I. INTRODUCTION AND RATIONALE

The Philippines still maintains less than one (1) percent prevalence rate of HIV infection. Preventive interventions must be undertaken by the country in order to maintain its low prevalence status, and the Department of Health and other concerned agencies are focusing their efforts thereon.

Pursuant to the 4th AIDS Medium Term Plan (2005-2010), HIV counseling and testing is one of the preventive interventions used to reach the most at risk population. The at-risk and vulnerable populations for HIV infection include people in prostitution, men having sex with men, people who inject drugs, and migrant workers. HIV counseling and testing is being advocated to the most at risk population because through this intervention, the same are given the opportunity to know their HIV status and at the same time are provided with information on risk reduction strategies and location of facilities to treat HIV positive individual.

Since counseling is anchored on HIV testing, efficient post-test counseling can appropriately manage the negative consequences of client ™s knowing their HIV status especially if the client tested positive for HIV. On the other hand, poor quality counseling which may inadequately address client issues may result in suicide, depression and other-psychological consequences in persons tested positive for HIV.

Furthermore, the importance of implementing quality counseling anchored on HIV testing as mandated by Republic Act No. 8504, œAIDS Prevention and Control Act of 1988 , will not only benefit the individual being tested but will also scale up preventive intervention so as to slow down or halt the spread of HIV. Hence, there is a need to provide a standard in the conduct of HIV counseling and testing.

II. OBJECTIVES

General Objective:

To provide policies and guidelines in the conduct of HIV counseling and testing (HCT) at community and health facility settings.

Specific Objectives:

1. To identify the required components of HIV counseling and testing and set the protocol for these components;
2. To set the standards/requirements for an HIV counseling and testing facility; and
3. To define the roles and responsibilities of DOH and other stakeholders in the implementation of these guidelines.

III. SCOPE AND COVERAGE

This guideline covers all Sexually Transmitted Infection (STI) and HIV service providers, coordinators and managers of HIV clinics and /or testing laboratories, all facilities offering HIV testing for diagnostic purposes, surveillance and research, and blood safety purposes.

IV. DEFINITION OF TERMS

1. Blood Service Facility (BSF) - any unit, or office or institution providing any of the blood transfusion services and which can be a blood center, blood bank, blood collection unit or blood station.

2. Confirmatory test/testing - refers to the test performed on samples that have tested reactive to the screening test to find out if the results were true positive or not.

3. DOH Retained Hospitals - hospitals that remain under the management and supervision of the Department even after the devolution.

4. Fourth AIDS Medium Term Plan - The five-years Plan containing the country ™s action and response towards maintaining the low HIV prevalence status of the Philippines and preventing the spread of HIV infection.

5. Informed written consent - refers to the voluntary written agreement of a person allowing him/herself to undergo or be subjected to a procedure based on full information.

6. Overseas Filipino Workers (OFW ) clinics - these are clinics that conduct pre-employment medical examination for Filipinos bound for abroad.

7. Pre-donation counseling - a process in blood donor selection wherein donors are informed about health conditions or risk behavior that would make them unsuitable to donate blood. The donor ™s informed consent to blood donation and to the blood testing is obtained during counseling.

8. Reactive sample - the blood sample from patient/client has antibodies that reacted to the HIV antigen or vice versa present in the screening test. However, the presence of reactive sample does not totally confirm that the person has HIV infection.

9. Screening test - refers to initial serological test performed to determine the presence of antibody and/or antigen against HIV1 and HIV2.

10. Social Hygiene Clinics - these are clinics of the local government unit that are usually part of the municipal/city health office providing reproductive health service including management of STI.

11. Treatment hub - a hospital facility with an organized HIV/AIDS Core Team (HACT) providing prevention, treatment care and support services to People Living with HIV (PLHIV) including but not limited to HIV counseling and testing, clinical management, patient monitoring and other care and support services. ARV treatment can only be assessed through these facilities. Refer to Annex II^* for the list of treatment hubs.

12. HIV Counseling and Testing (HCT) - also called Voluntary Counseling and Testing(VCT) is a counseling process that enables a client make an informed choice about being tested for HIV. The counseling process has two components, the pre and post HIV test counseling.

12.1 Pre-HIV test counseling - a process that prepares the client for the HIV test. Pre HIV test counseling explains the implications of knowing that one is or is not infected with HIV, facilitates discussion about ways to cope with knowing one ™s HIV status, to enable an individual to practice strategy to reduce future risk behaviors. It can be Client initiated (CICT) or provider initiated HIV counseling and testing (PICT), both process is voluntary and enables client make informed decision about being tested for HIV infection.

12.2 Post HIV test counseling - process conducted by a trained personnel to assist the client understand and cope with the HIV test result and be able to identify options for future plans including physical, mental, social, reproductive and other personal concerns.

13. HCT facility - any health facility equipped in providing services on HIV counseling and testing recognized by DOH. It can be free-standing or incorporated into existing health-care services.

V. GENERAL GUIDELINES

1. All HCT facilities shall observe the principles of counseling, informed consent and confidentiality at all times. (Refer to Annex 1^* for Minimum Information provided during Pre-test counseling).

2. All HCT facilities shall be duly licensed and comply with the standards set by the Department of Health for an HIV Testing Center.

3. All Social Hygiene Clinics (SHC) shall offer to most at risk and vulnerable clients HIV counseling and testing services or referral at regular intervals.

4. All DOH-licensed OFW clinics shall provide pre-HIV test and post-HIV test counseling to all their clients for HIV testing as mandated by Republic Act No. 8504, œAIDS Prevention and Control Act of 1998 . Provision for counseling shall be part of the accreditation requirements of OFW clinics.

5. Blood service facilities(BSF) shall include in its pre-donation counseling an assessment of risk behavior among all its potential blood donors. All individuals seen at BSF with high risk behavior shall be deferred and shall be referred to a HCT facility for counseling and HIV testing.

6. All identified treatment hubs (see Annex II) and DOH-retained hospitals shall set-up and provide HIV counseling and testing as part of HIV AIDS Core Team (HACT) services and as potential referral facilities for LGU and NGO based HIV counseling and testing facilities.

7. Private and LGU hospitals shall be encouraged to set-up within their systems provision of HIV counseling and testing services for walk in clients. The said services shall be closely linked to the HACT of the hospital.

8. All persons who underwent HCT shall be provided with their test results with post-test counseling, except for testing done during blood donation, surveillance and research purposes. No other person shall be provided with the result other than the person tested except in circumstances allowed by RA 8504 or similar guidelines.

VI. SPECIFIC GUIDELINES

1. Conduct of Pre - HIV Test Counseling

1.1 Client Initiated Counseling and Testing

a. All clients who want to be tested for HIV shall be provided with pre-HIV test counseling in a space where privacy could be observed and confidentially ensured.
b. Pre-HIV test counseling shall either be conducted in individual or group settings. Clients shall be strongly encouraged to bring their confidants during the pre- and post-HIV test counseling.
c. The same counselor is highly recommended to conduct both pre- and post-test counseling and, if needed, follow-up sessions for a client.
d. Adult clients shall be counseled in a setting that is safe and secure for both counselor and client.
e. Pre- and post-HIV test counseling of children shall take into consideration the maturity of the client and, when necessary, responsible parents or a legal guardian, including any registered social worker, shall be involved.
f. Counselors shall ensure that clients understand the information printed on the consent form. All necessary and correct information that clients need to make decisions for themselves shall be provided.
g. Counselors shall strongly encourage follow-up counseling sessions and ensure that clients utilize referral networks that are in place and functional.
h. All counselors shall have basic knowledge on voluntary blood donation and incorporate facts on blood donation when appropriate.

1.2 Provider - Initiated Counseling and Testing

a. As part of medical management, HIV testing shall be offered by health care provider to ALL the following:   

1. Clients assessed for STI in an STI clinic or elsewhere;
2. Pregnant women with one or more of the following HIV risks:

i. multiple sex partners
ii. person who inject drugs (PWID)
iii. history of STI, including a diagnosis of syphilis
iv. husband or partner has multiple sex partners, history of STI or is a known PWID.

3. People accessing community-based services designed for males having sex with males, people in prostitution and those who inject drugs:

4. Diagnosed TB patients, as discussed in AO 2008-0022, otherwise known as œPolicies and Guidelines in the Collaborative Approach of TB and HIV Prevention and Control. 

5. Patients showing signs and symptoms consistent with HIV-related diseases or AIDS seen by the attending physician.

6. Parents / Guardian of all children born to HIV infected mothers (or those with possible exposure)

b. Basic conditions on confidentiality, informed consent, and counseling shall be adhered to.

c. Pre-HIV test counseling shall be limited to basic information-giving that would help the patient decide whether to accept HIV testing (See Annex 1).^*

d. Post-HIV test counseling services shall be provided to all clients tested by trained personnel (See Annex III)^*

e. Counselors providing post test counseling services shall emphasize prevention for those that tested negative and, medical and psychosocial support to those that tested positive.

f. The capacities for pre and post HIV test counseling including the capacity to provide medical and psychosocial support shall be enhanced and the referral networks between and among these providers shall be functional.

2. Conduct HIV Testing

Only registered medical technologist with HIV proficiency training shall perform the HIV test using Food and Drug Administration (FDA) registered test kits. Other screening tests may be performed including but not limited to Enzyme Immunoassay (EIA), Particle Agglutination (PA) and Rapid Assay (RA). Reactive samples from clients/patients shall be brought to STD/AIDS Central Cooperative Laboratory (SACCL) at the San Lazaro Hospital for confirmatory testing (Refer to Annex IV for the current HIV Diagnostic Testing Algorithm)^* . For reactive blood units (not person) from blood banks, samples shall be referred to the Research Institute for Tropical Medicine (RITM) for confirmatory testing.

3. Release and Reporting of Test Result

Samples reactive to screening test shall not be reported directly to the client/patient. All reactive samples shall be referred for confirmatory testing. The reference laboratories namely SACCL and RITM shall not release the result of the confirmatory test directly to the patient/client under any circumstances but must send the result to the referring HIV testing facility. This is to ensure that the release of the HIV test shall be accompanied by post-test counseling especially if the result is positive. SACCL and RITM are required to report the confirmed positive samples to the National Epidemiology Center (NEC).

It is the responsibility of the BSF to ensure that donors have been screened properly and pre-donation counseling has been provided to all potential blood donors in order to prevent the occurrence of reactive and positive samples by eliminating those individual with high risk behaviors. For confirmed positive blood units, tracing the donor and informing him/her of the result is not recommended. Providing result to a free HIV test can put the blood supply at risk as high risk individuals within the window period may avail of this free services. Information campaign on HIV services available and stigma reduction activities will be intensified by CHD in areas where positive blood units are identified.

4. Conduct of Post - HIV Test Counseling

Post-HIV test counseling shall be provided together with the release of the test result whether the test is negative or positive. It shall be done in an enclosed space where counseling can be done in privacy. It is recommended that the trained counselor who performed the pre-test counseling shall also provide the post-test counseling. Refer to Annex III^* for the list of information that should be disclosed to the clients/patients during post-test counseling.

1. Special Concerns on Post HIV Test Counseling: Infant Feeding

HIV-infected pregnant women shall also be given information on the risk and benefits of exclusive breastfeeding, exclusive replacement feeding and guidance in selecting the most suitable option in their circumstances. (The entire spectrum of preventing mother to child transmission of HIV is described under AO No. 2009-0016).

VII. REQUIREMENTS FOR AN HIV COUNSELING AND TESTING FACILITY

1. Human Resources

a. Physician, allied medical/social welfare personnel trained in conducting pre-test and post-test counseling for HIV by DOH or any of its recognized organizations
b. Registered medical technologist with training on HIV proficiency testing

2. HIV test kits

a. Only FDA registered test kit or other available screening test (EIA/PA/RA) shall be used in HIV testing;
b. For HCT facilities with no HIV testing capacity, there shall be an explicit linkage to any DOH-accredited HIV laboratory for HIV testing.

3. Space - an enclosed room or devoted section/space where counseling can be done in privacy.

4. Annual certification of satisfactory performance in the National External Quality Assurance Programme of NRL - SACCL or its designate.

VIII. ROLES AND RESPONSIBILITIES

1. National Center for Disease Prevention and Control 

a. Advocate the setting up of HCT facilities to the local government units (LGU)/hospitals/health facilities as a preventive intervention in reaching the most at risk population.
b. Conduct awareness campaign on HIV and AIDS in the workplace including the availability of HIV counseling services either by the DOH - licensed HIV laboratory staff and/or HIV AIDS Core Team.

IX. FUNDING

The Infectious Disease Office of the NCDPC shall allocate budget for the implementation of these policies and guidelines including but not limited to fund for the augmentation of HIV test kits and funds for training. Other DOH Offices including CHD and DOH-retained hospitals shall support financially, as part of their annual budget, the implementation of these policies and guidelines.

X. REPEALING CLAUSE

Provisions in previous issuances that are inconsistent and contrary to this Administrative Order are hereby rescinded and repealed.

XI. EFFECTIVITY

This Administrative Order shall take effect immediately.

(SGD.) ENRIQUE T. ONA, MD, FPCS, FACS
  Secretary of Health

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^* Text Available at Office of the National Administrative Register, U.P. Law Complex, Diliman, Quezon City.