Tables and Figures.............................................................................................vi
Acronyms ......................................................................................................................vii
Chapter 1 Introduction.............................................................................................1
Chapter 2 Ethical and Legal Considerations............................................................3

2.1 HIV testing and counselling and human rights............................................3
2.2 Core values and Guiding principles................................................................4
2.3 Anonymous testing .........................................................................................6
2.4 Mandatory HIV testing....................................................................................6
2.5 Disclosure .........................................................................................................7
2.6 Partner notification .........................................................................................7
2.7 People Living with Disabilities........................................................................7
2.8 HTC and Post-Exposure Prophylaxis (PEP) ...................................................8
Chapter 3 Service Delivery Approaches and Models ...............................................9

3.1 Coordination of HTC Services.........................................................................9
3.2 Service delivery approaches ............................................................................9
3.3 HTC Service Delivery Models ........................................................................10
3.4 Operational requirements..............................................................................11
3.5 Minimum Requirements for Service Delivery ..............................................17
3.6 Minimum Supplies for all Service Delivery Models.....................................19
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Chapter 4 HIV Counselling ....................................................................................20

4.1 Guiding principles for HIV testing and Counselling (HTC)........................20
4.2 Counselling for Children and Adolescents...................................................21
4.3 Counselling for Adults ..................................................................................24
4.4 Counselling for pregnant and lactating women.........................................26
4.5 Couple counselling........................................................................................27
4.6 Counselling for Key Populations ..................................................................33
4.7 Counselling within community settings ......................................................37
4.8 Counsellor self-care and support .................................................................39
4.9 Quality assurance for HTC ............................................................................40
Chapter 5 HIV Testing and Supply Chain Management .......................................41

5.1 Coordination of HIV testing services ...........................................................41
5.2 HIV testing procedures..................................................................................41
5.3 HIV Testing Algorithms.................................................................................43
5.4 Repeat testing................................................................................................45
5.5 Retesting ........................................................................................................45
5.6 Minimum requirements for laboratory standards .......................................49
5.7 Quality Assurance (QA) .................................................................................49
5.8 Handling of contaminated waste.................................................................53
5.9 Laboratory Safety Rules ................................................................................53
5.10 Supply Chain Management ..........................................................................54
Chapter 6 Scaling Up HIV Testing and Counselling Services ...............................55

6.1 Ensuring a conducive policy environment ..................................................55
6.2 Community based demand creation............................................................56
6.3 Capacity building .........................................................................................59
6.4 Increasing demand for services ....................................................................60
6.5 Increasing access to services.........................................................................61
6.6 Normalizing HTC in communities................................................................62
6.7 Support groups..............................................................................................62
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Chapter 7 Monitoring and Evaluation...................................................................63

7.1 Defining monitoring and Evaluation...........................................................63
7.2 Purposes of Monitoring and evaluation......................................................63
7.3 Roles and Responsibilities.............................................................................64
7.4 Data Management and Use ..........................................................................66
References ....................................................................................................................67
Annexes
Annex 1: List of participants................................................................................69
List of Tables and Figures
List of Tables
Table 1: Advantages and key considerations for facility-based HTC services ...................11
Table 2: Advantages of community-based HTC services....................................................14
Table 3: Comparison of CHTC and Individual HTC ............................................................29
Table 4: Possible HIV test results in CHTC...........................................................................31
Table 5: Additional counselling considerations for key populations.................................35
Table 6: Key counselling considerations for specific community based HTC models.....38
Table 7: Level-specific QA responsibilities for HIV testing .................................................51
Table 8: M&E activities by level of health care ...................................................................65
List of figures
Figure 1: Linkages between CHTC and other programmes ................................................30
Figure 2: Algorithm for Serial HIV Testing ..........................................................................44
Figure 3: Retesting Guideline for the General Population ................................................46
Figure 4: Retesting Guideline for Pregnant Women...........................................................47
Figure 5: Retesting for Lactating mothers...........................................................................48
Figure 6: Flow of HIV Testing and Counselling Data.........................................................64
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Acronyms
AIDS Acquired Immune Deficiency Syndrome

ANC Antenatal Care
ART Anti-Retroviral Therapy
ARVs Anti-Retroviral Drugs
CBOs Community Based Organizations
DNA Deoxyribonucleic acid
ELISA Enzyme-Linked Immunosorbent Assay
FBOs Faith-based organizations
FCH Family and Child Health
HIV Human Immune deficiency Virus
IDUs Intravenous Drug Users
NHIS National Health Information System
MLCSC Medical Laboratory and Clinical Scientists Council
MOHCC Ministry of Health and Child Care
MSM Men who have Sex with Men
NGO Non-Governmental Organization
PC Primary Counsellor(s)
PCR Polymerase chain reaction
PEP Pre Exposure prophylaxis
PITC Provider Initiated Testing and Counselling
PLWHIV People Living with HIV
PMTCT Prevention of Mother-To-Child Transmission of HIV
PPF Prevention Partnership Forum
QA Quality Assurance
RNA Ribonucleic acid
SOP Standard Operational Procedure
STI(s) Sexually Transmitted Infection(s)
TB Tuberculosis
WHO World Health Organization
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Summary Table of Contents
Chapter 1 Introduction ..........................................................................1
Chapter 2 Ethical and Legal Considerations.........................................3
Chapter 3 Service Delivery Approaches and Models ...........................9
Chapter 4 HIV Counselling ..................................................................20
Chapter 5 HIV Testing and Supply Chain Management......................41
Chapter 6 Scaling Up HIV Testing and Counselling Services ...............55
Chapter 7 Monitoring and Evaluation .................................................63
References ............................................................................................67
Annex 1: List of participants ..............................................................69

chapter 1
Introduction
Zimbabwe is among one of the countries Zimbabwe, His Excellency Comrade

with the highest HIV infection rates in Robert Gabriel Mugabe, launched the
Sub-Saharan Africa. The estimated HIV National HIV and AIDS Policy for
prevalence amongst the adult population providing guidance for HIV and AIDS
is 15% while 1.4 million people (adults intervention and prevention strategies.
and children) are living with HIV and These included HIV testing and
AIDS1 and 1056 483 (adults and counselling, which aim at reducing high-
children) in urgent need of antiretroviral risk behaviour through promotion of
therapy (ART) in 2014. An estimated sustained behaviour change, and early
46 000 (adults and children) in 2013 diagnosis of those who need treatment?
succumbed to HIV and AIDS-related The need for increased access to HIV
diseases annually, leading to many child- testing and counselling services is
headed households and orphans who are increasingly compelling as HIV infection
estimated at more than 1 million.1 rates in the country are high. The
government realizes that knowledge of
The AIDS epidemic in Zimbabwe is HIV status among Zimbabweans is an
highest in the sexual active and most important prevention and treatment
economically productive age group of intervention strategy that influences
15 49 years, robbing the nation of positive behaviour change.
crucial resources for economic
development. The Government of HIV testing and counselling is the entry
Zimbabwe has demonstrated a high level point to HIV prevention, treatment care
of commitment to fight the HIV and and support. It also contributes to
AIDS epidemic. In 1999, the President of reduction of the stigma and
1 Zimbabwe National HIV and AIDS estimates 2012 and 2013. Health Information
and Surveillance Unit, Department of Disease Prevention and Control, AIDS and
TB Programme, Ministry of Health and Child Welfare, Harare, Zimbabwe.
1
discrimination that surrounds HIV and important step towards achieving

AIDS. In Zimbabwe, access to knowledge universal access to ARV medicines for
of ones HIV status has mainly been treating and preventing HIV, therefore
through the client-initiated approach this calls for universal access to HIV
(VCT), whereby clients proactively seek testing and counselling. HIV testing and
the service and through provider initiated counselling is the gateway to HIV
testing and counselling (PITC) where HIV prevention, treatment and care hence the
testing and counselling is routinely need to come up with innovative and
offered to all patients seeking health diverse models of providing HIV testing
care. However, with the new and counselling in Zimbabwe. It is
opportunities for HIV prevention, against this background that Zimbabwe
treatment, care and support including revised the HTC guidelines to include
treatment for prevention, there is need to other innovative strategies of increasing
rapidly scale up HTC services. This will access to HTC services through
enable the early identification and community based approaches, thus
linkage of those in need of HIV care and complementing the facility based testing
treatment as well as other prevention and counselling (PITC and CITC). The
interventions. overall aim is to identify as many people
living with HIV as early as possible and
In July 2013 the WHO launched the link them to prevention, treatment, care
2013 2 Consolidated Guidelines on the and support services.
use of Antiretroviral medicines for
Treating and Preventing HIV infection. The purpose of these guidelines is to
The consolidated, guidelines provide provide national standards that must be
guidance on the diagnosis of Human adhered to by all institutions,
Immunodeficiency Virus (HIV) infection, organisations and individuals for the
the care of people living with HIV and provision of high quality HIV testing and
use of antiretroviral (ARV) medicines for counselling services in Zimbabwe for
treating and preventing HIV infection. both facility based and community based
The 2013 guidelines represent an approaches.
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chapter 2
Ethical and
Legal Considerations
2.1 HIV testing and The human rights principles most

counselling and relevant to HTC and which every service
human rights provider and client should be made
aware of include:
The Government of Zimbabwe has stated
that it is every Zimbabweans right to l The right to give informed consent
know his or her HIV status. HIV testing before a medical procedure is carried
and counselling (HTC) services must out
therefore be provided in an environment
l The right to correct information for
where human rights are respected. Such
making choices about ones health
an environment allows all citizens
and well being
infected or affected by HIV to live a life
of dignity and access prevention, l The right to privacy, including the
treatment, care and support services right not to have a health condition
without discrimination. The Constitution disclosed
of Zimbabwe states that Every citizen l The right to non-discrimination,
and permanent resident of Zimbabwe equal protection and equality before
has the right to have access to basic the law
health-care services, including
l The right to marry and found a
reproductive health-care services and
family
that Every person living with a chronic
illness has the right to have access to l The right to bodily integrity
basic healthcare and that the l The right to the highest attainable
Government must take reasonable standard of physical and mental
legislative and other measures to achieve health
progressive realisation of these rights.
3
2.2 Core values and Guiding quality HTC services, and quality
principles assurance measures should be in place to
ensure that HTC is routinely offered and
In Zimbabwe, all health care providers are correct test results provided. All persons
bound by an ethical principle to do all providing HTC should be trained to
that is necessary and available to provide provide quality HTC services, receive
the best possible care. As such, HTC supportive supervision and consultative
service provision should be guided by the support on improving their professional
following core values and guiding practice. They should recognize any
principles: boundaries and limitations of their
competence and make appropriate
2.2.1 Core Values referrals.
l Benefitting others: Services offered
should be of value to the patient. ii) Confidentiality
Confidentiality in the provision of HTC
l Respect for human life: Service
services must be protected at all times.
providers should recognize the
The clients privacy should be respected
fundamental rights, dignity and
in all matters regarding his or her testing
worth of all people and ensure that
for HIV; health and related information
clients suffer no physical or
disclosed or discovered as part of the pre-
psychological harm during
test counselling, HIV testing, or post-test
counselling.
counselling process; and the clients HIV
l Promote human rights: HTC services test results. Service providers should offer
should be offered to everyone, the highest possible levels of
irrespective of nationality, race, confidentiality in order to respect the
colour, tribe, place of birth, ethnic or clients privacy and create the trust
social origin, language, class, necessary for counseling. Any limitation
religious belief, political affiliation,
on the degree of confidentiality is likely
opinion, custom, culture, sex, gender,
to diminish the effectiveness of
marital status, age, pregnancy,
counseling.
disability or economic or social
status, or whether they were born in
The service provider should:
or out of wedlock.
l Agree with the client on the level
and limits of confidentiality offered.
2.2.2 Guiding Principles
The agreement should be reviewed
i) Competence and changed by negotiation between
Service providers should provide high- the service provider and client.
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chapter 2
No information concerning the client a) Providing pre-test information on
should be shared without the the purpose of testing (see Section
permission of the client 4.3.2)
l Respect agreements about b) Ensuring client is informed of post-
confidentiality even after the clients test HIV prevention, treatment, care
death, unless there are overriding and support services that are
legal or ethical considerations available
l Inform the client of shared c) Confirming understanding by the
confidentiality which entails sharing client, while respecting their
the HIV test results , as necessary, autonomy
with other relevant health workers
involved in the clients medical care It is only when these elements are in
l Maintain confidentiality of the place that a client can make a fully
identity of others revealed through informed decision on whether or not to
the counselling process be tested for HIV. In addition, a client
has the right to withdraw their consent
l Make provision for maintaining the at any time, even after blood has been
storage and disposal of client records taken for HIV testing.
in accordance with appropriate
standards of confidentiality, ensuring iv) Age of Informed Consent for HTC
that only persons with a direct role in
the management of the client should l Any child who is aged16 years or
have access to these records above, or is married, pregnant or a
parent, who requests HTC is
iii) Consent considered able to give full informed
HIV testing must be voluntary, with the consent.
client making an informed decision l The consent of a parent or caregiver
about taking an HIV test. The service is required before performing an HIV
provider should explain the procedure test on a child who is below 16 years
and make sure that the client is of age.
requesting HIV testing without coercion. l A child below the age of 16 who is a
The fundamental value to be applied is mature minor may provide informed
respecting the choice of the client to give consent for HTC. A mature minor is a
consent. Three crucial elements are child or adolescent who can
necessary in obtaining informed consent demonstrate that he or she is mature
for HIV testing: enough to make a decision on their
5
own. A counsellor should consider l A child is sexually active

the following factors in determining l A child is concerned about mother-
whether a child or adolescent should to-child transmission
be treated as a mature minor:
l A child has been exposed to HIV
- The minors ability to appreciate through vertical or sexual
the seriousness of HTC and the test transmission
result and to give informed consent
l A child expresses concern that, given
- The minors physical, emotional and an HIV positive result, he or she will
mental development be denied access to care and
- The degree of responsibility the treatment by a parent/caregiver
minor has assumed for his or her
own life, such as heading a 2.3 Anonymous testing
household or living independently
from a parent/caregiver Anonymous testing refers to testing
l If a parent or caregiver will not or someone for HIV using a code number,
cannot give consent for a child delinked from a persons name, and
below 16 years of age, the health without sharing the results. Anonymous
worker can exercise the best interest testing is conducted as part of research
of the child principle and seek studies and surveys, with the approval of
approval from the person in charge the Medical Research Council of
of the clinic or hospital to perform Zimbabwe and Ethics Board.
the HIV test.
2.4 Mandatory HIV testing
v) Best Interests of the Child Principle
A service provider should seek approval Mandatory HIV testing is neither
from the person in charge of the clinic or
effective for public health interventions
hospital in order to provide HTC without
nor ethical as it denies individuals choice
consent from a parent or caregiver when
and violates principles such as the right
it is in the best interests of a child. This
to health, including the right to privacy.
includes when
However, it can be considered in special
l A child is ill and diagnosis will circumstances such as for perpetrators of
facilitate appropriate care and rape and for blood donation. In all these
treatment cases, HIV testing must be accompanied
l A child is a survivor of sexual abuse by counselling.
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chapter 2
2.5 Disclosure hospital or outreach team to disclose the
test results.
HIV test results should be shared in
person only to the client. Disclosure of 2.6 Partner notification
the results to anyone else should only be
done with the clients consent, which According to the Zimbabwe Constitution,
should be documented. every person has the right to privacy,
including the right not to have their
Informing children of their HIV status health condition disclosed. However,
will depend on a thorough assessment of the Constitution also provides for the
the childs ability to understand HIV and limitation of these rights in the interest
AIDS issues and level of maturity. It is of public health. Therefore all clients
important to remember that disclosure is should be counselled to inform their
an on-going, gradual process of sharing sexual partner(s) about their HIV test
information with the child about his/her results, whether negative or positive.
own HIV status in a way which helps The service provider should inform the
him/her to understand and cope with client before testing that sexual partners
events in his/her life at that time. If a may be informed about the HIV test
parent/caregiver refuses to have the result if the client fails to disclose after
results disclosed to a child below 16 three documented counselling sessions
years of age, then the same principles and the service provider feels that the
of mature minor and acting in the best clients partner is at risk of HIV infection.
interests of the child should apply.
Specifically, the counselor should 2.7 People Living with
determine whether: Disabilities
l the child is mature enough to cope
People living with disabilities such as
with the results of the HIV test
hearing and visual impairments and
l the child has other people who can mental health concerns, have the right to
provide him or her with access HTC services. This includes access
psychological and emotional support to appropriate materials and counselling
l knowledge of the results will benefit to ensure full understanding of the HIV
the childs care and treatment test, test results and linkages to prevention,
treatment, care and support services.
The counselor should continue to In the case of people with mental health
counsel the parent/caregiver, but may concerns, regardless of age, a guardian
seek approval from the head of the clinic, should provide informed consent.
7
2.8 HTC and Post-Exposure 2.8.2 Rape

Prophylaxis (PEP) HTC should be offered to all survivors of
rape as part of the protocols for
2.8.1 Occupational Exposure management of sexual violence. This
In the case of occupational exposure to includes starting ARVs for post-exposure
HIV, the national guidelines on post- prophylaxis as soon as one hour and
exposure prophylaxis (PEP) should be within 72 hours following the exposure.
followed. This includes starting The standard rapid HIV antibody test
antiretroviral medicines (ARVs) for PEP should be used and the results obtained
as soon as one hour after exposure, as quickly as possible. PEP should be
preferably within 36 hours, and no later provided even when an HIV test is not
than 72 hours following the exposure or immediately available and/or a police
according to the latest PEP guidelines. report made. Mandatory HTC for the
HTC should be offered to both the source perpetrator may only be performed with
patient/client and the exposed person. a court order and the results disclosed to
The standard rapid HIV antibody test the magistrate or judge handling the
should be used and the results of the test case.
obtained as quickly as possible. Viral
DNA/RNA testing should be offered if the
source is suspected to be in the window
period.
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chapter 3
Service Delivery
Approaches and Models
3.1 Coordination of HTC services in Zimbabwe should be

Services registered with the relevant authorities
under the MOHCC.
At the national level, the Ministry of
Health and Child Care (MOHCC), through 3.2 Service delivery
the AIDS and TB Programme, is approaches
responsible for policy direction,
coordination and monitoring of HTC In Zimbabwe the client-initiated and the
services in Zimbabwe. Programme provider-initiated are the two HTC
implementation is through existing service provision approaches.
provincial and district structures that are
also responsible for coordinating the 3.2.1 Client Initiated HIV Testing
implementation of activities at the lower and Counselling (CITC)
levels. The National HIV Prevention In the client-initiated approach (also
Partnership Forum (PPF) advocates for a known as voluntary HIV counselling and
conducive policy environment for testing - VCT) the client voluntarily
provision of HTC services, shares ideas, makes a decision to learn his/her HIV
experiences, evidence-based best status and seeks HTC at a site providing
practices, latest innovations and possible the service. These are mainly stand-alone
areas for operations research. The sites supported by nongovernmental
Medical Laboratory and Clinical Scientists organizations (NGOs).
Council (MLCSC) on behalf of the
Secretary for Health and Child Care, 3.2.2 Provider Initiated HIV Testing
guides and sets standards for HIV testing and Counselling (PITC)
in the country. All the above bodies The provider initiated approach requires
conduct their activities on behalf of the that health care providers routinely
MOHCC. All facilities providing HTC initiate an offer of an HIV test in health
9
care settings for all clients attending 3.3.1 Facility Based Model
health care institutions. This can be for
3.3.1.1 Health care facility-based HTC
diagnostic purposes or routine for
services
knowledge of ones HIV status in order
to access HIV prevention, treatment, care HTC services should be provided with
and support services. PITC places the other services being offered in health
onus of HTC on the health care provider care facilities in the public, private and
and eliminates the need for personal NGO sectors. PITC services should be
motivation, especially where stigma and provided to all adults, adolescents and
discrimination are high. The pre-test children attending all health facilities as
information giving approach is preferably the recommended standard of care.
through the group education session and Settings for HTC service provision include
then offer of rapid HIV testing where antenatal care (ANC), tuberculosis (TB),
client can choose to proceed or opt out. sexually transmitted infection (STI) and
Clients who opt out will require
outpatient clinics; medical and surgical,
individual pre-test counselling to identify
pediatric wards; maternal, newborn and
and address barriers to HTC as well as
child health (MNCH) services;
conduct individual risk assessment and
risk reduction. The main emphasis is on reproductive health, nutrition, mental
individual posttest counselling. health and male circumcision services.
3.3 HTC Service Delivery 3.3.1.2 Stand-alone HTC services

Models Stand-alone HTC services should be
provided in sites that are situated outside
The importance of early identification of health care facilities. Additional HIV
people living with HIV (PLWHIV) so that related services namely HIV prevention,
they access relevant HIV prevention, treatment, care and support services can
treatment, care and support services early also be provided from these sites.
necessitates that various approaches be
utilized in reaching them. In Zimbabwe
Below is a summary of the advantages
the two complimentary models that will
and key considerations for facility-based
be utilized in the provision of HTC
services are the facility-based model and HTC services.
the community-based model.
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chapter 3
Table 1: Advantages and key considerations for facility-based HTC services
Model Target Advantages Key

(HTC group Considerations
Approach)
Health People l HTC integrated into existing services l Counselling space
care seeking l Reduces missed opportunities to could be a challenge
facility- health identify HIV positive persons l Not ideal for people
based services l Links HIV positive persons to who do not frequent
prevention, treatment, care and health services e.g.
( PITC) support services men and youths
l Excludes HIV infection in high risk l Operating hours may
clients (STI, TB) and offers an limit or affect access
opportunity for behaviour change to HTC services
communication and counselling
l Cost effective, efficient and less
expensive
l Low stigmatization as people could
be attending the facility for other
services
l Close links with other existing
medical services
l Can provide outreach services
l Minimises workload and strengthens
team work as clients are referred
from one service point/ area to
another with continued
management, communication and
counselling
Stand- General l Convenient to those who do not l Attracts the more

alone population want to be seen visiting public motivated clients
HTC site including health care facilities l Poor referral
those that l Accessible to key populations mechanisms for follow
(CITC) do not l Can be located in busy, easily up care and support
frequent accessible locations l High likelihood of staff
health l Staff are dedicated to full time HTC burnout
care service provision l Possibility of stigma-
facilities l Anonymous and confidential HIV tization of the site
testing is offered l Expensive to maintain
l Flexible operating hours and sustain services
l Can provide outreach services as they are usually
donor-funded
l Could be underutilized
if services are not
advertised
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3.3.2 Community-based Model access to hard-to-reach, rural and

Community-based HIV testing and underserved populations. Known HIV
counselling (CBHTC) refers to HTC positive or TB patients can act as index
services provided in community settings. patients and consent to provision of HTC
It contributes to reduction in stigma and services in their homes.
discrimination by removing social barriers
to HTC. Through increased access to ii) Outreach and Mobile
services, more people can access HIV Outreach HTC services could be provided
prevention, treatment, care and support from health care facilities and stand-
services. CBHTC increases access to HIV alone sites. Mobile teams can provide
testing (reduced cost of transportation to outreach HTC services in premises such
VCT sites or health facilities; convenient as community and church halls, school
for family members; enhances privacy; and youth facilities. They target the
helps reduce stigma). It promotes general population, people living in
behavior change leading to the reduction remote rural areas and key populations
of HIV transmission while increasing who include those at high risk of
access for couple/partners HTC and acquiring HIV (e.g. sex workers) and
enhances disclosure. It provides an vulnerable groups (e.g. prisoners and
opportunity to address HIV discordance highly mobile populations such as long
among couples/partners. distance truck drivers).Service providers
Different settings/ approaches can be must ensure that the premises from
used to provide CBHTC as follows: which outreach services are provided
l Home based, including index meet the required standards for quality
clients/ patients HTC services in Zimbabwe. It is
l Mobile and Outreach mandatory that a strong support system
l Workplace and referral mechanisms are established
l Educational institutions at community level before initiating
l Campaigns outreach HTC services.
l Self-testing
iii) Workplace
N.B. Refer to Section 4.7 for more Both men and women who are in formal
detail on implementing the CBHTC and informal employment can be reached
through their workplaces where services
i) Home based HTC including index can be provided either as a static service
patients or as an outreach from facilities
HTC services could be provided using the providing HTC services. People who do
door-to-door approach. This facilitates not want or do not have time to access
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chapter 3
public health facilities for HTC can on HIV self-testing will be provided in
benefit from this model. the near future. This option affords one
the leeway of choosing where and when
iv) Educational institutions to have the test without worrying about
Students in educational institutions can confidentiality. However, it is critical to
access HTC through services especially ensure posttest support and follow up
aimed at this group. Issues concerning care following a positive HIV test result.
informed and parental concern,
confidentiality, peer pressure, linkages The benefits of community based HTC
and follow up will need to be addressed include:
before setting up such services. This l HTC easily accessible to the
model contributes to normalization of
community
HTC and early access to knowledge of
ones HIV status. l Increases number of first time testers
l Promotes testing of partners and
v) Campaigns children and reduces missed
HTC campaigns can take different forms opportunities
including service provision through
l Normalizes HTC thus reducing
mobile or outreach services, creating
awareness and directing clients to service stigma and discrimination in
provision sites, and as part of disease community settings
prevention campaigns e.g. malaria l Enhances confidentiality,
campaigns. They can vary in duration affordability, feasibility and
and can target specific populations such acceptability
as couples or youths and
l Does not rely on people making a
commemoration of specific events such
self-assessment of need for HTC
as World AIDS day.
this is important where risk
perception is low
vi) Self-testing
HIV self-testing is as any form of HIV l Has high uptake and coverage -
testing in which an individual collects his brings service to the client
or her own sample, performs a simple, l Promotes family-centred approach to
rapid HIV test, and is therefore, the first
HIV prevention, treatment, care and
to know the results.
support
HIV self-testing is one of the options l Enhances disclosure among couples

that MOHCC is considering and guidance and families
13
l Reduces fear of HIV and therefore access individuals and families in

stigma their home and community settings
l Leads to earlier diagnosis and linkage l Depot holder/ distributor for self-
to prevention, treatment, care and testing kits requires special skills to
support instruct clients to conduct self-
testing, interpret results, and refer
The challenges of community based HTC for further management
are detailed in Table 6 below: l Addressing barriers experienced by
l Tend to be more time consuming the client in accessing health
l Requires more man power than facilities
facility-based model
Below is a summary of the advantages
l Requires extra training and skills to of community-based HTC services.
Table 2: Advantages of community-based HTC services
Model Target Advantages

(HTC group
Approach)
Home l Hard to l Families test together and increase opportunities for behaviour
based reach change
including l Under- l Early identification of infected children
index served l Cost-effective
(PITC l Rural l Increases HTC uptake
and l Index l Services are brought to the people (removes bus fare barrier)
CITC) l Reduces inequities
l Increases number of first time testers
l Early identification of HIV infected people including sero-
discordant couples
l Can be offered in different settings e.g. churches, educational
institutions, workplaces, at various events
l Normalises HIV testing
l Reduces financial costs to the client
l Moonlighting services can be provided at times and locations
that are convenient to some clients including key populations
e.g.at night for sex workers and their clients
l Able to reach men who find it difficult to create time to go to
health facilities
14
chapter 3
Model Target group Advantages
(HTC
Approach) l Rural
Mobile and populations l Can be offered in different settings e.g. churches,
Outreach l Marginalised educational institutions, workplaces, at various events
populations l Normalises HIV testing
(PITC) l Populations l Reduces financial costs to the client
underserved l Moonlighting services can be provided at times and
by formal locations that are convenient to some clients including
health system key populations e.g.at night for sex workers and their
l Key clients
populations
Workplace Employees and l Able to reach men who find it difficult to create time to
their families go to health facilities
l Able to provide HTC to employees families
(PITC and
CITC) l Convenient for both employers and employees
l Employers can have HTC services in the company
clinic
Educational Students, l Normalises HIV testing thus reducing stigma

institutions teachers and l Early identification of HIV infected children, adolescents
lecturers and young adults
l Early linkages to prevention, treatment, care and
(PITC and
support services
CITC)
l Access to information on HIV prevention
l Instils sense of responsibility to health matters in young
people
Campaigns l General l Mobilises communities to support HTC thus normalising

population HIV testing
l Selected, l Increases HTC uptake
(PITC and targeted l Can target specific groups
CITC) populations
l Can be linked to specific events
Self-testing l General l Autonomy and empowerment

population l Confidentiality
l Health l Convenient.
(CITC) workers
l Less stigma around HIV testing
l Key
l Fewer resource requirements from the health system
populations
15
3.4 Operational l Community/peer counsellors are

requirements often without formal education but
are respected members of their
3.4.1 Capacity building communities and have valuable life
National efforts to scale up and roll out experiences. They can sometimes
HIV prevention, treatment and care offer on-going support to people
programs demand that the counselling who have received HTC if they are
capacity in the country is enhanced. This given the right training and get
has been achieved through training of supported thereafter.
various cadres as detailed below:
l Primary Counsellors (PCs) provide 3.4.2 Training of counsellors
counselling in facilities that offer It is necessary to train counsellors drawn
HIV-related counselling services such from a wide range of backgrounds in
as HTC, PMTCT, care, support and order to achieve significantly improved
ART adherence access to HTC services. All training for
l Health workers HTC service providers must be
l Social workers, teachers, youth undertaken by qualified trainers using
leaders, church leaders curricula approved by the MOHCC.
The trained cadres should be certified.
l PLWHIV should not be discriminated
against in selecting counsellors Community based service providers such
because of their sero status. as community-based counsellors (CBCs)
As counsellors they can offer should be trained to provide psychosocial
particularly valuable services and can support to the infected and affected.
help to support others who are HIV- There is need to ensure that there are
positive as peer counsellors. However, adequate numbers of child counsellors
they themselves may be vulnerable to to cater for the infected and affected
work-related stress and burnout and children.
may need careful support and
supervision. Pre-service training curricula for cadres
such as health workers and teachers
l Retired professionals such as health
should continue to incorporate HIV
workers, teachers and preachers
counselling in order to increase the
frequently possess counselling skills
number of professionals who can offer
and hold the trust of their
communities. They can often work HIV counselling services in their areas of
part-time or cover out-of-hours work. In-service training must be
services. provided to maintain high quality HTC
16
chapter 3
services and to help counsellors cope preferable and encouraged that HTC
with complex cases, augment and update service providers be willing to be
their skills. Refresher training should be voluntarily tested for HIV, both for their
conducted at least once a year. own personal risk-reduction planning
and to understand the clients perspective
3.4.3 Quality Improvement and when they receive HTC services. This will
Clinical Mentorship also ensure that they support the services
Counsellors have an ethical and rendered at the facility.
professional duty to adhere to HIV
counselling standards and policies and 3.4.5 Training of personnel to
to provide services of the highest quality. perform rapid HIV testing
All providers of HIV counselling services Rapid HIV testing is competency based
are responsible for ensuring quality training. Laboratory Scientists who are
assurance and quality improvement. recommended by the Medical Laboratory
Institutions such as hospitals, clinics and and Scientists Council of Zimbabwe
non-profit agencies are required to shalltrain all service providers to perform
conduct quality assurance and rapid HIV testing as well as provide
mentorship activities as well as support supervision and quality
operational and mystery client surveys assurance.
to ensure quality and client satisfaction.
Clinical mentoring is a system of practical 3.5 Minimum Requirements

training and consultation that fosters for Service Delivery
ongoing professional development to
yield sustainable high-quality clinical 3.5.1 Health care facilities
care outcomes. It should be integrated
with and immediately follow initial Infrastructure and equipment
training and is case-based and requirements
participatory, based on the principles of Although all health facilities have
adult learning. consulting rooms, there is need to ensure
privacy during counselling sessions.
3.4.4 Orientation of management Areas where rapid HIV testing is to be
and support staff conducted must be equipped according
Orientation should be carried out to to standardized national laboratory
cover the following issues: basic guidelines for rapid HIV testing. (Refer
communication skills, provision of HTC to Chapter 5 for more information on
services, and confidentiality. It is infrastructural requirements for HTC).
17
Staffing l Laboratory (if site is performing

In addition to providing clinical services, Elisa tests) equipped with: desk;
existing staff will also provide PITC chair; washable work counter;
services. Additional staffing will be storage space for medical
provided through the deployment of consumables; lockable storage for
Primary Counsellor (PCs). Nurse test kits that do not need
counsellors and health workers who have refrigeration; refrigerator for test kits
received the requisite training are and/or reagents needing
authorized to perform rapid HIV tests in refrigeration; standard contaminated
order to support the expansion of HTC waste disposal containers; sink and
services in Zimbabwe. running water. Other equipment
deemed necessary in accordance with
3.5.2 Stand Alone facilities Laboratory Standards for Zimbabwe.
l Toilets- for male clients, female
Infrastructure and equipment
clients and staff.
requirements
The following are the requirements:
Staffing
l Reception area equipped with: Desk
and chair; filing cabinet/s; computer l Manager is essential in ensuring the
for data entry, communication provision of high quality HTC
gadgets (e.g. telephone) and IEC services, planning and coordination
materials. of services and staff supervision and
support.
l Waiting area equipped with:
comfortable sitting facility; open l Counsellors: must be adequate in
display area for educational number and trained to offer full time
materials, including those that HTC.
explain the HIV testing procedure; l Personnel to perform rapid HIV
audio-visual equipment. testing: nurse counsellors and health
l Counselling rooms in which rapid workers who have received the
HIV tests can be conducted, and requisite training will perform rapid
equipped with: 3 chairs; small table HIV tests.
with a washable surface; sink with l Data entry personnel: The
running water; storage space for receptionist or data entry clerk will
blood drawing equipment; sharps perform data entry duties and
disposal container; lockable transmit the information to MOHCC
cupboard. through the NHIS.
18
chapter 3
l Receptionist: will welcome clients, 3.5.4 Private sector HTC services
register them, collect user fees, The private sector should follow the
explain procedures, provide health care facility or stand-alone model
educational materials and enter data in providing CITC and/or PITC services.
where applicable. The staffing, space and equipment
l Ancillary staff includes general staff requirements will therefore depend on
such as cleaners, security guards, and the service/s provided.
drivers.
3.6 Minimum Supplies for all
3.5.3 Community based services Service Delivery Models
Mobile and outreach HTC services can be
provided from both the health facilities The quantity and type of supplies will
and stand-alone sites to homes, depend on the volume of clients
workplaces, educational institutions and expected. Additionally, if other medical
during campaigns. It is imperative for procedures (e.g. TB or STI screening) are
management to ensure that premises envisaged as part of the service, then
from which outreach services are supply lists will need to be appropriately
provided meet the required standards for modified. Some of the critical supplies
quality HTC service provision. An include the following:
outreach mobile team should comprise of l HIV test kits, algorithms, Standard
at least two counselors and a driver. The Operating Procedures (SOPs), data
team should be in a position to set up a collection tools, IEC materials and
temporary HTC site using available child friendly materials
resources. Equipment and critical l Medical consumables: needles,
supplies needed at a temporary site syringes, lancets, swabs, methylated
should include a tent where applicable, spirit, disinfectants
at least three chairs and a table/desk.
l Gloves and all other medical supplies
The mobile outreach team should link
for universal precautions
with community structures which help
with mobilization of intended l PEP guidelines and medicines for
beneficiaries for HTC services. A strong PEP
community support system for patients l Sharps disposal containers
and clients who will receive HTC services l Contaminated waste disposal
must be in place. Waste disposal containers
guidelines and measures must be in
place. l Male and female condoms and
models
19
chapter 4
HIV Counselling
4.1 Guiding principles for HIV storage and disposal of client records
Testing and Counselling in accordance with appropriate
(HTC) standards of confidentiality.
l Counselling the client can receive
All forms of HTC should be voluntary high quality group education, or
and adhere to the following individual pre-test information or
5CsGuiding Principles, and for labour pre-test counselling followed by
and delivery HTC, an additional C is individual post-test counselling.
added for Comfort in labour:
l Correct and accurate HIV test
l Consent All clients offered the test results should be provided by trained
should receive sufficient information service providers with support for
and should be helped to an adequate internal and external quality
understanding of the testing process assurance and control from the
and possible consequences of being Laboratory personnel as stipulated in
tested. Clients receiving HTC services the National Rapid HIV testing QA/
must give informed consent, which QC protocols.
can be written or verbal consent.
Both forms of consent are binding. l Connections to HIV prevention,
They should be informed of the treatment, care and support services
process of HTC and their right to must be in place with follow up
defer HIV testing. services and appropriate long term
HIV treatment, care and support for
l Confidentiality discussions
those who test HIV positive. Clients
between the service provider and the
who test HIV negative should be
client should not be disclosed to
anyone without the permission of linked to HIV prevention services
the client. Inform the client of shared focusing on risk reduction and the
confidentiality and ensure proper need to remain HIV negative.
20
l Comfort: HTC should be offered The MOHCC has developed detailed

during the early stage of labour. Guidelines for HIV Testing and
The health worker should assess the Counselling in Children and
womans stage of labour, comfort Adolescents. This section will highlight
level, and need for analgesics. key points for HTC in children and
Providers need to show empathy adolescents.
while presenting information about
HTC to women in labour. The 4.2.1 Definition of HIV Counselling
content should be short, to the in Children and Adolescents
point, and explained based on the Counselling for HIV is a confidential
comfort level of the woman, between dialogue between a child/adolescent/
contractions. The health worker parent/caregiver and a service provider
should ask the woman to signal for a aimed at enabling the child/adolescent/
pause when a contraction is starting. parent/caregiver to cope with knowledge
The health worker should frequently of HIV status and make informed
make sure that the woman is decisions pertaining to HIV and AIDS
comfortable to proceed with the and to cope with related stressors.
session.
4.2.2 Counselling approach
4.2 Counselling for Children It is important to remember that when
and Adolescents a child/adolescent is HIV infected, the
whole family is affected and some family
Definition of a Child members may need counselling as the
A child is any individual under the age childs result is perceived to mirror the
of 18years (UN Convention on the Rights mothers or parents HIV status.
of the Child, 1990). The counselling process will be guided
According to the World Health by the individual circumstances, age and
Organization (WHO): developmental stage of the child/
l adolescents are individuals in the adolescent.
1019 year age group
Counselling should be child-focused
l youth are individuals in the 1524 and should aim at protecting the best
year age group interests of the child at all times. It
l young people combines both should also be family-centred as the
adolescents and youth and include family forms an important support
the 1024 year age group. system for the child/adolescent.
21
Three scenarios that can be used based However the child/adolescent can be
on the counsellors assessment of the tested without the consent of the
situation are as follows: parent/caregiver if it is in the best
l Counsellor meets with interests of the child (see Chapter 2).
parent/guardian first then with In Zimbabwe the general guide for
parent/guardian and child/adolescent providing informed consent divides the
together children/adolescents into the following
age groups:
l Counsellor meets with
parent/guardian first, then with the l 0-6 years: The child at this stage is
child/adolescent and lastly with totally dependent on the parent or
parent/guardian and child/adolescent guardian and therefore is not able to
together give consent. The decision to consent
to the testing of the child rests solely
l Counsellor meets with with the parent or guardian.
parent/guardian and child/adolescent
together, then meets with them l 7-15 years: At this stage the child
separately may have the capacity to understand
the implications of the test. However,
4.2.3 Informed consent the law requires that consent for HIV
Informed consent refers to a testing be obtained from the parent
child/adolescent or parent/caregiver or guardian, unless the child is a
being given an opportunity to consider: mature minor. Child/adolescent to
assent to the test and actively
l the benefits and potential difficulties participate in the counselling session.
associated with having access to A child below the age of 16 years
information regarding the who, for example, is heading a
childs/adolescents HIV status; household or living independently
l an understanding of the HIV testing from a parent/guardian, being
procedure; and married, pregnant or a parent is
l taking a decision for the considered a mature minor and can
child/adolescent either to be tested consent to HTC because of
or not tested for HIV. The child or assumption of responsibility for his
parent/caregiver should be able to or her own life.
consider the implications of a l 16-18 years: Child/Adolescent can
positive HIV test result on the give his or her own consent for HIV
childs/adolescents life and the life testing, and must be linked to post-
of his or her family. test services for children.
22
chapter 4
l Older than 18 years-adolescent has positive or HIV negative), including how
reached the legal age of majority and to cope with the results.
can consent on his/her own behalf
4.2.6 Disclosure
Situations may arise when the counsellor Disclosure is the process of informing the
may need to override the parents/ child/adolescent of his or her own HIV
caregivers decision to refuse the test if status or informing someone else about
knowledge of the childs/ adolescents the childs/ adolescents HIV status. It
HIV status is in the best interests of the may be determined by readiness of the
child such as when the child is ill. In such parent/caregiver to talk about it and
cases, the health worker can exercise the readiness of the child/adolescent to
best interest of the child principle and understand and change their lives as a
seek approval from the person in charge result of the knowledge of his/her status.
of the clinic or hospital to perform the A thorough assessment of the childs
HIV test. knowledge and attitude towards HIV and
AIDS issues, age and level of maturity is
4.2.4 Pre-test essential for assessing readiness to
information/counselling session receive information about HIV status.
Pretest information/counselling session
is the process during which a This is an ongoing process beginning
child/adolescent and caregiver undergo with age-appropriate content and
confidential counselling before testing language.
in order to make an informed consent l Partial disclosure starts with
about whether or not to have the revelation to a child sometimes as
child/adolescent tested for HIV. young as 6 years without mentioning
The session can be directed to the HIV or AIDS and can use age
parent/caregiver if the child is below appropriate communication and
7 years of age and to the child if aged counselling techniques.
7 years and above and developing
l Progressive disclosure is when more
normally.
and more information about the
childs HIV status is shared with the
4.2.5 Post-test counselling session
child/adolescent as he/she develops
Post-test counselling must be provided
and matures.
for both HIV positive and HIV negative
children/adolescents. The session helps l Full disclosure is when the child is
the parent/caregiver and child/adolescent given all the information about
to understand the implications of the his/her HIV status during a
results of the HIV test (whether HIV counselling session.
23
Children/Adolescents will also need dialogue between a client(s) and a service

assistance with making decisions around provider aimed at enabling the client to
if, how, to whom and when to disclose make informed personal decisions about
their HIV status. They should have full HIV testing, to know their HIV status and
understanding of the possible cope with the implications of a positive
consequences of disclosure and non- or negative result.
disclosure.
4.3.2 Pre-test
4.2.7 Follow up counselling, information/counselling session
care and support Group information giving has
Both HIV positive and HIV negative considerably reduced the need for long
children/adolescents need follow up pretest counselling sessions with
counselling to help them cope with emphasis on quality individual post-test
either a positive or negative HIV status. counselling. The main aim of pretest
A number of sessions, sometimes counseling is on personalized risk
including the family members, may be assessment and risk reduction and not
needed. Children/Adolescents on on education and persuasion for HIV
antiretroviral therapy (ART) will also need testing. The pretest sessions assist
adherence counselling and sustained patients and clients to:
psychosocial support. l Understand the basic facts of HIV
Understand the benefits of HIV
4.2.8 Connections to Post Test testing
Services and Referral
l Assess their own risk of acquiring
This is a two-way process that creates
HIV with an emphasis on risk
and maintains linkages between the
reduction
health/HTC facility and the community
to ensure that children/adolescents l Appreciate the HIV testing procedure
access HIV prevention, treatment, care, and meaning of possible results
support and other relevant services after l Explore support system and
HTC. Children/Adolescents should also be discussion of disclosure mechanism
referred to join support groups.
l Be aware of the range of options and
services available to them
4.3 Counselling for Adults
l Understand the implications of the
4.3.1 Definition of HIV Counselling HIV test result and how to cope with
in Adults a negative or positive result
Counselling for HIV is a confidential l Give consent for HIV testing
24
chapter 4
Group information sessions, with skilled 4.3.4 Follow up counselling and
facilitation, can be used prior to referrals
provision of both CITC and PITC services. Follow up counselling must be provided
These sessions are aimed at providing to both HIV negative and HIV positive
information rather than individual patients and clients. It empowers the HIV
counselling. The goal of these sessions is negative patients or clients to continue
to discuss general information about HIV with their risk reduction strategies so as
and AIDS including HTC specifically, prior to remain HIV negative. Those who are
to rapid HIV testing. This is then HIV positive will also reinforce their
followed by quality individual post-test positive prevention strategies and live
positively. Community based counsellors
counselling sessions.
and PCs play a critical role in the
provision of this service, especially at
4.3.3 Post-test counselling session
community level.
Individual post-test counselling is
provided for both HIV positive and HIV
The patient or client can also be referred
negative clients. This session assesses the
for appropriate services such as for
clients readiness to receive results, opportunistic infection (OI), ART, VMMC,
confirm clients identity and prepares the Cervical Cancer Screening, STI and TB
client to: screening and management; prevention
l Cope with the HIV test result of mother to child transmission of HIV
(PMTCT); family planning; nutrition;
l Assess clients risk if from group
psychosocial and any other support
session and conduct or review their
deemed necessary.
risk reduction plan
l Review post-test support and 4.3.5 Adherence counselling
psychosocial support This is a process that aims to reduce the
impact of stressors, develop coping
l Discuss disclosure of test results and
strategies as well as prepare and support
partner referral
clients during management of chronic
l Be connected to post test support conditions. Stages of ART adherence
services and counselling include:
l Plan for follow up counselling l Pre-ART initiation: Client education
(window period for HIV negative on HIV and AIDS and introduction to
clients and long term management ART; readiness assessment
for HIV positive clients) (including potential influences on
25
adherence and ways to address test counselling and counselling for the
them), client preparation and procedure and post procedure. Follow up
development of a treatment plan. counselling is routinely done on day 2,
l ART initiation: Tailor the day 7, day 14 and day 42 or more
counselling according to clients frequently if there is need.
regimen and lifestyle and discuss
side-effects and factors that are 4.4 Counselling for pregnant
inhibiting adherence. It is very and lactating women
important to carry out follow-up
visits soon after initiation. This can 4.4.1 Pretest processes
be done in partnership with other The MOHCC has adopted the opt-out
health workers, community approach to be used in providing HTC
counsellors and outreach teams. services for pregnant and lactating
women as the model that will bring
l Maintenance: counsel on dose women into the PMTCT programme. By
frequency, nutrition, and medicines this approach, HTC is offered routinely to
and treatment of associated ANC clients as part of the standard of
conditions. Discuss clients coping care, using the PITC approach. However,
mechanisms and reinforce strengths. it is important to note that HIV testing is
l Treatment change or re-motivation: still voluntary and a pregnant or
Counsel for ART adjustment and lactating woman has the right to consent
possible of cause treatment failure. to or decline HIV testing should she
Reassess mental health and suicide choose to do so. If a woman declines to
risk. Re-motivate the client who be tested, she should be counselled at
continues on the same regimen. every opportunity during pregnancy and
Ensure continuous consultation with breast feeding period and encouraged to
the health care team. take up the HIV test. The benefits of
testing should be clearly explained to her.
4.3.6 Counselling for voluntary medical
male circumcision (VMMC) Counsellors should adhere to the 5 Cs
In VMMC service provision, the principle when providing HTC for
counsellor ensures that the client/couple pregnant and lactating women, and an
have all the information needed to additional C for Comfort in the event
decide on HTC before undergoing the that she is being counselled during
procedure. The VMMC counselling labour and delivery. The pre-test process
process includes: group information is the same as for adults as discussed in
giving followed by HIV testing then post- Section 4.3.2
26
chapter 4
4.4.2 Possible HIV test results for 4.4.3 HIV testing for Women
pregnant and lactating women presenting in labour
l HIV-negative: Unbooked women, women of unknown
HIV status, and HIV negative women
Women who test HIV-negative who are due for retesting reporting in
should receive post-test counselling labour should be offered HTC during the
on risk reduction interventions, latent phase of labour, preferably during
focusing mainly on how to maintain the first stage of labour. The 6th C
their HIV-negative status while principle (Comfort) should be observed in
continuing to receive routine addition to the 5Cs. They should be
antenatal care. They should also be offered a PMTCT intervention if HIV
retested for HIV at 32-34 weeks to positive and their infants offered ARVs
detect late seroconversion and to after delivery, in line with the National
allow time for service providers to PMTCT guidelines.
implement PMTCT interventions.
4.5 Couple counselling
l HIV-positive:
All HIV-positive pregnant women 4.5.1 Definition of a Couple
should be: A couple is defined as two persons in an
ongoing sexual relationship, and each of
n Assessed for clinical stage these persons is referred to as a partner
according to WHO staging in the relationship. How individuals
n Screened for TB, using the TB define their relationships varies according
screening tool for PLHIV to cultural and social contexts, and any
n Receive rapid adherence persons who are in a sexual relationship
counselling and initiated on and wish to test together and mutually
Option B+ (life-long ART) on the disclose their results should be supported
same day they get the positive to receive CHTC. Health workers should
ensure that services are inclusive and
result and be followed up
non-judgmental, and support partners to
thereafter.
test together irrespective of the length or
stability of their relationship. It should be
Pregnant women should be encouraged
noted that in premarital counselling, the
to bring their partners for couple HIV
two individuals may not be having a
testing and counselling if they have not sexual relationship but can receive couple
done so already. This will make it counseling services, with the assumption
possible for appropriate interventions to that they will be having sexual
be put in place. relationship after they are married.
27
4.5.2 Definition of Couple HIV confidentiality where each partner,

testing and counselling (CHTC) knowing the other partners HIV status,
This refers to HTC for two or more sexual will agree not to share the results with
partners together. They could be married, anyone else unless they both agree to do
cohabiting, regular sexual partners or so; including to whom they should
intending to have sex. They undergo disclose.
counseling and testing in the same
sitting and receive results together. iii) Counselling: the couple should
The service is intended to facilitate both receive high quality pre-test information
mutual knowledge and disclosure of and post-test counselling.
ones HIV status to their sexual
partner(s). iv) Correct and accurate HIV test
results should be provided by trained
4.5.3 Guiding principles for CHTC service providers with support for
internal and external quality assurance
4.5.3.1 CHTC should adhere to the and control from Laboratory personnel as
following 5Cs Guiding Principles: stipulated in the National Rapid HIV
i) Consent: Couples can experience testing QA/QC protocols.
gender imbalances resulting in one
partner coercing the other partner to v) Connections to prevention, treatment,
undergo HTC. Counsellors need to be care and support services must be in
aware of this possibility and assess each place with follow up services and
couple accordingly, deferring the CHTC appropriate long term, HIV prevention,
session if coercion of one partner is treatment, care and support for those
suspected. Both partners receiving CHTC who test HIV positive. Clients who test
services must give informed consent. HIV negative should be linked to HIV
They should be informed of the process prevention services focusing on risk
of HTC and their right to decline HIV reduction and the need to remain HIV
testing. Ideally both partners should negative.
agree to be counselled together and
receive their HIV test results together. 4.5.3.2 Other CHTC Considerations
l Fundamental principles of human
ii) Confidentiality: discussions between rights must be adhered to.
the service provider and the couple
should not be disclosed to anyone i) CHTC should be voluntary for
without permission of both partners. both partners
Both partners should agree to shared ii) People should not be turned
28
chapter 4
away if they cannot or do not l Initiate ART to the HIV positive
want to bring their partners partner in a sero discordant
iii) If a couple does not want to test relationship as ART will reduce the
together they should be offered risk of HIV transmission to the HIV
individual HTC services negative partner (ART as prevention)
Both partners should be counselled
l Counsel clients on how to access
in order to understand that the ART
justice in the event of them being
is for HIV prevention as this will help
subjected to emotional, sexual or
them make an informed decision for
physical violence as this can occur
lifelong adherence to ART.
especially to women who are HIV
positive. Relevant support services
4.5.4 Benefits of CHTC
and linkages with health facilities/
The benefits of CHTC are detailed in
HTC sites must be available so that
Table 3 below where a comparison is
appropriate referrals can be made by
made between Individual HTC and CHTC.
the counsellors.
Table 3: Comparison of CHTC and Individual HTC
Couples HTC Individual HTC

Learns of own status alone. May
Partners learn of their HIV statuses together wrongly assume that partners status is
same as his/hers
Has to assume burden of disclosure to
Mutual disclosure is immediate
partner alone
Counsellor can help ease tension and diffuse Has to deal with tension and blame on
blame their own
Partners hear information together,
Only one partner hears the information.
enhancing likelihood of shared understanding
Counselling messages tailored based on test Counselling messages tailored based
results of both partners on test results of one partner
Counsellor facilitates the couples discussion Counsellor is not present to facilitate the
about difficult issues couples discussion about difficult issues
Prevention, treatment and care decisions can Prevention, treatment and care decisions
be made together are more likely to be made in isolation
Decisions about family or child testing as well Individual bears burden of getting family
as family planning can be made together members tested
29
Linkages between CHTC and other programmes are illustrated in the diagram below.
Figure 1: Linkages between CHTC and other programmes
Increased
marital cohesion
Decreased and reduced
stigma and intimate partner
normalization violence (IPV)
of HIV
HIV prevention
within couples
(condom use
Increased and ART)
uptake and
adherence to
PMTCT resulting in
less HIV infected
infants CHTC Safer
contraception
or family planning
Safer
conception
Male
circumcision
HIV
Increased prevention to
uptake and external partners if
adherence to ART any (encourage
for own health condom use and
ART)
Reduced
morbidity, mortality
and HIV drug
4.5.5 Pretest information/ noted that this session is conducted with

counselling in CHTC both partners present in the same room.
Pre-test counselling content for couples Partner testing is when one partner has
is the same as for individual counselling already been tested, and the other
(Section 4.3.2). However, it should be partner is then tested separately.
30
chapter 4
4.5.6 Post-test counselling in CHTC l Seroconcordant negative couple-
The post-test counselling content for both partners are HIV negative
couples is the same as for individual l Serodiscordant couple - where one
counselling (Section 4.3.3) but, in partner is HIV positive while the
addition, the counsellor facilitates mutual other is HIV negative. The need for
disclosure of the test results and disclosure in serodiscordance cannot
manages any sequelae to knowledge of be overemphasized. It is crucial that
test results. the window period and need for
l Disclosure is when one partner retesting of the HIV negative partner
shares his or her HIV status with their are discussed with the couple and
partner or any other person. the retest performed after 3 months
in order to close the window period.
l Assisted disclosure is when
Risk reduction should be emphasized
disclosing the HIV status to a partner
to couples so as to maximise chances
is carried out with assistance from a
of the HIV negative partner
trained counsellor or health care
remaining HIV negative. It is possible
provider.
for couples to stay HIV
l Mutual disclosure is when two serodiscordant indefinitely if they
partners share their HIV status with consistently practice safer sex using
one another. condoms correctly and consistently.
There are a number of possible couple If the male partner is HIV negative,
test result scenarios which are detailed in he is offered VMMC; and the HIV
Table 4 below and include the following: positive partner is initiated on ART
l Sero concordant positive couple - and encouraged to adhere to ART
both partners HIV positive as an HIV prevention strategy.
Table 4: Possible HIV test results in CHTC
CHTC Test Possible Service Potential Benefits

Results Interventions
Seroconcordant l Efficient case finding l Early ART initiation
positive l Prevention l Increased HIV prevention with other
(Both partners counselling sexual partners
HIV positive) l Couple counselling l Increased strength of relationship,
l Mutual disclosure quality of life and
l Enrolment into support l Increased uptake and adherence to
groups family planning, PMTCT, ART
l Cervical cancer l Increased emotional, psychosocial
screening and economic support
31
CHTC Test Possible Service Potential Benefits

Results Interventions
Seroconcordant l Prevention l Increased strength of relationship
negative counselling and quality of life
(Both partners l Couple counselling l Increased emotional support
HIV negative) l Mutual disclosure l Decreased HIV acquisition from
l Opportunity for VMMC other sexual partners
and Cervical cancer
screening
Serodisconcordant l Earlier initiation of ART l Decreased transmission within

l Male HIV positive for prevention current relationship and with other
l Female HIV l Pre-conception sexual partners
negative counselling with ART l Safer conception
for prevention l Increased HIV prevention with
l Prevention other sexual partners
counselling l Increased strength of relationship,
l Couple counselling quality of life and
l Mutual disclosure l Increased uptake and adherence
l Enrolment into support to family planning, PMTCT, ART
groups l Increased emotional, psychosocial
l Opportunity for VMMC and economic support
and Cervical cancer
screening
Serodisconcordant l Early initiation of ART l Decreased transmission within

male negative, for prevention current relationship and with other
female positive l Pre-conception sexual partners
l Male HIV negative counselling with ART l Safer conception
l Female HIV for prevention l Increased HIV prevention with
positive l Prevention counselling other sexual partners
l Couple counselling l Increased strength of relationship,
quality of life and emotional
l Mutual disclosure support
l Enrolment into support l Increased uptake and adherence
groups to family planning, PMTCT, ART
l Opportunity for VMMC l Increased psychosocial and
and Cervical cancer economic support. Increased
screening psychosocial and economic
support
l Decreased HIV acquisition from
current partner and other sexual
partners
32
chapter 4
4.6 Counselling for Key 4.6.2 Guiding principles for HTC for
Populations key populations
i) 5Cs Guiding Principles
4.6.1 Defining key populations These principles also apply to key
Key populations are people who are at populations:
higher risk of being infected or affected l Consent with voluntarism even
by HIV. They play a key role in the spread though some of the key populations
of HIV and whose involvement is vital for are engaging in illegal practices or
an effective and sustainable response to activities which are punishable by
HIV. They include both most-at-risk law.
populations and vulnerable populations. l Confidentiality: discussions between
the service provider and the client
Most-at-risk populations are those who should not be disclosed to anyone
are most likely to be exposed to HIV and without the express permission of
most likely to be infected. Some of their the client. This is particularly
behaviours create, increase and important in the case of prisoners
perpetuate risk e.g. unprotected sex, who may be perceived as having lost
multiple sexual partners and injecting their rights to confidentiality as a
drug use with contaminated needles. result of their incarceration.
They include sex workers, injecting drug l Counselling: the client should receive
users (IDU) Trans gender people (TG) and high quality pre-test information and
men who have sex with men (MSM). post-test counselling.
l Correct and accurate test results
Vulnerable populations are at risk due to should be provided by trained service
such factors as age, social mobility, providers with support for internal
gender and the environment in which and external quality assurance and
they live e.g. poverty, gender control from the Laboratory
discrimination, lack of health services personnel as stipulated in the
and lesser legal, social or policy National Rapid HIV testing QA/ QC
protection resulting in limited ability to protocols .
access HIV prevention services. They l Connections to prevention,
include adolescents especially girls, treatment, care and support services
orphans, street children, people in closed must be in place, with follow up
settings (e.g. prisoners), people with services and appropriate long term
disabilities (PWD), mobile workers such as care. There may also be need to refer
long distance truck drivers (LDTD) and some of the clients for hepatitis
migrant populations including refugees screening and vaccinations.
33
ii) Couple HTC key populations care CD4 count machines when providing
should be encouraged to undergo CHTC HTC services for key populations so as to
(Refer to Section 4.5) facilitate ease of access to early
treatment, care and support.
iii) Human rights
l All key populations are entitled to vii) Access to ART
full protection of their human rights Eligible key populations should have
which include the 5 C principles of access to ART in accordance with the
counseling including non- MOHCCs ART guidelines. It is important
discrimination, security of person to expand HTC, prevention, treatment,
and privacy ,recognition and equality care and support to these populations
before the law. through the use of expanded outreach
and community based approaches.
iv) Convenient locations and scheduling
Due to specific peculiarities of the viii) Multiple HTC approaches to be
different key populations and illegality employed in service provision
of some of their activities, HTC services It is important to use different HTC
need to be provided at locations and approaches when providing HTC services
scheduled at times most convenient for for key populations due to their varied
the population, including at night needs which cannot be addressed using
sometimes referred to as moonlighting. one approach. Peer involvement to bring
services to the specific target group and
v) Integrated service provision to establish trust between the service
Provision of integrated services is providers and service recipients should be
necessitated by the existence of such
considered.
co-morbidities as HIV/SRH, HIV/Hepatitis
B virus; HIV/mental conditions and
4.6.5.3 Pretest information/counselling
HIV/TB and Hepatitis C virus (HCV)
and Post-test counselling
infections are a silent epidemic
Pre-test information/counselling and
affecting more people than HIV. Both
post-test counselling content for key
infections are especially common among
populations is the same as for individuals
IDUs due to sharing of contaminated
(Sections 4.3.2 and 4.3.3). Table 5 below
injecting equipment. A vaccine is
highlights some of the counselling
available for HBV but not for HCV.
considerations that apply to specific
vi) Point of care CD4: populations and should be taken into
There may also be need to have point of account when counselling the clients.
34
chapter 4
Table 5: Additional counselling considerations for key populations
Key Important features Additional counselling

population of the group issues
Sex workers l Multiple sexual partners l Condom negotiation skills
(male and l Unsafe working environments l Consistent and correct use
female) l Weak condom negotiation power of both male and female
l Social marginalization condoms.
l Stigma and discrimination l STI screening , family
l Criminalization of sex work planning and other
l Violence and abusive law reproductive health services
enforcers l Cervical cancer screening
l Alcohol and illicit drug abuse l Referral for HBV vaccine
l HBV infection l Access to ART for HIV
l Act as bridging population for HIV prevention for HIV positive
transmission through clients in sex workers
steady relationships l Peers as service providers
l May need snow balling referral -explore on violence and abuse
Men who l Criminalization of MSM activities l Emphasis on risk of

have sex with l Legal and policy barriers contracting HIV through anal
men(MSM) l Social marginalization sex being higher than
l Stigma and discrimination through vaginal sex
l Proneness to l Access to condoms and
depression/suicide/anxiety water-based lubricants
l Alcohol and substance abuse
l Subjected to homophobia
Transgender l Criminalization of TG activities l Emphasis on risk of

people (TG) l Social marginalization contracting HIV through anal
l Stigma and discrimination sex being higher than
l Proneness to depression/ through vaginal sex
suicide/anxiety l Access to condoms and
l Alcohol and substance abuse water-based lubricants
l Subjected to transphobia
Injecting l HBV and HCV infections through l Defer HTC in clients who are
Drug users sharing of contaminated injecting evidently under the influence
(IDU) equipment of drugs
l Need for needle and syringe l Referral for screening for
programmes HBV and HCV
l Likelihood of HIV/HBV/HCV l Appropriate referral for
co-infection rehabilitation or treatment for
l Vaccine available for HBV drug abuse
35

Prisoners l Service providers may need l Explore possibility of

security clearance to enter MSM and IDU activities
prison and provide HTC l Access to both male and
services female condoms
l May have strict hours for HTC l Referral for screening for
service provision HBV, HCV and TB
l Risk of unprotected sex
l HCV from IDU in prison
Long l Spend long time away from l Access to both male and
Distance home female condoms
Truck l May drive through many l Emphasize CHTC and
Drivers countries condom use with regular
(LDTD) l Short time spent at service partner
delivery points
l Inadequate HIV services at
border posts
l Multiple and concurrent
relationships
Migrant l Displacement increases l Access to both male and

populations vulnerability to HIV female condoms
including l Prone to sexual abuse and l Emphasize CHTC and
refugees harassment and intimate condom use with all
partner violence sexual partners
l Low levels of condom use l Highlight on risks of
l Multiple sexual partnerships concurrent and multiple
l Varying cultural values sexual relationships and
l Access to treatment and care sexual networks
maybe difficult l Awareness of different
cultural values
l Use appropriate
language
l Explore where client can
best get treatment, care
and support services
36
chapter 4
People living l Different kinds of physical, l HTC service providers

with mental and other disabilities may need special
disabilities which may need the following: communication skills
(PWD) i) Sign language l Guardian may be
ii) Braille needed to give consent
iii) Wheelchair access l Explore issues of sexual
iv) Home based service abuse
provision l May need to refer client
for specialized care in
line with the clients
specific disability
4.7 Counselling within achieved through community education

community settings and mobilization, highlighting the
benefits of HTC to the individual, family,
4.7.1 Purpose of community community and nation.
based HTC l Proper planning for service delivery
The main purpose of HTC in community
will include assessment of
settings is to bring the services to
community support systems,
individuals and household members,
clearance from community leaders,
overcoming some of the barriers of
adequate trained service providers,
access to HIV testing services and
enough supplies for providing high
providing testing to individuals who
quality services (e.g. setting of
might not otherwise seek services
through the facility based approach. targets and accurate forecasting of
Community based HTC allows test kit needs for campaigns) and
individuals, couples, and families to learn waste disposal facilities.
their HIV status in their community l The 5Cs guiding principles for
environment while addressing the fears counselling are applicable and must
of confidentiality, stigma and be followed.
discrimination.
The key counselling issues pertaining to
4.7.2 Guiding principles for each model of community based HTC are
community based HTC highlighted in Table 6 below.
Conducive environment for HTC can be
37
Table 6: Key counselling considerations for specific community based

HTC models
Model Key counselling considerations
Home based l Quality assurance to ensure correct and accurate results

including l Maintaining client confidentiality, privacy and facilitating disclosure.
index clients l Managing negative emotional reactions to HIV positive results
l Linkages to prevention, treatment, care and support services
Mobile and l Privacy and confidentiality

Outreach l Quality assurance to ensure correct and accurate results
l Linkages to prevention, treatment and care services
l Post-test support systems
Workplace l Inadequate counselling space

l Privacy
l Coercion and confidentiality
l Linkages to HIV prevention, treatment, care and support services
l Follow up of tested clients
l Stigma and discrimination at the workplace
Educational l Informed consent and parental consent

institutions l Peer pressure and confidentiality
l Counselling space and privacy
l Provision of youth friendly services
l Capacity to provide HTC for children and adolescents
Campaigns l Quality of services

l Linkages to prevention, treatment, care and support services
l Timely advocacy and community mobilisation through community
systems.
l Planning, implementation, monitoring and evaluation with
community structures.
Self-testing l Lack of pre-test counselling

l Greater potential for inaccurate interpretation of HIV test results
l Difficulties with follow up services and support
l Potential unethical use of self-testing
l Challenges with safe disposal of bio hazardous material
l Choice of Algorithm including connection and linkage for further
management
38
chapter 4
4.8 Counsellor self-care and transmission of blood-borne
support infections. It is desirable that
counsellors receive Hepatitis B
Burn-out has been described as a immunization. In cases of
physical, emotional, psychological and occupational exposure, such as
spiritual phenomenon, characterized by needle-stick injuries, post-exposure
progressive loss of idealism, energy and prophylaxis (PEP) must be available
purpose experienced by people working as soon as possible preferably within
in helping professions. All HTC the first hour and within 72 hours of
counsellors need formal support and exposure. National guidelines on
wellness programs for stress management procedures to be followed for PEP
as well as mentoring strategies to prevent must be adhered to at all times and
or mitigate the effects of burnout. the PEP SOPs must be displayed at
all service delivery points counselling
Counselling support strategies include: for adherence must accompany the
administration of PEP.
l Ensuring that counsellors have clear
l A more experienced counsellor must
roles and responsibilities.
act as a mentor for a less
l Ensuring periodic medical screening experienced counsellor. The mentor
for all counsellors as they may be must be readily available and
exposed to other diseases in the accessible for support at all times.
course of their work. All areas used l Periodic counselling review meetings
for counselling must be well and debriefing sessions should be
ventilated and counsellors should held at least once a week. During
receive routine preventive health these meetings the counsellors can
screening, especially for TB. Those discuss challenging cases, share
who are HIV positive should be experiences and be updated on new
provided access to prevention, developments in HIV, AIDS and other
treatment care and support services. related topics.
l All counsellors are encouraged to go l Periodic case conferencing sessions
through the process of HTC so that should be convened and minuted.
they understand the process and are l Counsellors should form support
more empathetic when providing groups in order to support and assist
services. Knowledge of their own HIV each other in an informal
status will also help counsellors environment where both social and
access prevention, treatment, care work-related activities will be
and support services. discussed. This mutual support will
l Every measure must be taken to help in minimizing stress and
reduce the risk of occupational burnout.
39
4.9 Quality assurance for ii) Peer observation of HIV

HTC counselling session:
managers/supervisors will
Counsellors have an ethical and occasionally observe counsellors
professional duty to adhere to HIV providing HIV counselling
counselling standards and policies and services to clients. It is
to provide services of the highest quality. recommended that HIV
All providers of HIV counselling services counsellors observe each others
are responsible for ensuring quality session on a regular basis,
assurance and quality improvement. providing critical feedback and
Quality assurance is a way of monitoring support to each other. All
and evaluating the quality of services observation of counselling
provided in accordance with established sessions must be undertaken
national guidelines, policies and only with the informed consent
standards. of clients
iii) Case conferences: Depending
Institutions such as hospitals, clinics and upon the work environment,
non-profit agencies are required to counsellors may be invited to
conduct quality assurance and meet with other HIV counsellors
mentorship activities as well as on a regular basis - sometimes
operational and mystery client surveys to weekly, monthly, and quarterly -
ensure quality and client satisfaction. to discuss management of
Clinical mentoring is a system of practical emerging issues and share
training and consultation that fosters experiences.
ongoing professional development to
l Regular training
yield sustainable high-quality clinical
care outcomes. It should be integrated l Supportive supervision
with and immediately follow initial l Wellness and stress management
training. It is case-based and sessions
participatory, based on the principles of
adult learning. l Mystery client surveys
l Client exit interviews to measure
Approaches for assessing HTC services client satisfaction
include the following: l Operations research.
l Mentorship strategies:
i) Counsellor self-assessment These approaches must be used regularly
whereby counsellors regularly to assess and monitor the quality of
evaluate their own HIV counselling provided at each facility and
counselling performance. in the community.
40
chapter 5
HIV Testing and

Supply Chain Management
5.1 Coordination of HIV 5.2 HIV testing procedures

testing services
The indications for HIV testing include:
At the national level the MOHCC, l Knowledge of ones HIV status
through the AIDS and TB programme, is including in key populations
responsible for direction and l Diagnosis of HIV infection in
coordination of HIV testing services in children born to HIV positive mothers
Zimbabwe. The coordination is through l Voluntary Medical Male Circumcision
existing provincial and district structures
l Diagnosis of HIV infection in adults
under direction of the National
Microbiology Reference Laboratory l Screening of donated blood and
blood products for transfusion
(NMRL). The district and provincial
structures are responsible for l Surveillance of HIV prevalence or
trends over time in a given
coordinating HIV testing activities at
population
lower levels. The Medical Laboratory and
Clinical Scientists Council of Zimbabwe l Management of sexual assault cases
(MLCSCZ) on behalf of the MOHCC sets l Management of work related
standards for HIV testing in the country exposure to HIV.
as well as accreditation of all public and
5.2.1 Recommended HIV test kits
private facilities to carry out HTC
An essential requirement of all HIV
services. All facilities providing HIV
testing is accuracy of the test result. The
testing services in Zimbabwe should be
rapid test kits used in the country are
registered with the Zimbabwe National those that are recommended by World
Quality Assurance Programme (ZINQAP) Health Organization (WHO) and have
for External Quality Assurance. been evaluated in the country by NMRL
41
before local use. The list of infection are HIV Rapid Antibody tests.
recommended rapid test kits can be Enzyme-linked Immunosorbent Assays
obtained from the MLCSCZ. The (ELISAs) are mostly used for Quality
nationally approved algorithm is selected Assurance and surveillance. Western blot
by the MOHCC. All MOHCC incoming testing is used predominantly as a
lots/batches of HIV test kits are verified confirmatory test in research settings
by the NMRL before they are distributed
for use at the HIV testing sites. Clients who test HIV negative but who
may have been exposed to HIV infection
5.2.2 Laboratory HIV tests should be encouraged to return for a
Different tests are available for detection retest in 12 weeks. HIV Rapid tests are
of HIV Infection and can be grouped into recommended for HIV testing and
2 main groups as Antibody tests or counselling services in Zimbabwe because
Antigen tests. they are relatively simple to perform in
settings without laboratories or
i) Antibody tests on blood specialized laboratory equipment.
Persons who become infected with HIV Task shifting to nurses and Primary
produce HIV antibodies as an
Counsellors has been implemented after
immunological response to the infection.
comprehensive HIV Rapid Test training
The window period is the period from
by the MLCSCZ. Laboratory Scientists in
getting infected with HIV to the time
the different national or private
when the body has produced enough
structures provide testing oversight and
antibodies to be detected with an HIV
continuous supervision.
antibody test. This period is usually
within 12 weeks. This means that a
ii) Antibody tests on oral fluid
person who has just been infected may
Technological advances in HIV testing
test negative for the HIV antibody
technologies have availed non-blood
because their body has not produced
enough antibodies to be detected by the based HIV test kits, the most common of
test. However, he/she will be highly which are oral fluid tests. These test kits
infectious and can transmit the virus to have made self-testing a possibility.
others. Antibody testing on oral fluid may be
used in community based HIV testing.
In Zimbabwe HIV infection is usually
diagnosed by testing for antibodies Minimum standards to support self-
against HIV in blood samples. The most testing need to be put in place and key
commonly used screening tests for HIV elements are:
42
chapter 5
l The test kits must be evaluated and iii) Antigen/Nucleic Acid tests
approved for use in Zimbabwe Nucleic Acid tests detect the viral
Deoxyribonucleic acid (DNA) or
l Feasibility/Pilot studies on oral fluid
self-testing must be carried out to Ribonucleic acid (RNA) in a persons
generate data that can be used to blood sample. DNA testing is used
inform the oral fluid self-testing primarily for diagnosis of HIV infection
programme. in children less than 18 months. RNA
testing, commonly known as viral load
l Service providers must be trained
testing, is used primarily for monitoring
and approved to dispense, counsel
response to ART.
and demonstrate how to use the test
kit to the clients as the need arises.
5.2.3 HIV testing for children less
This will ensure that the clients who
than 18 months
want to self-test know how to
conduct the test, correctly interpret
the test result as well as access Antibodies to HIV can be passed from an
follow up and support services HIV positive mother to their baby
within their area. The service through the placenta and breast milk and
providers should also ensure that test may persist in the babys blood for up to
kits that are dispensed are within 18 months. This means that it is not
their expiry dates and storage possible to determine whether a baby is
conditions are adequate. HIV infected using HIV antibody tests
until the baby is older than 18 months.
l Care needs to be taken to avoid
misuse of the test kits as well as Children below 18 months are diagnosed
prevent cases of negative social for HIV Infection using DNA Polymerase
outcomes. Chain Reaction (PCR). DNA PCR is
currently offered through the NMRL via
Waste generated from community testing Dried Blood Spot (DBS) samples from
should be disposed of appropriately clinics. Plans are underway to
according to MOHCC guidelines. decentralize DNA PCR testing.
l Because of the above factors an

analysis of scientific evidence, 5.3 HIV Testing Algorithms
logistics, test performance and
affordability of using oral fluid for 5.3.1 Serial Algorithm
carrying out HIV antibody self- As a policy, the country has moved from
testing is currently being explored in a parallel testing to a serial testing
Zimbabwe. algorithm where an initial (screening)
43
blood sample is taken and tested using positive, the result is given to the client
one rapid HIV test. If the result is as HIV positive. If the second test is
negative, the result is given to the client negative a third rapid HIV test is used as
as HIV negative. If the result is positive a tiebreaker and the result is given out to
the initial (screening) blood sample is the client whether HIV negative or
tested using a different (confirmatory), positive as illustrated in the flow chart
rapid HIV test. If the second test is also below (Figure 2).
Figure 2: Algorithm for Serial HIV Testing
44
chapter 5
Parallel testing which was used in the period of time for explicit reasons which
past involved testing a blood sample with include:
two different HIV test kits (paired l Specific incident of possible HIV
according to algorithm) simultaneously exposure within the past three
(in parallel).If the results from the both months
tests are the same ( concordant) the
l Ongoing risk of HIV exposure such as
client is issued the result. If one test is
sharing injecting equipment, sexual
positive and another is negative
contact and breastfeeding
(discordant) the tests are repeated using
the same test kits during the same visit. Re-testing is always performed on a new
If the results are still discordant, a specimen and may or may not use the
recommended tie breaker- according to same rapid HIV tests as the ones used at
algorithm is used and the result of the the initial test visit.
tiebreaker is given to the client.
l In general, for the general
population the timeframes for
5.4 Repeat testing retesting are after 3 months to close
the window and annually. In cases of
When using the serial testing algorithm, known or suspected exposure to HIV,
repeat testing is done when an invalid testing should be carried out within
result (one in which the control line on 6 months. For high risk groups, retest
the HIV testing device does not come more frequently in accordance with
out) after carrying out an HIV test. the degree of exposure.
This can happen at any stage along the l For pregnant women:
testing algorithm (1st test, 2nd test or i) Those tested in first and second
3rd test).This indicates a failure in the trimester, retest at 32 weeks of
testing system whereby either the HIV pregnancy
testing device is not working correctly or ii) Those tested in the third
the procedure was not followed correctly. trimester, retest at 6 weeks post-
Repeat testing is done while the client is delivery
waiting and, if possible, its done on the
iii) Those tested at delivery, retest at
same specimen using the same assays.
14 weeks post-delivery.
l For lactating mothers, retest every
5.5 Retesting 6 months till cessation of breast
feeding and thereafter, with each
Refers to testing an individual who pregnancy or annually if sexually
previously tested negative after a defined active.
45
Figure 3: Retesting Guideline for the General Population
General
Is HIV Status
known? NO
YES, Known HIV status

HIV Test at point of
contact
HIV results
Re-test 3 months (Close window period)
If sexually If considered part of at -risk group
Re-test at least once annually but more

Re-test annually
frequently if possible
46
chapter 5
Figure 4: Retesting Guideline for Pregnant Women
Pregnant Women
1st and 2nd 3rd Labor &

Trimester Trimester Delivery
Is HIV
Is HIV Is HIV Status
Status Status known?
known? known? YES, HIV NO
NO NO
YES, HIV result from YES, HIV
YES, HIV Result from 1st
3rd Trimester
contact ONLY
or at 32
Weeks
HIV Test HIV Test HIV Test
Re-test
HIV HIV immediately
result HIV
result result
HIV
result
Re-test at 32 Weeks Re-test at 6 weeks

OR During 3rd post delivery Re-test at 14 Weeks
Trimester Post-Delivery
47
Figure 5: Retesting for Lactating mothers
women
During Breast- Subsequent Tests

Feeding
Is HIV
Is HIV
Status
Status
known?
known? NO
NO
YES, HIV
YES, HIV
HIV
HIV Test
Test
HIV
HIV result
Re-test result Re-test with each
every 6 months pregnancyor
of annually if
sexually
48
chapter 5
5.6 Minimum requirements collection tubes, lancets, tourniquet,
for laboratory standards cotton wool, methylated
spirit/alcohol swabs
In order to ensure a consistent and l Test kits according to approved
coherent approach to monitor, assess and algorithm
improve the quality of HIV testing l Functional First Aid Kit
services all HIV testing sites must adhere
l PEP procedures
to Quality Assurance (QA) guidelines
which must be systematic and planned. l Testing Standard Operating
QA systems must be in place at all levels Procedures (SOPs) and HIV testing
including policy, testing, counselling, algorithms
logistics and data management. They l Data collection tools
should enable continuous monitoring
and improvement of the quality of Every HTC facility must have and must
service. adhere to procedures for safe handling of
bio- hazardous material. This should
In general HIV testing sites should be include instructions on use of gloves,
clean, organized, well lit, and well hand washing, handling and disposing of
ventilated with an environmental sharps, how to clean up a spill, how to
temperature that does not exceed that disinfect HIV testing areas and proper
required by the test kits. The testing area disposal of used test kits. No eating,
should offer privacy and have the drinking or smoking should take place in
following equipment: HIV testing areas. Procedures must be in
l Table and 3 chairs ( in case of place on how to respond in the case of
couples or minors) and lockable accidental exposure to bio-hazardous or
cupboard infectious material.
l Running water, wash-basin, soap and 5.7 Quality Assurance (QA)

disposal towels
l Disinfectant QA systems are essential for a coherent
l Sharps containers and lined bins for and functioning service delivery system
other waste at all levels. They help to ensure that
needs and expectations of clients and
l Refrigerator or cooler box with ice communities are being met. They also
(for storage of controls) allow the generation and use of data to
l Enough supplies including gloves, assess whether services are delivered in
vacutainer syringes and blood accordance with set standards.
49
5.7.1 Internal QA l Steps to ensure accurate reading of

QA begins at the national level with the results.
evaluation, approval and registration of
HIV test kits and ends when the correct iii) Post Analytical Phase
result has been issued to the correct These are steps taken to assure quality of
client. The Internal quality assurance results after testing has been completed
cycle has 3 stages namely: preanalytical, and key elements are:
analytical and post analytical stages. l Correct interpretation of results
i) Pre-analytical Stage l Correct recording, issuing and filing

These are the steps taken to assure the of results
quality of results before actual testing l Correct compilation and periodic
takes place. Key elements in the pre- reporting of data as per program
analytical stage include: requirements.
l Selection of test kits and algorithm
to be used for testing 5.7.2 External QA (EQA)
EQA is a system of objectively checking
l Sample collection as per facility SOP
and/or national Job Aid testing performance using an external or
different facility. In Zimbabwe all
l Proper storage of kits as per
facilities providing HIV testing and
manufacturer instructions
counselling services should participate in
l Proper identification of samples the ZINQAP External Quality Assurance
l Proper identification of client Programme. ZINQAP creates blood
l Personnel training, supervision and samples of pre-known HIV status and
competency sends them to the district for distribution
l Stock management to the testing facilities. Quarterly supplies
of HIV Dried Tube Samples (DTS)
ii) Analytical Phase together with instructions for storage,
These are steps taken to assure the handling and testing, reporting and
quality of results during testing and key returning results are dispatched to the
elements include: district. The District Nursing Officer
l Use of internal negative and positive (DNO) and District Medical Laboratory
controls (to be provided by Scientist are responsible for distributing
supporting laboratory) proficiency panels to all the testing sites
l Adherence to SOPs for tests being in the district. They are also responsible
carried out for forwarding to ZINQAP results
50
chapter 5
submitted by the testing facilities. ensure compliance with set minimum
All facilities failing proficiency testing standards and QA guidelines.
need to institute corrective action
measures with assistance from the district 5.7.4 Blinded rechecking
or supporting laboratory. Blinded rechecking of 5-10% of all blood
samples is recommended as a QA
5.7.3 Support and monitoring visits measure. The blood samples are
Regular on-going supervision of HIV randomly selected from testing facilities
testing sites and competency assessment and sent to NMRL or delegated centres
of personnel is critical to ensuring high for retesting. The percentage can be
quality services are being offered in the revised with guidance from NMRL
program. As part of the QA system, the depending on the feasibility of obtaining
District/ Supporting Laboratory Scientist 5-10% of the total samples. Root cause
shall periodically carry out support and analysis and corrective action should be
monitoring visits to testing facilities. carried out in the event of discordant
Standard supervisory/assessment tools results.
should be used. As the regulatory body,
the MLCSCZ shall carry out periodic site The level specific QA responsibilities are
monitoring visits to testing facilities to summarized in Table 7 below.
Table 7: Level-specific QA responsibilities for HIV testing
Quality
Level Quality Assurance Task Responsibility
Indicator
National Formulation of QA Strategies MOHCC
Capacity building (human Resources, facilities)
MOHCC
to meet minimum requirements
Accreditation and registration of facilities to carry
MLCSCZ
out testing
Evaluation and approval of WHO-certified test
MLCSCZ &
kits including new technologies(oral fluid) and lot
NMRL
to lot testing
Directorate
Selection of evaluated test kits and formulation
of Laboratory
of national algorithm
Services
Training and certification of designated cadres to MLCSCZ &

carry out HIV Testing MOHCC
51
Quality
Indicator
Preparation and distribution of EQA Panels

ZINQAP
as well as grading results
MLCSCZ &
Periodic quality monitoring visits to sites Provincial

including private facilities Laboratory/
Quality Officer
Quantification, Procurement and Supply Lab Directorate

chain management of test kits and other Logistics &
consumables Natpharm
Provincial
Delegation and follow up of support and
Provincial Laboratory
supervision of sites to district level
Scientist
Supervision of EQA panel distribution from Provincial

district to HTC facilities and submission of Laboratory
EQA results from district to ZINQAP Scientist
Support and supervisory visits to testing District Laboratory

District
sites Scientist
Support and supervisory visits to testing District Laboratory

sites Scientist
District level distribution of EQA panels District Laboratory

and reports to and from ZINQAP Scientist
Availability of SOPs and training to ensure District Laboratory

SOPs are understood at testing facilities Scientist
Preparation and distribution of Internal

District Laboratory
(positive and negative) controls to all
Scientist
testing sites in the district
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chapter 5
Quality
Indicator
Authorized testing
Facility Ensure adherence to SOPs when testing
personnel
Authorized testing
Proper handling and storage of kits
personnel
Running EQA samples and submitting Authorized testing

results personnel
Carrying out and documentation of daily QA

Authorized testing
activities(disinfections, temperature moni-
personnel
toring, controls)
Confidential systematic reporting of results Authorized testing

and periodic report compilation personnel
Adherence to safety procedures and proper Authorized testing

disposal of waste personnel
5.8 Handling of 5.9 Laboratory Safety Rules

contaminated waste
Strict laboratory safety precautions must
Sharps such as lancets and needles must be followed as per training manual SOP.
be placed in a specially designed sharps All precautions to protect against blood
disposal containers. In the event that contamination should be observed.
conventional sharps containers are not A Post Exposure Prophylaxis (PEP)
available, puncture resistant plastic procedure and starter kit should be
containers may be used instead. Used test available in all testing sites and all staff
kits and blood-contaminated materials members should be familiar with the
should be placed in biohazard plastic procedure. Relevant staff vaccinations
bags. All containers containing bio- like Hepatitis B should be offered to
hazardous materials, including sharps staff.
containers, must be incinerated at the
nearest incineration facility.
53
5.10 Supply Chain from all NatPharm branches nationwide.

Management In consultation with MOHCC, Natpharm
will distribute test kits and DNA PCR
5.10.1 Product Selection and Bundles to public and selected private
Evaluation of HIV test kits health facilities using a harmonized
The Medical Laboratory and Clinical distribution system and will also maintain
Scientists Council of Zimbabwe an emergency or buffer stock of rapid
(MLCSCZ) is responsible for evaluating HIV test kits and DNA PCR Bundles for
WHO prequalified HIV test kits for use in distribution when needed. All other
Zimbabwe. The Directorate of Laboratory commodities related to HTC will be
Services together with AIDS and TB accessed through the general Essential
program managers select test kits for use Medicines program
from the evaluated list.
5.10.4 Stock Management
5.10.2 Quantification Stock Management of tests kits, DNA
The selected products are forecasted PCR Bundles and related commodities
annually by the Directorates of Pharmacy Every facility providing HTC services will
and Laboratory Services together with have staff members trained in Integrated
AIDS and TB program managers and stock management. On receipt,
partners. Supply plans are shared with commodities should:
partners for procurement. There will be l be counted and crosschecked with
semi-annual reviews of the collaborative delivery documentation.
annual forecast and supply plans.
l stored in well-lit and ventilated
rooms
5.10.3 Procurement, storage and
distribution procedures l stored to allow first expiry first out
HTC commodities will be procured by
government and its partners according to For proper storage of test kits and DNA
the supply plan in consultation with the PCR Bundles see Standard Operational
Ministry of Health and Child Care Procedures (SOP) manual (storage
(MOHCC). The National Pharmaceutical guidelines for health commodities).
Company of Zimbabwe (NatPharm) will
be responsible for storage and - (Quantification Standard Operating
distribution. All test kits and DNA PCR Procedure Manual January 2014
Bundles will be stored and distributed (Version 1-00)
54
chapter 6
Scaling Up of HIV
Testing and Counselling Services
The Government of Zimbabwe has set ii) Multi-sectoral coordination of HIV

the mitigation of the impact of HIV and and AIDS activities
AIDS as one of its priority interventions. The National AIDS Council (NAC) is a
HTC is a key entry point to accessing multi-sectoral body which was
prevention, care and support services. established through an Act of Parliament
In this regard, a number of strategies to coordinate, facilitate, mobilize
have been put in place to ensure resources, support and monitor a
increased access to HTC. decentralized national multi-sectoral
response to HIV and AIDS.
6.1 Ensuring a conducive
policy environment iii) Local resource mobilization
The Government of Zimbabwe has
i) National HIV and AIDS Strategic mandated that a 3% AIDS Levy is
Plan deducted from all employers and
The National AIDS Policy and the employees taxable income. These funds
Zimbabwe National HIV and AIDS are utilized for HIV and AIDS mitigation
Strategic Plan 2011-2015 have prioritized efforts for all levels of the society.
high impact interventions that include
HTC to achieve the set outcome of It is important to look at other possible
reducing HIV incidence. HTC is one of sources for funding HTC programmes at
the prioritized interventions that are set community level. Supporting HTC at
to increase peoples level of knowledge community level can be part of the
of HIV and perception of personal risk corporate social responsibility initiatives
that will facilitate increased uptake of that different companies can play in
prevention services. The policy and supporting the communities they operate
strategic plan set a good platform for in. Examples can include mining firms
availing and scaling up HTC services. operating in various communities across
55
the country, including those in border 6.2 Community based

areas that have high HIV prevalence. demand creation
Local communities should be empowered For the purposes of this guideline,

to know that the required resources for communities will include: -
HTC at community level are not only
l Political, community and traditional
financial, but communities can also
leaders
creatively look at other areas to support
the programme. This can include l Educational institutions
assisting in mobilizing people during l Faith based groups
campaigns, assisting in distribution of
l Support groups
IEC materials and other areas. This local
support can contribute in successfully l Community health workers
scaling up HTC in the communities. l Community members
l Workplace
iv) Mainstreaming HIV and AIDS in all
sectors l Other communities there is need to
All public and private sectors, including look at communities outside the
the civil society have been mandated to above-mentioned, especially with
mainstream HIV and AIDS in all their regards to the different community
programmes, including HTC for their dynamics that exist. There are some
staff members and families. Local leaders people, particularly young people in
need to be empowered so that they play urban areas who at times are difficult
an active role in ensuring that the public to reach out to, especially at
and private organizations, including civil traditional gathering points in the
society are complying with this and that communities. Due to technological
the staff and their families do access HTC advancements, these can be reached
and other HIV-related services. through social media such as
Facebook, WhatsApp, twitter, hence
v) HTC as part of standard of care the importance of being innovative
All health facilities in Zimbabwe, both in reaching out to them.
private and public sectors are being
encouraged to adopted Provider The current Public Health Act exempts
Initiated Testing and Counselling as part HIV from being treated as any other
of the standard of care for all patients communicable disease. Since it is a
and clients seeking services at their fundamental human right for every
institutions. Zimbabwean to know their HIV status if
56
chapter 6
they so wish, there is need to increase singled out and incorporated in our
knowledge about HTC in the programmes. These leaders should have
communities. Whilst it is essential that the capacity of advocating for HTC in the
communities are made aware of HTC, community and also be the ones to
it is also important to note that they are spearhead this by being tested themselves
not passive recipients, but organised (where possible).
structures that can also contribute
positively to HTC goals. Community leaders should take the
leading role in addressing barriers to HTC
Five key community involvement focus in the community, including religious
areas that will be discussed include: and traditional barriers.
l Advocacy
User fees have traditionally been a
l Communication and Social hindrance to accessing services in
Mobilisation Zimbabwe. There is therefore a clear need
l Accurate information dissemination to advocate the removal of user fees for
and awareness HIV related services, particularly for key
l Community support systems populations.
strengthening
6.2.2 Communication and Social
l Strengthening community health Mobilization
systems linkages Various communication strategies to
l Family-centred approaches communicate appropriate HTC messages
that suit different populations in the
6.2.1 Advocacy communities should be used. Strategies
Community advocacy should focus on include but are not limited to radio,
recognition and implementation of television, social media (such as
policies that are supportive of HTC. WhatsApp, Facebook, twitter), print
Advocacy should also centre on Patients media which would include posters,
Charter, childs rights and the principle of pamphlets, community newspapers and
the best interest of the child among other IEC materials. Use of interpersonal
other issues. communication (IPC) methods should
also be emphasized. Various trained
Advocacy initiatives in the communities community health workers, including
need to clearly outline who the different Peer Educators can effectively raise
influential leaders in the community are. awareness of HTC in the community and
These community leaders should be these also have the added advantage of
57
being able to address myths and 6.2.3 Accurate information

misconceptions concerning HTC in the dissemination and awareness
community. Accurate information should be
developed and disseminated to demystify
Continued collaborations with other myths and misconceptions in the
relevant Ministries that can support HTC community. It is essential that
goals and interventions cannot be over communities are aware of the importance
emphasized. Integration of other of HTC in the fight against HIV and
MOHCC Communication Strategies to AIDS. Therefore, existing and new
address HTC issues as a collaborative strategies on creating community
intervention should be implemented. awareness and mobilization should be
intensified and implemented. This will
6.2.2.1 Social Marketing ensure that HTC is accepted as an entry
The social marketing approach of point to prevention, treatment, care and
branding the client-initiated and provider support for the infected and affected
initiated services should be adopted by people.
MOHCC and civil society organizations
(CSOs) as a strategy to reach Information should be made available
communities. Relevant media adverts and through multi-media campaigns, to
branding should also be used. Role create awareness that HTC will be part of
models, including those at community the standard of care in all health
level, should be used to ensure effective facilities. Approaches for reaching those
communication. who are illiterate, and various categories
of people living with disabilities should
6.2.2.2 Social Mobilization be implemented at all times.
Social mobilization strategies should be
utilized to increase HTC uptake. MOHCC 6.2.4 Community support systems
and CSOs should utilise strategies to strengthening
mobilise specific groups e.g. reaching out Community systems should provide
to men in social gatherings and strategic comprehensive support services to HTC
settings, such as bars, churches, funerals, clients. Existing community systems
work places, etc. social mobilization should be strengthened to promote HTC
should be intensified in all communities, services uptake. The community
until community members have a clear structures like political leaders, support
understanding of the benefits of HTC groups, community health workers and
and they even demand for the services traditional and religious leaders must be
themselves. capacitated to create demand and
58
chapter 6
complement HTC services. Community should map out all possible linkages in
leaders are expected to take a leading the community and vital planning
role in promoting HTC goals and partnerships and clinical collaborations.
interventions. Testimonials from Expert This will contribute to strengthening of
Clients should be used to encourage the referral process.
other community members to seek HTC
services. HTC service providers should engage in
community mobilization and support
6.2.5 Strengthening Community efforts. They should meet regularly with
Health Systems Linkages communities and HIV and AIDS service
The MOHCC recognizes that community providers to create demand and ensure
care and support services contribute support for clients who have undergone
significantly to the continuum of care HTC.
through home-based and family care by
volunteers.There is need for clear referral 6.2.6 Family Centred Approaches
protocols from both community and There should be a family centred
health systems. It should be encouraged approach to HTC. If a family member
that there be regular interaction between visits the health facility for HTC services,
the two systems and that information this opportunity should be used to reach
and skills sharing take place out to other family members so all family
continuously. Referral for HTC services members access HTC. Families can also
should be a two-way process that creates be approached by household HTC
linkages between the community and the services. Workplace HTC services should
facility providing the service. be accessed by spouses and family
members. Community Health care
Community-based linkages include workers should also offer HTC services
networking with political leaders, to family members of HTC clients.
religious leaders, traditional healers,
traditional leaders, youth leaders, sexual 6.3 Capacity building
partners of clients, peer educators,
community home based care groups, In order to enhance the counseling
AIDS Action Committees, community capacity in all communities and facilities
based organizations (CBOs), faith-based providing HTC services, the country will
organizations (FBOs), nutrition support continue to implement innovative
organizations, mens groups such as strategies for training of HTC service
Padare, and post-test support groups or providers from different sectors both at
clubs. All facilities providing HTC services pre-service and in-service levels.
59
6.4 Increasing demand for ii) HTC Advocates

services Men and women with a passion for HTC
and/or HIV-related services should be
i) Male involvement identified and encouraged to volunteer
Zimbabwe is a patriarchal society where as HTC Advocates/Champions/
the role of males in the decision-making Ambassadors in their communities.
process is important and needs to be These men and women, regardless of
recognized, especially with regards to their HIV status should actively
sexual reproductive matters. The encourage people to be tested for HIV
government will continue to step up in their communities.
efforts to inform and educate men so
that they understand and support iii) HTC in Tertiary Institutions
programmes, for example, PMTCT and It is important to ensure that HTC
the benefit for the family. Men should services are available in tertiary
also be encouraged to undergo couple institutions. Peer Educators can be
HTC so that both partners and their trained within these institutions to raise
families benefit from prevention, awareness of the importance of HTC.
treatment, care and support programmes.
6.5 Increasing access to
It also important that HTC services are services
structured in such a way that they are
male-friendly. Some important i) Involvement of various sectors in
considerations include the following: - service provision
Different sectors and organizations in the
l HTC services should be offered country should continue to be involved
during times that are flexible for in the provision of HTC services,
men, since they can be at work following national standards and
during the routine times for services guidelines. This involvement leads to
l Counselling should be provided improved access and meets the different
focusing on the mans issues as well needs of the various segments of the
community.
l HTC IEC materials should also
include males (in terms of messages ii) Scaling up PITC
and display images) PITC reduces missed opportunities for
l Services providers should be gender HTC and provides access to prevention,
sensitive treatment, care and support services.
PITC should be implemented by service
60
chapter 6
providers at health facilities and in around the benefits of HTC for the entire
communities. community, will enhance sex workers
capacity to negotiate for safer sex,
iii) Rolling out ART primarily through condom use.
The rolling out of the ART programme,
calls for urgent scaling up of HTC Care must be taken to ensure that people
services in the country. The availability living with various forms of disabilities
of ART for both treatment and and confined groups such as prisoners
prevention will reduce transmission of have access to appropriate information
HIV from HIV positive persons. on the importance of HTC.
iv) Reducing waiting period for HIV 6.6 Normalizing HTC in

test results communities
Rapid HIV testing should continue in all
facilities providing HTC services in PITC and community based testing are
Zimbabwe. The use of rapid tests ensures current strategies to normalize HTC in
availability of test results on the same Zimbabwe, as it increases availability of
day. This reduces the need for repeat services.
visits for collection of results, and
ensures timely implementation of Public HIV testing efforts by influential
prevention, treatment, care and support people and role models in the society
interventions. have resulted in the increased
normalization of the importance of
v) Targeting key populations knowing ones status. Some have
All key populations face a number of disclosed their HIV sero status, and
challenges in accessing HTC and other shared their encouraging experiences
HIV and AIDS services. It is imperative regarding positive living and ART.
that they are specially targeted on This initiative should continue in
information and education pertaining to assisting the country to address stigma
HTC. Women in particular face a lot of and discrimination so as to normalize
challenges, especially economic HIV testing and counselling in the
challenges which then makes some of country.
them engage in high-risk behaviour. In
the case of sex workers, it is essential to 6.7 Support groups
target their client communities at the
same time so as to facilitate behavior Post-test clubs (support groups) comprise
change. Education and mobilization of clients who have undergone HTC,
61
regardless of their HIV status. These clubs PLWH, should be formed in all
are a forum to promote positive attitude, communities. They should develop close
behavior and messages as well as to links with HTC facilities and other service
increase knowledge and demand for HTC. providers in the community and make
Formation of these support groups plans for cross referrals. Meaningful
should be scaled up even in rural areas. involvement of PLWH in the planning
and implementation of HTC services
These support groups or clubs are often should be encouraged. They should also
a useful feature of HTC service provision. ensure good linkages with health
These support groups, especially for facilities.
62
chapter 7
Monitoring and Evaluation

7.1 Defining monitoring and system. This information is essential for

Evaluation the effective management and
improvement of HTC services. Whereas
Monitoring is the regular and routine monitoring involves the regular, routine
tracking of key program elements assessment of ongoing activities,
collected on a regular and on-going evaluation is episodic and examines large
basis. Monitoring allows MOHCC to scale impact and achievements to answer
track, document and report the quantity specific management and epidemiologic
and quality of HTC services provided. questions that will guide future actions,
Monitoring of the HTC programme helps planning, and decision making regarding
to assess program performance, detect HTC. Both monitoring and evaluation are
and correct performance problems and critical components of Zimbabwes
make more efficient use of resources. National HIV and AIDS Monitoring and
Evaluation Framework outlined in the
Evaluation is episodic assessment of Zimbabwe National HIV and AIDS
change in specific result areas that can Strategic Plan (ZNASP) 2011 to 2015.
be attributed to an intervention e.g. All HTC service providers should be
assessing the uptake of HTC services as actively engaged in M&E processes, and
a result of a targeted behaviour change are encouraged to utilize their own
and communication campaign. programme level data to improve and
strengthen their operations.
7.2 Purposes of Monitoring
and evaluation (M&E) Up-to-date monitoring of HTC allows for
prompt identification and resolution of
M&E involves data collection, analysis, the challenges (and successes) of an HTC
interpretation, use and report writing at programme. M&E allows for observation
all levels of the health care delivery of a programmes trends, which can
63
guide priority setting and resource working framework for M&E of HIV and
allocation at the local and national levels. AIDS programs in Zimbabwe. The HMIS
Finally, M&E data can be used to answer ensures that specific indicators are
critical questions about Zimbabwes HIV collected at the service delivery level
epidemic in a regional, national, or using standard M&E registers and report
international context. Scientific inquiries forms. The national health information
and surveillance documents such as the unit conducts regular review of existing
Zimbabwe Demographic and Health M&E systems to ensure that current
Survey (ZDHS) also utilize data collected procedures correspond with national and
during standard M&E procedures. international priorities and the scientific
Information from HTC service delivery and policy environments. It is the
points should be treated with the same responsibility of all health personnel to
level of confidentiality that all medical contribute to accurate record keeping,
records are given. Only authorized
and staff should be provided with
officers should be permitted to handle
adequate internal or external training
client-level data.
and tools to be able to provide quality
management of M&E procedures.
7.3 Roles and Responsibilities
Figure 6 shows the flow of HTC data
The national Health Management
from communities through national level.
Information System (HMIS) provides a
Figure 6: Flow of HIV Testing and Counselling Data
64
chapter 7
Table 8: M&E activities by level of health care
Level Activities
National l Adaptation of guidelines

l Revision of HTC program indicators
l Revision, printing and distribution of M&E tools and standard
operating procedures
l Supporting M&E capacity building of health workers including
trainings
l Quarterly support and supervision to lower level structures including
routine data quality assessments
l Data verification, analysis and report writing
Province l Supporting M&E capacity building of health workers including

trainings
l Supportive supervision to districts once every 2 months
l Conducting routine data quality assessments
l Distribution of revised M&E tools and standard operating
procedures
l Data verification, analysis and report writing
l Conducting quarterly data review meetings
District l Monthly supportive supervision to health facilities including on-site

coaching and mentorship
l Conducting routine data quality assessments
l Distribution of revised M&E tools and standard operating
procedures
l On-site data verification, analysis and report writing
l Conducting quarterly data review meetings
Health l Documentation in the standard M&E tools should be done as soon

Facility as the service is provided
l Monthly data aggregation, verification and submission to district
level
l Quarterly on-site data verification, analysis and report writing
l Participating in quarterly data review meetings
Community/ l Documentation in the standard M&E tools should be done as soon

NGO as the service is provided
l Monthly data aggregation, verification and submission to local
health facility
l Monthly data verification, analysis and report writing
l Participating in health center committee meetings
65
7.4 Data Management and place whilst the client is still in the
Use counselling room
l NGOs organizations providing HTC
The National HIV and AIDS M&E services should submit monthly data
Framework provides information on the to local health facilities
key indicators that are required for
l All health facilities and service
national level HTC data collection.
providers should produce monthly,
As these indicators are updated to
quarterly and annual reports of HTC
correspond with national and
activities
international priorities, HTC service
providers will be informed of changes to l Data should be analysed at all service
national reporting tools and requirements delivery levels and utilized for
and provided with appropriate training. programme design and planning
The following are some of the points l National annual HTC reports should
that guide management of HTC data in be produced by MOHCC and
Zimbabwe: feedback given to health facilities
l All HTC service providers should be l HTC annual reports should be
aware of all data collection tools and discussed in annual meetings where
reporting requirements progress to date, challenges faced in
l All HTC service providers including service provision, best practices and
private sector and NGOs should use way forward will be agreed upon
standardized registers with l The MOHCC should ensure that
standardized variables and on-going implementation research is
harmonized data reporting tools with carried out to address specific
the same indicators program gaps including the work
l Data capture in registers should take place.
66
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Transgender People. Recommendations for a Public Health Approach.
14. WHO/UNAIDS (2011). Joint Strategic Action Framework to Accelerate the Scale-
Up of Voluntary Medical Male Circumcision for HIV Prevention in Eastern and
Southern Africa: 20112-2016. Geneva. Switzerland
15. Zimbabwe National HIV and AIDS estimates 2012 and 2013. Health
Information and Surveillance Unit, Department of Disease Prevention and Control,
AIDS and TB Programme, Ministry of Health and Child Welfare, Harare, Zimbabwe
68
annex 1
List of Participants
Participants for Harmonization of HTC Guidelines Process for the 2 Workshops:

4-7 March 2014 and 8 May 2014
Name Designation Organization

Regional Programme
1 Dr. Buhle Ncube HIV Prevention Focal Point on HIV and AIDS
WHO/Afro
Director AIDS and TB MOHCC AIDS & TB
2 Dr. Owen Mugurungi
Programme Programme
National HIV Prevention MOHCC AIDS & TB
3 Getrude Ncube
Coordinator Programme
Dr Christine C. National Professional Officer
4 WHO Country Office
Chakanyuka HIV/TUB
5 Judith Sherman HIV and AIDS Advisor UNICEF
National PMTCT & Paediatric MOHCC AIDS & TB
6 Dr Angella Mushavi
ART Coordinator Programme
Deputy National ART MOHCC AIDS & TB
7 Dr Joseph Murungu
MOHCC AIDS & TB
8 Dr Tsitsi Mutasa Apollo Deputy Director HIV/STIs
Programme
Monitoring and Evaluation MOHCC AIDS & TB
9 Christopher Ncube
Officer Programme
MOHCC AIDS & TB
10 Beatrice Dupwa HTC Training Officer
Programme
MOHCC AIDS & TB
11 Rowesai Gandanga PMTCT Programme Officer
Programme
Advocacy and MOHCC AIDS & TB
12 Brian Nachipo
Communications Officer Programme
69

Assistant HTC Programme MOHCC AIDS & TB
13 Susan C. Gwashure
Officer Programme
National STI and Condom MOHCC AIDS & TB
14 Annah Machiha
Monitoring and Evaluation MOHCC AIDS & TB
15 Anesu Chimwaza
Officer Programme
Mentorship Programme MOHCC AIDS & TB
16 Dr Albert Mulingwa
Provincial HIV/STI Focal PMD Mashonaland
17 Magret Kurehwa
Person Central Province
Provincial Mental Health
18 Stella Khumalo PMD Midlands
Nurse
Ministry of Primary and
19 Loreen Antonio Educational Psychologist
Secondary Education
Elizabeth Glazer
Care and Treatment
20 Tembinkosi Ncomanzi Pediatric AIDS
Technical Officer
Foundation
Elizabeth Glazer
Emmanuel Monitoring and Evaluation
21 Pediatric AIDS
Tachiwenyika Officer
Foundation
22 Stanford Mpandasekwa Laboratory Scientist NMRL
23 Shame Muparutsa PSI Zimbabwe
Manager
24 Norah Vere Laboratory Manager PSI Zimbabwe
25 Miriam Mutseta PSI Zimbabwe
Manager
Child Sexual Abuse
26 Grace Machamire CONTACT
Coordinator
United Bulawayo
27 Spiwe Gumbo Sister In Charge OI Clinic
Hospitals
28 Evelyn Hungwe Senior Trainer CONNECT
Murewa District
29 Lydia Haji Sister in Charge
Hospital
Zimbabwe Lawyers for
30 Bekezela Mapanda Programme Officer
Human Rights
70
annex 1
31 Cuthbert Mashanda Council Chairman MLCSCZ
32 Agnes Chigora Registrar MLCSCZ
ZVITAMBO - SHINE
33 Naume Tavengwa Head of Programme
Survey
PMTCT Logistics
34 Blessing Mudzudzu Logistics Unit
Coordinator
Mabvuku Polyclinic -
35 Annah Mushayabasa Primary Counsellor
Harare
Registered General Nurse/ Kunaka Hospital -
36 Milca Chitongo
Midwife Seke
Clinton Health Access
37 Mila. Owen eMTCT Analyst
Initiative
38 Richard Sabumba Logistics Unit Manager NATPHARM
Zimbabwe AIDS
38 Definate Nhamo Project Manager
Prevention Project
Shingirai TB Focal Person/
40 ZNNP+
Nziradzepatsva Faith Based Officer
41 Lynette Munamati Technical Manager ZINQAP
Gill, Godlonton &

42 Douglas Coltart Lawyer
Gerrans
Harare City Health
43 Norma Jenami District Nursing Officer
Department
Zimbabwe AIDS
44 Gwendolene Gumbo Life Skills Trainer
Prevention Project
45 Charity Maruva Programme Officer AFRICAID
Community Adolescent
46 Modest Muziringa AFRICAID
Treatment Supporter
47 Nicola Willis Director AFRICAID
71
Notes
72

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ZIMBABWE

Brigadier General (Dr) G Gwinji

Special acknowledgement and appreciation go to the teams from various organizations,

World Health Organisation (WHO) Zimbabwe Country Office is acknowledged for

Chapter 2 Ethical and Legal Considerations............................................................3

Chapter 3 Service Delivery Approaches and Models ...............................................9

Chapter 4 HIV Counselling ....................................................................................20

Chapter 5 HIV Testing and Supply Chain Management .......................................41

Chapter 6 Scaling Up HIV Testing and Counselling Services ...............................55

Chapter 7 Monitoring and Evaluation...................................................................63

Annex 1: List of participants................................................................................69

List of Tables and Figures

AIDS Acquired Immune Deficiency Syndrome

Chapter 1 Introduction ..........................................................................1

Chapter 2 Ethical and Legal Considerations.........................................3

Chapter 3 Service Delivery Approaches and Models ...........................9

Chapter 4 HIV Counselling ..................................................................20

Chapter 5 HIV Testing and Supply Chain Management......................41

Chapter 6 Scaling Up HIV Testing and Counselling Services ...............55

Chapter 7 Monitoring and Evaluation .................................................63

Annex 1: List of participants ..............................................................69

Zimbabwe is among one of the countries Zimbabwe, His Excellency Comrade

discrimination that surrounds HIV and important step towards achieving

2.1 HIV testing and The human rights principles most

own. A counsellor should consider l A child is sexually active

2.8 HTC and Post-Exposure 2.8.2 Rape

3.1 Coordination of HTC services in Zimbabwe should be

3.3 HTC Service Delivery 3.3.1.2 Stand-alone HTC services

Model Target Advantages Key

Stand- General l Convenient to those who do not l Attracts the more

3.3.2 Community-based Model access to hard-to-reach, rural and

HIV self-testing is one of the options l Enhances disclosure among couples

l Reduces fear of HIV and therefore access individuals and families in

Table 2: Advantages of community-based HTC services

Model Target Advantages

Educational Students, l Normalises HIV testing thus reducing stigma

Campaigns l General l Mobilises communities to support HTC thus normalising

Self-testing l General l Autonomy and empowerment

3.4 Operational l Community/peer counsellors are

Clinical mentoring is a system of practical 3.5 Minimum Requirements

Staffing l Laboratory (if site is performing

l Comfort: HTC should be offered The MOHCC has developed detailed

Children/Adolescents will also need dialogue between a client(s) and a service

4.5.2 Definition of Couple HIV confidentiality where each partner,

Table 3: Comparison of CHTC and Individual HTC

Couples HTC Individual HTC

Figure 1: Linkages between CHTC and other programmes

4.5.5 Pretest information/ noted that this session is conducted with

Table 4: Possible HIV test results in CHTC

CHTC Test Possible Service Potential Benefits

CHTC Test Possible Service Potential Benefits

Serodisconcordant l Earlier initiation of ART l Decreased transmission within

Serodisconcordant l Early initiation of ART l Decreased transmission within

Key Important features Additional counselling

Men who l Criminalization of MSM activities l Emphasis on risk of

Transgender l Criminalization of TG activities l Emphasis on risk of

Key Important features Additional counselling

Prisoners l Service providers may need l Explore possibility of

Migrant l Displacement increases l Access to both male and

People living l Different kinds of physical, l HTC service providers

4.7 Counselling within achieved through community education

Table 6: Key counselling considerations for specific community based

Model Key counselling considerations

Home based l Quality assurance to ensure correct and accurate results