PMTCT, and National's - Health Systems Trust

6.1 Antenatal Counselling and Testing
This chapter attempts to highlight the key findings from this evaluation that relate to counselling
and testing services for pregnant women and to raise specific areas that require further
discussion and in some instances policy guidance. Specific issues relating to lay counsellors
will be discussed in a subsequent chapter.
The interim evaluation of the PMTCT programme made specific recommendations about
counselling and testing for PMTCT. These included:
• The creation of a cadre of generic lay health workers with standardised employment
conditions including fair salaries.
• The creation of adequate space within facilities for HIV counselling.
• The broadening of the notion of counselling to include ongoing support beyond the
initial period of testing, and the promotion of couple counselling.
KEY FINDINGS FROM THE EVALUATION
PMTCT Counselling
In most of the facilities visited for this evaluation, antenatal clients are introduced to the
components of the PMTCT programme during a group information session. All first antenatal
clients are therefore informed about the PMTCT programme together. However, in some facilities
this is not done, due either to a shortage of staff, or a low client load which allows for individual
information sessions. In Limpopo, group information sessions are not given and nurses have
argued convincingly that they achieve better communication and testing uptake by concentrating
on one-to-one communication. A cause for concern was the finding that group information
sessions in many provinces include information on formula feeding. This should not be part
of group information to woman prior to testing as it may confuse the general public and
undermine breastfeeding practices.
Following the information session, in most facilities, individual pre-test counselling is offered
and women can decide whether or not to have an individual counselling session. In KwaZulu-
Natal individual HIV counselling is seen as compulsory in order for women to make an
informed choice regarding HIV testing. The presence of lay counsellors in every facility offering
PMTCT in KwaZulu-Natal allows this approach to succeed. The very high uptake of HIV testing
in this province may be related to the approach of providing individual counselling to every
antenatal client.
In many but not all of the facilities offering PMTCT, counselling is performed by lay counsellors.
In Mpumalanga, the Eastern Cape, North West and the Northern Cape there are still problems
with the employment of lay counsellors. In these provinces, most counselling is performed by
nurses with numerous clinical duties. The low uptake of HIV testing in these provinces may
be attributable to the lack of lay counsellors.
In addition to human resource support for counselling, the physical infrastructure of facilities
also impacts on the ability to provide individual, confidential counselling. As with the previous
evaluation, this evaluation found large differences between facilities with regard to physical
space to perform counselling. In some instances rooms have dual purposes, serving as storerooms
and counselling rooms. This results in frequent interruptions during counselling sessions.
Table 6.1.1 includes one facility from each province with an indication of the numbers of lay
counsellors, the numbers of dedicated counselling rooms and the testing uptake rate for 2002.
Clearly some facilities have insufficient dedicated space for counselling. This has implications
for client waiting times and the level of confidence in the ability of a facility to provide a
confidential service, both of which impact on decisions to take an HIV test. The table suggests
that the availability of space for private counselling influences the rate of testing uptake amongst
antenatal clients. In some facilities inadequate space for counselling has led to correspondingly
low rates of testing uptake. Facilities with sufficient space appear to achieve higher testing
uptake rates although the examples of Church of Scotland Hospital in KZN and Natalspruit
Hospital in Gauteng show that a high uptake of HIV testing is possible with constraints on
physical space.
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