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Changing from anonymous to confidential HIV voluntary counseling and testing in Uganda

Baryarama, Fulgentiusa; Bunnell, Rebeccaa; Ransom, Raya; Mubangizi, Jothamb; Tumuhairwe, Estherb; Kalule, Josephineb; Hitimana-Lukanika, Charlesb; Mermin, Jonathana

doi: 10.1097/01.aids.0000189568.10471.fd

aCDC Uganda, Global AIDS Program, National Center for HIV, STD and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA

bAIDS Information Centre, Kampala, Uganda.

Received 8 June, 2005

Revised 12 July, 2005

Accepted 20 July, 2005

Two thirds of all individuals with HIV worldwide live in Africa [1], where increasingly diagnostic and routine HIV testing is used to refer HIV-infected individuals to care and prevention programmes [2,3]. This challenges healthcare systems throughout Africa that are interested in integrating care and antiretroviral treatment into prevention programmes, because anonymous HIV testing limits the success of referrals to health services and adds costs as a result of repeat testing. The cost of a single HIV counseling and testing session is relatively high, and in Uganda is similar (US$13) to the national per capita expenditure on healthcare (US$14) [4,5].

HIV-positive clients benefit from many services, including psychosocial support, CD4 cell count testing and disease staging, cotrimoxazole and isoniazid prophylaxis, tuberculosis screening and treatment, and provision of antiretroviral treatment if indicated. They also benefit from HIV prevention services such as the prevention of mother-to-child transmission, safer sex counseling, and condom provision. Many of these interventions require long-term follow-up for maintaining effectiveness and assessing adherence [6]. The provision of these services is impeded within the context of anonymous HIV testing. For example, in Uganda, national policy states that name-based registration for voluntary counseling and testing (VCT) may occur; however, it has been extremely uncommon in practice [7].

We assessed the acceptability of a confidential name-based registration system at the AIDS Information Center (AIC), the largest VCT organization in Uganda.

Since its inception in 1990, AIC has offered anonymous VCT services to over 600 000 clients and registered 126 364 VCT sessions in 2003 alone. AIC maintains four main centres that provided services to 36% of all clients, and 138 indirect sites that are supported mostly at district hospitals. AIC routinely provides clients with VCT, family planning services, and sexually transmitted disease assessment and treatment. For anonymous registration, AIC gives each new client a card bearing the client's number. The card is brought at each follow-up visit. The card serves to help retrieve client records at follow-up visits. Frequently, clients return without their card, impeding the retrieval of their records and linkage to previous care. In April 2001, we piloted confidential name-based registration at the main site in Kampala, the capital city. Receptionists asked clients if they were willing to provide their names. The names of consenting clients were written in a registration book that did not contain clients’ VCT information. Non-consenting clients were offered VCT based on the anonymous protocol. The name-based registration book was kept in a locked cabinet at the reception and was used by the receptionist to track client follow-up visits. The acceptance rates of confidential testing and demographic characteristics of clients were compared over the 8-month period before and after the introduction of confidential testing. After the pilot, confidential VCT was implemented at all four main VCT sites and utilization was assessed for the subsequent 3 years.

Of 11 034 clients served in the 8-month pilot, 10 789 (98%) accepted confidential testing, and 245 (2%) declined to provide their name. The demographic characteristics of clients tested anonymously were no different from those who provided their name; for both, the median age was 30 years and 50% were women. HIV prevalence was 21% among clients tested anonymously compared with 19% among those with confidential testing (P = 0.4). A 17% increase in the number of clients requesting VCT services was documented during the 8 months after the introduction of confidential testing. In January 2002, confidential HIV VCT was implemented at all four main HIV testing centres of AIC, serving 142 953 clients who provided their names (to December 2004). Name-based client registration eased staff workload and improved record retrieval at follow-up visits. During the 3 years after the introduction of name-based registration, 21 700 HIV-positive clients were screened for active tuberculosis, and 1508 clients were diagnosed with latent tuberculosis initiated to a 9-month regimen of isoniazid preventive therapy. The quality and completeness of data in the AIC database also improved allowing for the enhanced use of VCT data for programme evaluation and HIV surveillance. For example, the proportion of repeat testers with complete previous test information was 61% in 1999, 64% in 2000, 89% in 2001 (the year in which confidential testing was introduced), and 97% for 2002 and 2003.

After the introduction of confidential testing, AIC experienced an increase in the number of individuals requesting VCT, an improved ability to follow up patients, and improved data quality in their client records. These findings support the use of confidential, name-based HIV testing in Uganda. Programmes in Africa should consider name-based VCT as it allows for efficient, integrated prevention and care programmes, and provides more reliable data for programme evaluation.

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© 2005 Lippincott Williams & Wilkins, Inc.