Voluntary counseling and testing (VCT) paper for the UNAIDS expert panel on HIV testing in United Nations

peacekeeping operations. 2 September, 2001

Voluntary counseling and testing (VCT).

Paper for the UNAIDS expert panel on HIV testing in United
Nations peacekeeping operations.
17-18th September 2001, New York
Dr Rachel Baggaley
Hon Research Fellow, Department of Infections and Tropical Diseases, London School of
Hygiene and Tropical Medicine, London

Background
The promotion of voluntary counseling and testing (VCT) as an essential element in
the response to the HIV epidemic, is a priority of UNAIDS. VCT is a key component
of HIV programmes in industrialized countries, but until recently it has not been a
major strategy for developing countries1. However, the importance of VCT as a cost-
effective HIV prevention intervention2 and its role in improving access to care and
support3 means that VCT services are being more widely promoted and developed,
and many developing countries are gradually instituting VCT as part of their primary
health care package4. Furthermore recent developments in the area of
cotrimoxazole prophylaxis5,6 and tuberculosis preventive therapies7 for people with
HIV, and antiretroviral (ARV) therapy for the treatment of HIV disease 8 and the
prevention of mother-to-child transmission (PMTCT)9, have focused attention on
expanding access to VCT.

Mandatory screening for HIV except for the screening of blood and blood products
for HIV, is not supported by UNAIDS. The International Guidelines on HIV/AIDS and
Human Rights, advises against mandatory HIV testing on both public health and
human rights grounds 10. The World Health Assembly resolved that there was no
public health rationale for any measures that limit the rights of the individual, notably
measures establishing mandatory (HIV) screening11.

In 1998 UNAIDS published policy guidance on HIV testing in the military in general 12.
UNAIDS stated that VCT has an important role within a comprehensive range of
measures for HIV prevention and care. However mandatory testing without informed
consent is a violation of human rights, and there is no evidence that it achieves public
health goals.

Recent Context
The United Nations Security Council recently considered the impact of the HIV
epidemic on peace and security in Africa and in particular to issues concerning HIV in
conflict situations, including among international peacekeeping forces and
populations affected by peacekeeping operations13. It noted the potentially damaging
impact of HIV on the health of international peacekeeping and support personnel. As
a response member states could consider developing effective long-term strategies
for HIV education, prevention, VCT and treatment of their personnel, as an important
part of their preparation for their participation in peacekeeping operations.
Furthermore it recommended Member States to increase international cooperation
among their relevant national bodies to assist with the creation and execution of
policies, reflecting best practices, for HIV prevention and care, including VCT for
personnel to be deployed in international peacekeeping operations. In response
UNAIDS14 has established an expert panel to analyze and formulate a
comprehensive position on the issue of HIV testing for peacekeepers.

In this paper the essential elements of VCT and the minimum requirements for its
ethical delivery will be outlined. The benefits and cautions of providing VCT to
peacekeeping personnel will be discussed. The various available approaches to
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VCT delivery and their relevance for peacekeepers will be considered. Factors that
may influence the choice of VCT model will also be reviewed.

What is VCT

VCT is the process by which an individual undergoes counseling enabling him or her
to make an informed choice about being tested for HIV. This decision must be
entirely the choice of the individual and he or she must be assured that the process
will be confidential.

VCT has a vital role to play within a comprehensive range of measures for HIV
prevention and care, and should be promoted. The potential benefits of VCT for the
individual include improved health status through good nutritional advice and earlier
access to care and treatment/prevention for HIV-related illness; emotional support;
better ability to cope with HIV-related anxiety; awareness of options for prevention of
MTCT feeding; and motivation to initiate or maintain safer sexual and drug-related
behaviors. Other benefits include safer blood donation.

UNAIDS therefore encourages countries to establish national VCT policies along the
following lines15,16.
 Make good-quality VCT available and accessible
 Ensure informed consent and confidentiality in clinical care, research, the
donation of blood, blood products or organs, and other situations where an
individual's identity will be linked to his or her HIV test results.
 Strengthen quality assurance and safeguards on potential abuse before
licensing commercial HIV home collection and home self-tests.
 Encourage community involvement in sentinel surveillance and epidemiological
surveys.
 Discourage mandatory testing.

Elements of VCT

 HIV counseling
HIV counseling has been defined as:

“A confidential dialogue between a person and a care provider aimed at enabling

the person to cope with stress and make personal decisions related to HIV/AIDS.
The counseling process includes an evaluation of personal risk of HIV transmission
and facilitation of preventive behavior.”17

The objectives of HIV counseling are the prevention of HIV transmission and the
emotional support of those who wish to consider HIV testing, both to help them
make a decision about whether or not to be tested, and to provide support and
facilitated decision making following testing. People often come for HIV testing in
states of considerable anxiety – for their health, their family’s health, their
relationship, and their future employment. This makes the role of counseling all the
more important – it can help provide confidence to be tested, and to decide on
possible future courses of action for the benefit of themselves and their loved-ones.
With the consent of the client, counseling can be extended to spouses and/or other
sexual partners and other supportive family members or trusted friends where
appropriate. Counselors may come from a variety of backgrounds including health
care workers, colleagues in workplaces, social workers, lay volunteers, people
living with HIV (PLHA), members of the community such as teachers, or religious
workers/leaders.

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HIV counseling can be carried out anywhere that provides an environment that
ensures confidentiality and allows for private discussion of sexual matters and
personal worries. Counseling must be flexible and focused on the individual client’s
specific needs and situation.

In some settings HIV counseling is available without testing. This may help also
promote changes in sexual risk behavior.

 Voluntary testing
HIV testing may have far-reaching implications and consequences for the person
being tested. Although there are important benefits to knowing one's HIV status,
HIV is, in many communities, a stigmatising condition, and this can lead to negative
outcomes for some people following testing. These include ostracism, loss of
livelihood, and of family and community respect. Stigma may actively prevent
people accessing care, gaining support, and preventing onward transmission. That
is why UNAIDS stipulates that testing should be voluntary, and VCT should take
place in collaboration with stigma-reducing activities.

 Confidentiality
Many people are afraid to seek HIV services because they fear stigma and
discrimination from their families and community, and loss of employment. VCT
services should therefore always preserve individuals’ needs for confidentiality.
Trust between the counselor and client enhances adherence to care, and
discussion of HIV prevention. In circumstances where people who test seropositive
may face discrimination, violence and abuse, it is important that confidentiality be
guaranteed. In some circumstances the person requesting VCT will ask for a
partner, relative or friend to be present. This shared confidentiality is appropriate
and often very beneficial. There are also great benefits with sharing HIV status with
health care staff. For people who test seropositive it can be important for health
care staff to be aware of their status so that they can access HIV treatment options.
This may involve several different people being informed and has the potential for
HIV test results to be leaked. Sharing HIV results with sexual partner/s is also
recommended18. In most VCT services people are seen alone. There is however
evidence that when couples receive VCT together there is a greater potential for
long-term sexual behavior change to prevent sexual transmission of HIV19,20,21.
Without HIV disclosure to a sexual partner consistent safer sex behavior is difficult
to achieve. However, in many settings barriers to disclosure have been identified,
particularly for seropositive women who risk abandonment or abuse.

Minimum requirement for ethical delivery of VCT

Whatever model of VCT is considered there are basic requirements, which must be
in place, if VCT services are to be ethical and beneficial

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Minimum requirement for VCT

 Informed consent: All models of VCT must ensure that testing is truly voluntary. People
should have the right to opt out or refuse testing if they do not think that it is in their best
interest. In some settings it is suggested that written consent is obtained before testing.

 Confidentiality: Although there are many advantages of sharing HIV status all people
undergoing VCT must be assured of the confidentiality of their test results. Although
confidentiality must be protected all people who undergo VCT should be encouraged to
share their test result with health care staff and sexual partners. :

 Legislation to prevent discrimination: Unless seropositive people can be assured that

they will not be discriminated against following testing VCT services should not be
promoted and supported.

 Quality control: It is essential that the quality of both testing and counseling can be
assured with appropriate monitoring and evaluation as a key and planned component of
interventions.

Rationale for offering VCT to members of the UN peacekeeping forces

HIV infection rates are often significantly higher among men serving in the armed
forces than among men of similar ages and background in the civilian
population2223,24. Furthermore military personnel can be at high risk of transmitting
HIV infection to partners in host countries. UN peacekeepers may be an increased
risk from HIV acquisition and HIV transmission because of:
 Separation from their community, families and regular sexual partners may lead
peacekeepers to seek casual or short-term sexual partners in the host country.
 Sexual behavior associated with high risks of HIV infection such as multiple
causal sexual relationships, sex with sex workers and taking sexual risks (sex
without a condom) can be common25. These behaviors may be influenced by
peer pressure, loneliness and a risk-taking ethos, which is may be more
conspicuous in the armed forces and peacekeeping personnel.
 Same sex sexual activities may be more common among men and women in the
military, including among those who would consider themselves to be
heterosexual in their home environment.
 The economic environment and social disruption that may be present in host
countries where peacekeepers are stationed may be mean that sex workers
actively seek out military personnel.
 IDU is a significant problem among some military forces26.

Offering VCT could have an important role in HIV prevention among UN

peacekeepers and their sexual partners as well as increasing access to appropriate
care and support for those who test seropositive.

Benefits of VCT for UN peacekeepers

There are many benefits for peacekeepers to have access to VCT so that they can
know and understand their HIV status.

 HIV prevention. There is much evidence that when HIV testing is offered
together with high quality counseling people are able to make changes in their

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sexual behavior to prevent HIV transmission to partners if they test

seropositive, and to make changes to ensure that they remain negative
following a seronegative test result. HIV prevention should also address
injecting drug use and homosexual transmission where appropriate.

 Access to medical care. HIV prevalence rates among military personnel

from high prevalence countries are often significantly higher than in the
general population and this may mean that, for example in some countries in
sub-Saharan Africa more than 50% of peacekeepers may be HIV
seropositive. Xxxrefxxx There are many medical interventions that can
prevent morbidity and mortality among peacekeepers if they are identified as
being HIV infected. For example:

 Tuberculosis (TB) screening, treatment and TB preventive therapy (TBPT)

About a third of the 33 million HIV-infected people worldwide are co-infected with
Mycobacterium tuberculosis, and 70% of those co-infected live in sub-Saharan Africa 27,28. In
countries with advanced HIV epidemics, particularly those of sub-Saharan Africa, the majority
of people with tuberculosis (TB) are also infected with HIV 29 and TB kills more HIV-infected
people than any other cause30. Improved TB care can play a role in reducing the high
morbidity and mortality of people with HIV31. Seropositive individuals can be screened for TB
and given curative treatment if they are found to have clinical disease. Those who do not
have TB can be given TBPT, which significantly reduces the incidence of TB. This
intervention is not only beneficial for those with HIV, but as cases of clinical TB may be
diagnosed and treated early (or prevented in those taking TBPT), this can also reduce TB
infection in seronegative peacekeepers by decreasing TB transmission rates among
peacekeepers. TBPT is a cheap and feasible intervention requiring only basic clinical and
laboratory monitoring.

 Cotrimoxazole prophylaxis
Cotrimoxazole prophylaxis has been shown in several studies to reduce HIV related morality
and morbidity. UNAIDS has recommended that it should be made more widely available for
people with HIV, particularly in developing countries 32. This medical intervention if also cheap
and easy to administer with minimal adverse effects and could be of significant benefit to
peacekeepers who test seropositive.

 Antiretroviral (ARV) therapy

The development of ARV therapy for treatment of HIV has had a profound effect on mortality
and morbidity for people with HIV in industrialized countries. The benefits of undergoing VCT
to diagnose HIV infection in order to access appropriate ARV therapy can therefore be
enormous. Although programs are being developed to make ARV therapy more widely
available in developing countries, the vast majority of people with HIV currently have no
access to these drugs. Peacekeepers from developing countries will not benefit from these
treatments unless resources are devoted for the provision of ARVs, medical personnel
training and the development of laboratory infrastructure required for monitoring of therapy.

 Appropriate medical care

Even if ARVs are not available, knowledge of HIV status is of benefit allowing individuals who
test seropositive or seronegative to receive appropriate medical care.

 Improved coping. Several studies have shown that VCT which provides
ongoing counseling and support can help people to cope with their HIV
infection and prevent serious or prolonged psychological problems following
VCT33.

 Future planning. Several studies have noted that VCT can be beneficial in
helping people to plan for their and their dependents’ future. Knowledge of

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HIV status can also facilitate decisions about future relationships,

pregnancies and career choices.

Disadvantages of offering VCT to UN peacekeepers

 Cost. The cost of providing VCT in developing countries has been estimated at
between 4 and 29 US dollars 34,35,36, 37 but is significantly higher in industrialized
countries. The cost of HIV screening alone can be lower. In low prevalence
settings such as the USA where more than 99.5% of samples are non-reactive
and do not therefore need confirmatory testing, the cost per test is estimated at
less than 2.5 US dollars when a large volume of samples is tested38.

 Psychological trauma and personal harms. Although severe and long term
psychological problems are rare following voluntary testing with access to high
quality counseling, high levels of suicidal ideation and self harm have been
reported in military personnel in the first 3 months following mandatory HIV
screening39. However in a long term study a low number of suicides was reported
among military service applicants who underwent mandatory HIV testing. When
4,147 seropositive and 12,437 seronegative military applicants (who had been
discharged for other medical conditions) were followed there was no significant
difference in risk of suicide40.

 Stigma and discrimination. In many countries HIV remains a highly

stigmatizing condition and there are many anecdotal reports of people being
discriminated against or stigmatized for being seropositive. These concerns have
been noted more frequently among women or arise when breaches of
confidentiality occur or people are tested mandatorily or without adequate
counseling41,42. If, however, peacekeepers receive adequate pre- and post-test
counseling and ongoing counseling as required, and confidentiality is ensured,
stigma and discrimination can be avoided.

 Employment. Some countries have employment laws that discriminate against

people with HIV and pre-employment HIV screening continues to be practiced.
Many insurance policies exclude people with HIV, and HIV testing is required by
some institutions before offering further education opportunities or promotion. In
some settings military personnel are denied employment when they are found to
be seropositive in pre-employment screening 43. In other settings military
personnel found to be seropositive may be denied foreign country posting.

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VCT Approaches/models
There are several approaches to the delivery of VCT that are currently used. The
advantages and disadvantages of each model as appropriate for ethical VCT delivery
will be presented and discussed in the context of providing services for UN
peacekeepers.

Present VCT models

 Model 1. Individual pre- and post-test counseling and testing ("classic" model, most
free-standing VCT sites).

 Model 2. Group information, opt-in individual pre-test counseling,

individual post-test counseling (e.g. PMTCT in the UK until recently, Botswana etc.
outreach counselling for workplace, youth groups etc.)

 Model 3. Group information*, opt-out individual testing, individual post-test counseling

for seropositives, seronegatives are informed of their negative status (e.g. PMTCT in
Thailand and recent UK model).

 Model 4. Group information, opt-in couple/family pre-test counseling,

individual/couple/family post-test counseling (shared confidentiality model).

 Model 5. No pre-test information, screening/testing (with an option to opt-out),

individual post-test counseling for those found HIV+ (screening of STI attendees, drug
treatment programme attendees and women attending antenatal clinics in Russia,
USA-some PMTCT sites)

Other HIV testing models

 Mandatory testing. This is when HIV testing is a precondition for obtaining a service
or benefit. (pre-employment HIV testing, screening of migrant workers, pre-immigration
testing and pre-recruitment screening of military personnel, where failure to agree to
HIV testing will prevent recruitment)

 Compulsory screening. This is where a person has no choice in being tested and is
required to provide a blood sample. (incarcerated individuals, refugees, prisoners, sex
workers, IDUs, and in some states in the USA pregnant women and newborn infants)

 Counseling without testing

*may include/consists of written information

Model 1 : Classic VCT model of individual pre- and post-test counseling with
follow-up counseling for those requiring further support

This model has been adopted by the majority of free-standing VCT sites. It is viewed
as the “gold standard”, allowing the person attending VCT to have individual
counseling to help him/her make an informed decision about whether to test and
make a personal risk assessment and risk reduction plan. Individual and ongoing
counseling, preferably with the same counselor, provides support to cope following
testing and help in exploring options for follow-up care and support, sexual behavior
and involvement of partner or family.

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The advantage of this model is that it allows all people being offered an HIV test to
have an in-depth individual discussion of their personal risks of HIV infection and to
explore the benefits and cautions associated with HIV testing. It has been shown to
be acceptable to people and results in small numbers of long term adverse
consequences. In the VCT multi-center trial when clients were interviewed in-depth
following VCT, seronegative clients reported feelings of relief, decreased anxiety,
improved hope and increased confidence in themselves 44. Following counseling,
seropositive people reported better coping skills to deal with their situation, increased
hope, disappearance of suicidal thoughts and help in decreasing isolation and
normalization of their situation. Among seropositive people, most distress was
described as transient.

This model has been shown to be cost-effective in preventing HIV transmission in

higher prevalence settings45. Using a hypothetical cohort of 10,000 seeking VCT they
estimated that the intervention averted 1104 HIV infections in Kenya and 985 in
Tanzania. The cost per client for VCT was estimated to be US $29 in Tanzania, and
US $27 in Kenya.

Model 1

Classic VCT model

Development of awareness of the benefits of VCT as part of
peacekeepers HIV education/prevention programme

Decision to attend for VCT

Pre test counselling

Decision to test
Yes No

Post-test
counselling
HIV -ve
HIV +ve

Follow-up counselling and support as required 5

The disadvantage of this model is that it is time consuming, requiring a minimum of

15 minutes (and often longer) for pre-testing and 15 minutes (and usually 30 minutes
or longer) for post-test counseling. This can make it impractical when providing VCT
in a peacekeeping medical service for large numbers of individuals, such as army
recruits.

This model could however be used in countries where free-standing VCT sites are
already established. Peacekeepers could be referred for VCT and have the option to
attend with their partner. After receiving their HIV test result they would be
recommended to share it with their medical practitioner in the peacekeeping unit,
where they could, if found to be seropositive, discuss appropriate medical
interventions and make decisions about the appropriateness of overseas posting,
guided by clinical and military criteria. Offering VCT away from the peacekeeping
medical services can strengthen confidence that confidentiality will be protected.
Furthermore trained and experienced HIV counselors can provide in-depth post-test
counseling for seropositive individuals and follow-up support where needed.

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Model 2: Group information, "opt-in" individual pre-test counseling, individual

post-test counseling.

This VCT model has been widely used in high prevalence settings where
interventions such as those used for PMTCT are offered. It has also been used in
workplace and outreach counseling. In outreach counseling, groups of people are
invited, for example, from youth groups or workplaces to attend for group pre-test
information sessions. This model relies on much of the information that is shared in
pre-test counseling to be provided by group information. Following pre-test
information/education, people can then decide to proceed to HIV testing and “opt in”
for pre-test counseling and receive a shortened individual pre-test counseling
session. Post-test counseling is provided for everyone who accepts testing.

Model 2
“opt in” model
Development of awareness of the benefits of VCT as part of
peacekeepers HIV education/prevention programme

Group information
Opt in
Opt out
Short pre-test counselling

HIV test

Post-test
counselling HIV -ve
HIV +ve

Follow-up counselling and support as required 6

This model could be suitable for offering VCT for UN peacekeepers. General
information about HIV infection and transmission and the benefits of knowing one’s
HIV status can be discussed in a group. Information can be augmented by video or
written information. Peacekeepers can then choose to attend a shorter pre-test
counseling session where they can discuss their personal risks and other issues that
they do not feel comfortable about discussing in a group. Some people who have
previously undergone VCT or who do not want further pre-test counseling may opt to
proceed directly for HIV testing following the group counseling session. This model
of VCT could be used in conjunction with other peacekeeping medical services, or
peacekeepers could be referred as a group to a free-standing VCT site. A better
understanding of the benefits of VCT and thus a higher uptake could be achieved if
peacekeepers have received previous HIV education, which emphasises these
benefits.

It is important to ensure, if this model is used, that ongoing counseling support is

available for both those with seropositive and seronegative results if it is required.

Model 3: Group information/written information, "opt-out" individual testing,

individual post-test counseling for seropositive people. Seronegative people
are informed of their negative status.

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Model 3
“opt out” model

Development of awareness of the benefits of VCT as part of

peacekeepers HIV education/prevention programme

Group information/written
information
Opt out

Routine testing

HIV +ve HIV -ve

-

HIV test result

Post-test given
counselling

Follow-up counselling and support as required 7

This model is used in many low prevalence countries where large numbers of people
are seen for routine medical procedures, for example in antenatal clinics where
women can access PMTCT interventions46. HIV testing is offered during routine
screening as part of a medical examination where blood is also taken for other tests.
Attendees are informed that if they wish to opt out, they can do so; otherwise HIV
testing will be carried out. When the results are available those who are
seronegative are usually informed of their test result, but often little or no post-test
counseling/preventive counseling is given. Those who are seropositive receive post-
test counseling and referral for ongoing supportive counseling, and are often offered
medical interventions including ARVs for treatment of their own HIV disease.

When this "opt out" model has been used it has resulted in a much higher uptake of
HIV testing than when the "opt in" model is practiced.

The advantage of model 3 is that in low prevalence countries intensive individual

counseling can be focused on the small minority of people who test seropositive,
cutting down considerably on the need for trained health care workers with
counseling skills.

This model also depends on the availability of treatment and support for all
seropositive people. If no or inadequate services are available for seropositive
people they may be vulnerable and disadvantaged following testing.

A disadvantage of model 3 is that there is little or no emphasis on HIV prevention for

those who test seronegative. Although HIV prevention information can be provided
in, for example, a pre-test HIV information leaflet seronegative people will not receive
any individual counseling about HIV prevention. This model could be augmented by
provision of individual post-test counseling for all clients (but this would add to the
counseling staff requirements) or by providing group post-test information on HIV
prevention and/or ongoing HIV prevention programs.

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UN peacekeepers with limited formal education or understanding about HIV may not
appreciate that they have the option to "opt out" or feel intimidated to do so. In
practice this model often leads to very high uptake of testing as HIV testing is often
included as part of other blood screening. Some people may fear exclusion from
other medical services if they opt out.

Model 4: Group information, opt-in couple/family pre-test counseling,

individual/couple/family post-test counseling (shared confidentiality model).

Model 4

“Shared confidentiality” model

Development of awareness of the benefits of VCT as part of
peacekeepers HIV education/prevention programme

Couple/families decide to attend

Group information
Opt out

Couple/family counselling
Opt out
HIV +ve Sero-discordant HIV -ve

Post-test counselling

Follow-up counselling and support as required 8

This model is an enhanced version of model 2. In this model couples are

encouraged to attend together. If married/cohabiting couples attend for HIV counseling
together, serodiscordant couples1 can be identified and counseled to help prevent
transmission to the uninfected partner. Many studies have shown that a significant
proportion (7-21%) of couples in high prevalence countries in steady relationships have
serodiscordant HIV test results 47,48,49. The risk of seroconversion, has been estimated
to be 105.5 per 1000 person years for HIV-negative women married to HIV-infected
men and 51.7 for HIV-negative men married to HIV-infected women 50. Couple
counseling has been shown to be highly effective in promoting sexual behavior change
to prevent HIV transmission51,52. Offering VCT to couples overcomes the problem of
sharing test results. Couple counseling and testing is aimed at enabling the couple to
negotiate together appropriate changes in sexual behavior as well as plan together for
their and their dependants’ future, with the help and support from their counselor at both
pre- and post-test. Seeing couples together enables them to be counseled to avoid
blame and prepares couples prior to testing to make risk assessments and risk
reduction plans together.

1
Serodiscordant couples refers to one couple testing seropositive and the other testing
seronegative.

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Furthermore there are great benefits to this model as it has been shown that people
with HIV cope better if they are supported. However, this “shared confidentiality”
model must always be voluntary and people who decide after shared pre-test
counseling that they wish to be tested alone must be allowed to do this.

This couple-counseling model may not immediately be seen as relevant to UN

peacekeepers. However, for peacekeepers who are married or have a stable sexual
partner this effective VCT model could be considered.

Model 5 : No pre-test information, screening/testing (with an option to opt-out),

individual post-test counseling for those found seropositive.

This approach has been used as part of screening in antenatal, STI and drug
treatment clinics in some countries in Eastern Europe and other countries of low
prevalence. Because in these settings people may have little understanding of HIV
and HIV testing and people have high levels of “compliance” with medical demands,
in practice, very few people will opt out, and testing cannot often be considered as
truly voluntary. This concern has been raised in antenatal screening programs in the
USA where it has been argued that pregnant women may not be adequately
informed that they may refuse such testing. Furthermore using this approach, people
may not have an opportunity to obtain more detailed information about the benefits
and risks of HIV testing in this context53.

The disadvantage of this model is that because preventive counseling is not included
there is little benefit for people who test seronegative. This can be a particular loss
for people who are at higher risk from HIV infection such as peacekeepers going to
high prevalence host nations.

Despite the small amount of information, education and counseling, this untargeted
approach remains costly for low prevalence countries. Indeed, millions of tests are
currently performed in the former Soviet Union and some of the Newly Independent
States on military recruits and pregnant women with very small numbers of
seropositive individuals being identified. If this model is to be used the following
modifications should be considered:

 An HIV education program should be developed which includes discussion of the

benefits of HIV testing. All peacekeepers should participate in this program prior
to their medical assessment.
 All peacekeepers should be informed of their right to decline HIV testing.
 A pre-screening risk assessment could be carried out to identify peacekeepers
who could be at risk from HIV infection, and individual counseling could then be
offered.
 HIV preventive counseling and/or education could be offered to all peacekeepers
who test seonegative.

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Model 5

Model 5 HIV screening

= ways of improving the HIV screening approach
Development of awareness of the benefits of VCT as part of
peacekeepers HIV education/prevention programme

Routine pre-service HIV

screening
Risk assessment/check
list to identify higher-risk
Opt out individuals

HIV testing

HIV +ve HIV -ve

Post-test counselling
HIV test-result given and
targeted HIV prevention
Follow-up counselling and support as required information 9

6. Mandatory testing of all peacekeepers

Different terminology is often used for two types of involuntary or obligatory

testing.

 Mandatory testing means that HIV testing is a precondition for obtaining a

service or benefit. This is practiced in situations such as pre-employment HIV
testing, screening of migrant workers or pre-immigration testing. Mandatory
testing is sometimes practiced in pre-recruitment screening of military personnel,
where failure to agree to HIV testing will prevent recruitment. This model of HIV
testing is currently employed in the armed forces in many countries 54,55,56,57. In a
survey of 119 military establishments 78% reported mandatory testing and 58%
reported mandatory pre-recruitment testing. Recruitment was denied to
seropositive individuals in 17% of military establishments58. This approach can
be very costly in low prevalence countries. Mass screening of Italian army
recruits at entrance and discharge revealed HIV prevalence rates of >0.07%59.
Mass screening among US army reservists also revealed a low prevalence
(0.157%)60 and among women 0.065%61.

 Compulsory testing is where a person has no choice in being tested and is

required to provide a blood sample. Compulsory testing has been applied to
groups including incarcerated individuals, refugees, prisoners, sex workers, IDUs,
pregnant women62 and newborn infants63.

Mandatory testing is not recommended by UNAIDS, as testing without informed

consent is a violation of the nondiscriminatory principle under international human
rights law64. There are also strong public health policy grounds for not using
mandatory testing:

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 Mandatory testing without informed consent and counseling does not help people
make changes in their sexual behavior, which will reduce HIV transmissions to
others.

 Testing without counseling and follow up support can be devastating for those
who test seropositive and may lead to depression, and irresponsible actions
including violence to self and others.

 Testing without counseling may result in inaccurate results for those that test
seronegative and may be in the ‘window period’. As there is no preventive
counseling, seronegative peacekeepers may understand the need to protect
themselves from future HIV infection.

 Mandatory testing may give the message to the peacekeeping community that
HIV is a problem of ‘risk groups’ creating further fear, denial and stigma.

 If mandatory testing is used for discriminatory purposes (such as barring

peacekeepers from service) this ignores the long asymptomatic period during
which productive work can be performed. It is also inappropriate given the lack of
screening for other diseases causing equal or greater morbidity.

 Mandatory testing may lead to a false sense of security. For example it is illogical
to institute the mandatory testing of peacekeepers in order to ‘protect’ military
medical staff, as universal precautions should be applied to all patients, and
patients who test seronegative may be in the window period. The same
argument applies to field transfusions and in particular ‘buddy blood donation2’.
Effective rapid blood screening prior to donation and a VCT and HIV education
program is preferable to reliance of an assumed HIV-free pool of buddy donors.

 Insisting on testing employees or military recruits will not insure that they are HIV
free, as they may acquire HIV infection during their employment or military
service. It would be better to use resources to offer effective VCT, care and
support to those with HIV and provide comprehensive HIV prevention and
education programs for employees.

 The need to provide evidence of a negative test result has led to anecdotal
reports of health workers selling negative certificates to untested people.

 Mandatory testing in health care settings may lead to mistrust from clients and
discourage them from seeking health care. For example it has been proposed
that if mandatory testing is applied to all women attending antenatal services in
the USA a deterrence rate of 0.5% could be expected. This would lead to a
greater number of perinatal deaths due to lack of adequate antenatal care than
the number of infants spared HIV infection65.

Counseling without testing

There is evidence that counseling alone is of benefit and can reduce HIV
transmission. In a community-based study counseling significantly increased rates of
condom use among adults66. If HIV testing is not available HIV preventive counseling
should be offered to all peacekeepers. In a study from Thailand an HIV prevention
intervention was developed following formative research which identified particular
2
Buddy transfusion – field transfusions from soldiers who have previously been blood
grouped and tested for HIV and other transfusion transmissible infections

14
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factors that increase vulnerability to HIV infection among military recruits. The
importance of altering peer group norms was recognized and a wide range of
innovative HIV prevention interventions was developed. The incidence of STIs was 7
times lower in the group of conscripts who received this intensive HIV prevention
intervention, compared with those in the control groups67.

Factors which may influence choice of VCT model

There is no ‘ideal’ approach for delivering VCT to all peacekeepers in all settings.
The following factors should be considered:

 Seroprevalence
Among peacekeepers recruited from low prevalence member states, HIV infection
rates are often less than 0.5%, whereas those recruited from sub-Saharan Africa may
have prevalence rates exceeding 50%. Clearly different approaches will be
necessary to meet the needs of these very different populations. For example in a
low prevalence setting, model 3 could be employed with an emphasis on enhanced
individual counseling for seropositive peacekeepers and an intensive group HIV
prevention program for all. In a high prevalence setting models 1 or 2 would be more
appropriate, allowing individuals who are at very high risk from HIV infection to
understand the benefits and possible cautions of VCT through individual counseling
sessions.

 Social and environmental factors

The background and social environments from which the peacekeeping forces are
drawn may also influence the choice of VCT model. If large numbers of
peacekeepers are in stable sexual relationships and if married accommodation is
available at peacekeeper training centers, ‘couple VCT’ should be considered.

 Medical interventions available

The availability of medical interventions for seropositive peacekeepers will be a great
incentive to undergo VCT. Lack of medical services has been shown to be a barrier
to uptake of VCT in many settings.

 Outcomes for people following testing.

A clear policy on the outcomes for people testing seropositive following VCT is
important in deciding a VCT approach. If asymptomatic seropositive peacekeepers
are to be barred from service or surrender employment rights, this should be
addressed in pre-test counseling, and a VCT model which does not allow
peacekeepers to consider fully the implication of testing seropositive and opt out of
testing should not be contemplated.

 HIV testing strategies available

Many VCT services currently use simple/rapid testing which allows HIV test results to
be available with a short time facilitating same–day testing. Other services use
ELISA testing where serum samples are collected and batch tested at a laboratory
with results usually being available within 3 days to 2 weeks. If same day testing is
offered, peacekeepers may wish to defer testing until they have discussed it with
their partner or a close friend or relative. They may also wish to identify a supportive
person who would be available if their test proves to be seropositive.

 Attitudes to HIV testing

In low prevalence settings where peacekeepers do not perceive themselves to be at
high risk from HIV infection, uptake of VCT following group information may be high.
For example 83% of Chinese army recruits said that they would welcome the

15
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opportunity to undergo HIV testing68. In higher prevalence settings uptake may be

lower, unless peacekeepers are fully aware of the benefits of VCT, have the
opportunity for individual counseling and can be assured of emotional and medical
support following VCT. Integrating VCT with HIV programs which foster a supportive
environment for people who test seropositive will enhance acceptance of VCT in
military communities.

Options for approaches to the scaling up VCT implementation for UN

peacekeeping personnel

1. Pre-recruitment VCT
VCT could be offered as part of an intensive HIV education and prevention program
when peacekeeper candidates are being considered for peacekeeping service by the
armed forces or other similar organizations in contributing countries. In this context
the benefits of VCT could be emphasized and an approach considered that is most
suitable for the needs of the peacekeepers in a particular situation.

2. Inter-service/ post-services VCT

For peacekeepers who have anxieties following risk behavior during their peace-
keeping duties the opportunity for repeat VCT, further counseling or ongoing
counseling should be considered. Involvement of partners/spouses should also be
considered, where appropriate.

3. Post exposure VCT

Peacekeepers can also be at risk from HIV transmission following:
 Occupational exposure (needle stick injuries 3, particularly for field medical staff,
and accidental exposure during combat and accidents)
 Rape
 Condom failure

Administering ARV post exposure prophylaxis (PEP) can significantly reduce the risk of
HIV transmission in these circumstances. If PEP is to be considered VCT must be
available as knowledge of the peacekeepers HIV status at the time of exposure and at 6
weeks follow-up (to review for seroconversion) is required for appropriate management
with PEP.

The risk of transmission following occupational exposure is relative low - around 1-5 per
1000 exposures (0.3%) for each percutaneous 4 exposure and 0.03% each for muco-
cutaneous5 exposure69.

This risk of HIV transmission from male to female rape via penile-vaginal intercourse is
estimates as being less than 0.2%70. The per-contact infectivity rate for receptive anal
intercourse is higher, estimated to be as high as 2% 71. Violent, non-consensual sex
may significantly increase the probability of HIV transmission in both anal and vaginal
sex72.

3
Needle stick injury refers to puncture with a needle or sharp instrument that is
contaminated or potentially contaminated with blood.
4
Percutaneous exposure is when there has been exposure to blood through non-intact
skin.
5
Muco-cutaneous exposure is when blood is spilled onto intact skin or mucous membranes

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Prevention of exposure remains the most effective measure to reduce the risk of HIV
transmission due to occupational exposure. The priority therefore must be to train
peacekeepers (and peacekeeper medics and paramedics, in particular) in prevention
methods (universal precautions) and to provide them with the necessary safe materials
and protective equipment.

Post exposure prophylaxis (PEP) with a 4-6 week course of ARVs following
accidental occupational exposure can be effective in reducing the risk of HIV
transmission73. However the use of ARV PEP only makes sense if universal
precautions are widely taught and practised to reduce the occurrence of exposures to a
minimum74.

Following a peacekeeper having an occupational exposure to HIV infected (or

potentially infected) blood, if ARVs are available for PEP, administration of ARVs should
start within the 24 hours of exposure. HIV counselling should also be available. Blood
should also be taken as within the first few days following exposure to establish a
baseline HIV status. Follow up counselling and testing will also be required.

PEP should also be considered following rape. As with occupational exposure, ARVs
should be administered as soon as possible following the assault and counseling and
testing must be available in field settings.

In these situations a different VCT approach will be required. VCT will need to be
provided in response to an accident or assault often in a field situation. The training
of peacekeepers as focal points for VCT to carry out the initial assessment, starting
of treatments and referral, in these emergency settings could be considered.

Recommendations

 Promote and provide high quality VCT

VCT has been shown to be a beneficial intervention for both those who test
seropositive and seronegative. As peacekeepers are at increased risk from HIV
infection VCT services should be promoted and provided as a priority.

 Tailor the choice of VCT approach to the local situation and needs of
peacekeepers
There is no perfect VCT model that will be appropriate for all peacekeepers from all
countries. Approaches will have to be adapted but should include the minimum
requirements for ethical and effective delivery.

 Consider referral to free-standing VCT services

Referral of peacekeepers to free-standing VCT services which are independent of
the peacekeeping medical services could be considered. This may increase uptake
by guaranteeing confidentiality and may ensure a higher quality of counseling if
adequate numbers of trained HIV counsellors are not available in the peacekeeping
medical service.

 Ensure that discrimination of peacekeepers does not occur following VCT.

Exclusion from services should be on the basis of medical indications, rather than on
a seropositive status. Unless this can be guaranteed it will be difficult to promote VCT
as a beneficial service for peacekeepers.

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 Provide ongoing emotional support for seropositive peacekeepers.

Ongoing emotional support will be needed following VCT for some peacekeepers.
For most peacekeepers this will be short term, and it should not exclude them from
being able to participate in peacekeeping duties. This may be best achieved by
forming linkages with counseling organizations away for the military setting.

 Address stigma and discrimination

Attitudes among the peacekeeping force to HIV and VCT need to be addressed to
ensure that the benefits of VCT are understood and those peacekeepers with HIV
are not stigmatized or discriminated against.

 Ensure provision of medical care for seropositive peacekeepers.

With the increasing availability of ARV therapy and the development of simpler ARV
regimes which require less intensive and sophisticated laboratory and clinical
monitoring, provision of ARVs for peacekeepers who test seropositive should be
considered. Other cheaper and feasible prophylactic interventions should be
routinely provided for all peacekeepers who are found to be seropositive following
VCT.

 Ensure the provision of HIV preventive services

HIV prevention interventions must be consistently available (including STI treatment,
male and female condoms).

 Integrate VCT within a comprehensive HIV prevention program

There should also be an emphasis on HIV prevention counseling for HIV negative
individuals. In many VCT services this is often a missed opportunity. Innovative
approaches to HIV prevention which address peer norms and are developed
following involvement of the peacekeepers themselves, are more likely to be effective
in promoting behavior change to prevent HIV transmission than didactic HIV
prevention lectures.

 Provision of post-exposure prophylaxis (and VCT)

Peacekeepers may be suitable candidates for post-exposure prophylaxis (PEP)
following occupational/accidental exposure or rape. If PEP is to be provided,
availability of VCT in peacekeeping destinations should be considered.

 Provide monitoring and evaluation of the VCT services

To ensure that the quality of testing and counseling is maintained and that
seropositive peacekeepers are supported and not discriminated against following
VCT, routine monitoring and evaluation of VCT services should be developed.

18
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