Provider-initiated testing and counselling in India for HIV
R Meera, SV Sreeram
In India, healthcare providers initiate counselling and testing, diagnosis and treatment. They determine where you get tested, the shop you buy medicines from, which drugs you buy and which brands of these drugs. This is the background of the current debate on provider-initiated testing. According to the latest WHO guidance note (1), providers who believe that a patient is at risk of HIV may suggest a test for HIV. All testing for HIV, including provider initiated testing and counselling (PITC), may be done only in the following conditions: informed consent which includes the right to refuse, the availability of counselling with follow-up, and, in the event of a positive test result, treatment. Are these requirements for testing available in the Indian scenario?
The right to refuse
The new guidelines propose that patients may refuse testing but unless they do so, it is assumed that they have consented to the test. However, healthcare provision in India is based on a paternalistic relationship between provider and patient. Any policy that exacerbates this power imbalance will further compromise free and informed consent. This is especially true for women who rarely make health-related decisions even in their own families. To someone at the mercy of the healthcare provider the right to refuse is meaningless. How can a construction worker choose to refuse the advice of a skilled professional? It is not unreasonable for people to believe that refusal to be tested will result in denial of care. PITC will just become an excuse for coercive testing. Realistically, the only way to opt out of provider-initiated testing is to opt out of all healthcare services.
Proper pre- and post-test counselling is critical to ethical practice. The realities of voluntary counselling and testing centres in India are otherwise. We describe below the situation in the centre in our area:
There is no privacy during counselling and people walk in and walk out of the counselling room as they please. Once a person tests positive, counselling consists mostly of referring the person to a doctor; the positive person will not have any idea of what is happening. The insensitivity of staff is illustrated in the experience of an AIDS widow who came to the centre without her report. The woman on duty scolded her and said, “You knew very well how to roam around and get the disease, but not that you have to bring the report with you.” Lab technicians have been known to inform people directly of their reports, with statements like: “Your blood is spoilt and you have not more than three months to live.” Staff members are vindictive towards anyone who demands a minimum of courteous and decent behaviour. These are not isolated examples; we have heard similar reports from all over the country.
Policy makers have called for early detection to bring more numbers under antiretroviral treatment. The UNAIDS/WHO Policy Statement on HIV Testing (2) states, “Increasingly, provider-initiated approaches in clinical settings are being promoted, i.e. health care providers routinely initiating an offer of HIV testing in a context in which the provision of, or referral to, effective prevention and treatment services is assured.” In India, there is no such assurance. For instance, in our district, antiretroviral therapy (ART) is assured only for 6,000 positive people. Overall, India has provided ART to around 10 per cent of those who need it. With the current abysmal reach of the treatment programme, PITC would only harvest data; it would not lead to a scale-up of ART provision.
Stigma and discrimination
PITC also does not take into account the reason why current HIV testing services are underutilised. I believe that in India stigma and discrimination continue to be the most significant reason why people are reluctant to be tested for HIV. PITC has not been successful even in antenatal care. Many women do not return to government hospitals for their test results. For this reason an HIV test cannot be equated with other tests carried out on patients in public and private healthcare settings in India.
Conflicts of interest
Finally, we must take into account the state of medical practice in India. Healthcare practitioners are notorious for ordering unnecessary tests because they receive incentives from testing services. Many of them have tie-ups with diagnostic services, and may even own a stake in such services. This can be an inducement for the doctor to convince a patient to be tested. In sum, there can be a conflict between the interests of the patient who may or may not benefit from testing and those of the provider who stands to gain from recommending such testing.
- World Health Organization. Guidance on provider-initiated HIV testing and counselling in health facilities. Geneva: WHO; 200[Cited 2007 Sep 20]. Available from: http://www.who.int/hiv/who_pitc_guidelines.pdf
- Joint United Nations Programme on HIV/AIDS/ World Health Organization. UNAIDS/WHO policy statement on HIV testing. Geneva: UNAIDS/WHO. 200