Table 1. Access to HIV testing and counseling.
| Policy indicator | Year of WHO guideline | Malawi policy | Malawi practice: (i) Karonga HDSS facilities implementation, N = 6 offering HIV testing (number of facilities in parentheses) and (ii) insights from KIs |
|---|---|---|---|
| Service coverage and access factors | |||
| Free testing at public facilities | 2003 implied | HTC, as a service of the Essential Health Package, should be provided free of charge in public-sector facilities and in stand-alone sites (Ministry of Health Malawi, 2006b). CHAM/private facilities liaise with DHO to get testing kits and they do not charge a service fee, although they might charge a consultation fee. If the DHO runs out and the private facility has to buy them elsewhere, there would be a charge to the patient.a | Complies: In all 6 facilities, services reported as free for patients, including clinic registration fee, HIV test fee, equipment fees. |
| Provider-initiated testing and counseling (PITC) is standard for all clients including at ANC | 2004 | Health providers are asked to ascertain HIV status for all patients attending health services (PITC). Patients in ANC are especially encouraged for HTC, due to the Option B+ policy (Ministry of Health Malawi, 2011). The PITC concept was there at the beginning and started with ANC mothers.a | Partial: All 5 facilities offering ANC, offer PITC. 4 out of 5 facilities offer PITC to OPD, TB, and STI/FP clients. However, 4 facilities noted it was “opt-in” rather than “opt-out” testing. |
| Testing targeted at high-risk groups (e.g., sex workers, men who have sex with men, injecting drug users) | 2004 | No specific policy on groups such as MSM, IDU, sex workers. The lack of policy on targeting MSM/sex workers contrasts with a long section on targeting testing to the deaf, dumb and visually impaired (Ministry of Health Malawi, 2006b) | Unclear: Testing services are “offered” (note, not “targeted”) to: sex workers (5), MSM (0), drug users (3), prisoners (1), truck drivers (3), factory/estate workers (1). Some moonlight testing takes place, where mobile clinics target sex workers/truck drivers in hot spots.a |
| Parental consent not required for youth testing (<18) | 2007 | When any person aged 13+ is requesting HTC, they should be considered mature enough to give full and informed consent. Youth aged between 9 and 12 years and are sexually active should be regarded as mature minors and considered eligible to give consent for HTC. The HTC counselor should make an assessment of their readiness for HTC services. HTC for youth below 13 years of age should be done with the knowledge of their parents/guardians, unless this is not possible and the testing is for provision of treatment and care services. | Complies: Testing services are offered to schoolchildren in six facilities. |
| Quality of care factors | |||
| Anonymous HIV testing | No names recorded in HTC register. However, ART, TB, and ANC registers have names and HIV test results. For in-patients, the test result is documented in in-patient notes. All patient cards and clinic registers are the property of the Ministry of Health (MoH) and may only be kept at the respective facility or at the National Archives. They must be kept in a locked room and only accessed by clinic staff responsible for providing the respective service and by the national supervision team (Ministry of Health Malawi, 2011). | Not implemented: All facilities report they record patient HIV test data in registers/logbooks. One facility also records on patient-retained cards. The data collected are: sex, age/DOB, residence, name and test result. | |
| Counselor counsels 15 clients/day max | Not specified | Unclear: 3 facilities reported there is no maximum. 2 facilities reported max 8. 1 facility reported max 10. | |
| Periodic refresher training for counselors required | 2001 onwards. No frequency | No clear guidelines. No new counselors are being recruited until refreshers have been done for all HTC counselors. This is because there were concerns over quality of service, so refresher trainings were prioritized.a | Exceeds: 26 medical staff (doctors, clinical officers, nurses, trained counselors) provided HTC services. Out of these, 23 received formal training in HIV testing within the past 2 years. |
| Periodic quality control checks at testing sites required | 2005. No frequency | Activities to maintain and strengthen quality of HTC services include an internal and external quality assurance for rapid HIV testing by laboratory technologist and proper documentation and dissemination of QA procedures and protocols to testing service providers, mentorship and supervision of services, client satisfaction surveys, mystery client surveys, awards/prizes/rewards, centers of HTC excellence etc. (Ministry of Health Malawi, 2006b) | Complies: Quality of care reviews/audits of HIV testing are conducted once every 3 months (3 facilities), once a month (2), and once a year (1). |
| Coordination of care and patient tracking factors | |||
| Negatives retest every 6–12 months | 2007 | Re-testing every 6–12 months is beneficial for individuals at higher risk of HIV infections, e.g., persons with a history of STI, sex workers and their clients, and sexual partners of PLHIV (Ministry of Health Malawi, 2009). The policy might change such that low-risk people (repeat HIV-) can leave a longer space between each test (economizing use of test resources).a | Unclear: People who test HIV negative are advised to test again in 3 months (3 facilities), or test when they feel worried (3 facilities). It is unclear if the window period was misinterpreted as repeat testing, but if so, this is more frequent than policy. Testing when worried is ambiguous. |
| Repeat testing in 3rd trimester of pregnancy (if previously test negative) | 2010 | An HIV test should be provided on 1st ANC visit.a It is also stated that HIV- women’s status should be considered unknown after 3 months window period (Ministry of Health Malawi, 2010). Therefore, if the woman attended ANC early in pregnancy, she would have repeat testing in the 3rd trimester. | Partial: All 5 facilities reported women get tested at first ANC visit for this pregnancy. Only 2 out of 5 facilities said the woman gets tested at their 3rd trimester visit. |
| Support to PLHIV factors | |||
| Individual as well as group pre-test counseling recommended | 2003 | Pre-test counseling is a requirement, either individually or group (Ministry of Health Malawi, 2006b, 2010). If done in a group there should be between 5 and 15 people in a group, and attempts should be made to ensure that the group is homogenous in relation to age and sex, and is culturally appropriate (Ministry of Health Malawi, 2009). | Complies: Pre-test counseling “always” given in 5 out of 6 facilities, and “usually” given in the 6th facility. All 6 sites do individual pre-test counseling. 5 out of 6 sites do group pre-test counseling. |
| Couple counseling encouraged | 2004 | Patients encouraged to attend HTC with their marital/sexual partner (Ministry of Health Malawi, 2006b, 2011). It was also planned that there should be at least 1 counselor at each testing site with specialist couple counseling skills (Ministry of Health Malawi, 2006b). | Complies: VCT for couples is offered in all 6 facilities. |
CHAM=Christian Health Association of Malawi, DHO=District Health Office, MSM=Men who have sex with men, IDU=Injecting Drug User, TB=tuberculosis, OPD=Out patient department, STI=Sexually transmitted infection, DOB=Date of birth.
aSource: Key informant interview.