HIV Counselling and testing services (HCTS)

An individual who is infected with the human immunodeficiency virus (HIV) will not develop the acquired immunodeficiency syndrome (AIDS) immediately. The immune system of the individual will wage a consistent and prolonged war with the virus, right from the day of infection, delaying the onset of AIDS by many years. The time lag between infection and manifestation of signs and symptoms of AIDS is approximately 5–7 years. It is important that an individual who is HIV-infected is aware of his/her status as otherwise he/she could unknowingly transmit the virus to others. The only way to diagnose the presence of HIV and get timely treatment is through a simple blood test.


The challenge before us is to make all HIV-infected people in the country aware of their status so that they adopt healthy lifestyles and prevent the transmission of HIV to others, and access life-saving care and treatment. Thus, counselling and testing services are an important component of prevention and control of HIV/AIDS in the country.


HIV counselling and testing services are a key entry point to prevention of HIV infection, and to treatment and care of people who are infected with HIV. When availing counselling and testing services, people can access accurate information about HIV prevention and care, and undergo an HIV test in a supportive and confidential environment. People who are found HIV-negative are supported with information and counselling to reduce risks and remain HIV-negative. People who are found HIV-positive are provided psychosocial support and linked to treatment and care. As on Jan 2023, more than 75,000 people who are HIV-positive access the antiretroviral therapy (ART) programme and receiving free treatment for HIV/AIDS.


Integrated Counselling and Testing Centre: (ICTC)

An integrated counselling and testing centre is a place where a person is counselled and tested for HIV, on his own free will or as advised by a medical provider. The main functions of an ICTC include:

  • • Early detection of HIV.

  • • Provision of basic information on modes of transmission and prevention of HIV/AIDS for promoting behavioral change and reducing vulnerability.

  • • Link people with other HIV prevention, care and treatment services.

Ideally, a health facility should have one Integrated Counselling and Testing centre for all groups of people. However, an ICTC is located in facilities that serve specific categories such as high risk group, pregnant women, STI cases, TB Patients, HIV/ AIDS symptomatic patients. Accordingly, an ICTC is located in the General OPD or Obstetrics and Gynecology Department of a medical college or a district hospital or in a maternity home where the majority of clients can access counselling and testing services.As TB is the commonest co-infection in people who are infected with HIV, availability of HIV counselling and testing can help patients to have their status diagnosed for accessing early treatment.


HIV counselling and testing service is a key entry point to prevention of HIV infection and to treatment and care of people who are infected with HIV. When availing counselling and testing services, people can access accurate information about HIV prevention and care and undergo HIV test in a supportive and confidential environment. People who are found HIV negative are supported with information and counselling to reduce risks and remain HIV negative. People who are found HIV positive are provided psycho-social support and linked to treatment and care.


HCTS continues to envisage the provision of comprehensive services in an integrated manner, and not limited to HIV testing. HCTS comprises of (i) counselling (pre-test counselling, informed consent and post-test counselling); (ii) testing and prompt delivery of test results with embedded quality assurance;(iii) ensuring audio-visual privacy and confidentiality; and (iv) linkages to appropriate HIV prevention, care, support and treatment services. India meticulously follows the “5 Cs (Consent, Confidentiality, Counselling, Correct test results and Connection)”, as articulated in the WHO ‘Consolidated Guidelines on HIV Testing Services, 2015’, since the introduction of voluntary counselling and testing services for HIV.


HIV counselling and testing services were started in India in 1997. As on Feb 2023 in Bihar, there are 209 Integrated Counselling and Testing Centres (ICTC) and Screening Facility: 664 Facility Integrated Counselling and Testing Centres (F-ICTC) mainly located in government hospitals. Also 59 Prison F-ICTC and 647 PPP –ICTC established in private health facility.


Priority populations for HCTS:The focus should be on the following priority populations:

1. Infants and children: A child may acquire HIV from the HIV infected mother-in-utero (during pregnancy), peripartum (during delivery), postpartum (through breastfeeding) or via parenteral exposure through infected needles and syringes. Early diagnosis of HIV infection in infants/children is very important to plan their care, support and treatment, and to reduce morbidity and mortality. All newborn babies of HIV-positive mothers and infants/children with signs or symptoms suggestive of HIV infection should be tested for HIV.


2. Adolescents (age group 10–19 years): Adolescents are vulnerable to HIV due to physical and emotional transition, and potentially heightened risk-taking behavior. The NACP, in collaboration with the ‘Rashtriya Kishore SwasthyaKaryakram (RKSK)’, focuses on early diagnosis of HIV and appropriate referral linkages to address high-risk behavior, reproductive, sexual, STI/RTI and HIV-related issues among adolescents. If the adolescent is below 18 years of age, informed consent of the parent/guardian needs to be obtained for HIV testing.


3. Pregnant and breastfeeding women: Mother-to-child transmission (Vertical Transmission) of HIV during pregnancy, delivery or breastfeeding is the primary cause of HIV infection among children. It is estimated that without any intervention, the risk of transmission of HIV from infected mother to her child is between 20% and 45%. With appropriate interventions, this risk of HIV transmission can be reduced to less than 5% in breastfed children.

The Government of India is committed to eliminating HIV and syphilis amongst newborns through universal screening of pregnant women for HIV and syphilis as an essential component of the ANC service package. To achieve this objective, on-going PPTCT services are being implemented in close collaboration with theReproductive and Child Health (RCH) Programme of the National Health Mission (NHM). Even pregnant women coming direct-in-labour and breastfeeding women need to be tested for HIV and syphilis, if not tested during pregnancy.


4. Occupational exposure: Health-care workers exposed to infected material, with a possible risk of acquiring HIV, need to be referred to HCTS before initiating any Post Exposure Prophylaxis (PEP) and, after completion of the PEP course, for follow-up HIV testing.


5. Emergency settings (casualty): Patients who present with signs and symptoms suggestive of HIV/AIDS in emergency health-care setting need to be offered HCTS in the same emergency health-care setting.


6. Patients with Kala-azar (Visceral Leishmaniasis): Kala-azar is one of the opportunistic infections (OIs) seen among PLHIV. Morbidity and mortality is high in HIV and Kala-azar co-infected patients. Hence, the NACP and the National Vector-Borne Disease Control Programme have recommended that HCTS should be offered to all Kala-azar patients and persons suspected to have Kala-azar.


7. Tuberculosis patients including presumptive TB cases: Since TB is the most common OI and the leading cause of mortality in PLHIV, all TB patients and presumptive TB cases need to be tested for HIV. Partners of known HIV-positive TB patients should also be offered HCTS with mutual disclosure. Likewise, all individuals availing HCTS should be verbally screened for TB and all eligible symptomatic persons should be promptly referred to TB diagnostic facilities under the Revised National Tuberculosis Control Programme (RNTCP).


8. STI / RTI attendees and patients:HIV transmission is mostly through the sexual route. An unprotected sexual encounter with a casual sexual partner may put the individual at risk of acquiring STIs including HIV. As patients with STI / RTI are at higher risk of acquiring HIV infection, all STI / RTI attendees should be offered HCTS.


9. Sexual partners / spouses of PLHIV (couples): The chance of transmission of HIV from the index PLHIV to their sexual partner is the highest. Hence, efforts should be made to test all sexual partners for HIV with counselling support for mutual disclosure.


10. High-risk groups (HRGs): HRGs comprising core groups such as FSWs, MSM, IDUs, TS/TG and bridge populations such as migrants and truckers have a higher risk of acquiring HIV infection due to multiple casual sexual partners and risky sexual practices. Thus, for early diagnosis and prevention of HIV, HCTS should be routinely offered to all HRGs.


11. Prison inmates: Voluntary HIV testing should be an integral part of the health-care package for prison inmates.


12. Persons who have undergone sexual assault: HCTS should be offered to all individuals who have faced sexual assault. Such individuals should also be counselled for follow-up testing and care should be taken to avoid any form of stigmatization.


Flow of individuals for accessing HCTS:

Individuals can access HCTS in two ways:

1. “Self- initiated”: Individuals who self-perceive their risk and need for HIV testing and thus voluntarily approach for HCTS.


2. “Provider-initiated”: Individuals referred by a health-care provider for HIV testing.


Counselling for HIV Testing:

Counselling is a confidential dialogue between an individual and a counsellor. It aims to provide information onHIV/AIDS and bring about behaviour change in the individual. It also enables the individual to take a decision regarding HIV testing and to understand the implications of the test results. Counselling includes the assessment of an individual's risk of acquisition and transmission of HIV, facilitation of preventive behaviour, and coping mechanism sinc a sean individualis found to be HIV positive. More importantly, counselling is intended to address the physical, social, psychological and spiritual needs of the individual availing HCTS. Counselling is an integral part of HIV screen in gas well as confirmatory facilities underHCTS.Itensures audio-visual privacy and confidentiality of information shared by the individual, including HIV test results. All records and registers should be securely stored.


Elimination of Mother to Child Transmission: (Vertical Transmission)


National AIDS Control Organization (NACO),a division of Ministry of Health and Family Welfare, has adopted a public healthapproach to provide EMTCT services to allpregnant women and their children), whichinvolves free counselling and testing ofpregnant women, detection of HIV positivepregnant women, and the administrationof ART to HIV positive pregnant women andprophylactic ARV drugs to their infants toprevent the mother to child transmission ofHIV.

The Government of India strategy for EMTCTof syphilis include screening for maternal syphilis early in pregnancy and prompt treatment of sero-positive mothers that can prevent vertical transmission and mostcomplications associated with it.

Dual EMTCT of HIV and Syphilis serves toimprove a broad range of maternal andchild health (MCH) services and outcomes.This achievement directly contributes toSustainable Development Goals (SDGs) 3,5 and 10, which aspire to ensure health andwell-being for all, achieve gender equality,and empower women and girls, and reduceinequalities in access to services andcommodities.

The engagement of the private sectoris vital for achieving the national EMTCTgoal as around 30% of the antenatal careand deliveries services are provided byprivate providers. The private sector’s roleencompasses HIV and syphilis screening,confirmation, prompt starting of treatment,follow up, intrapartum and postpartum care,and the care of the new-born.

Goals of National EMTCT Program:
Elimination of new HIV infections among children is based on a four-pronged strategy
a. Primary HIV prevention of women in childbearing age group;
b. Prevention of unintended pregnancies among Positive Pregnant Women (PPW);
c. Prevention of parent to child transmission of HIV infection;
d. Provision of care, treatment, and support of HIV positive women and their families.


Early detection leads to elimination:

Early detection of HIV and initiation of ART in the first trimester will reduce viral transmission. All pregnant women should be counselled for HIV testing during their first contact with health facilities. A tripledrug ARV for more than 24 weeks with good adherence during pregnancy, which would be continued during delivery, breastfeeding and lifelong will reduce mother to child HIVtransmission to less than 2%.

Bihar is committed to achieve the goal of EMTCT for which there is strong need for regular review and development of need-based action plan to meet EMTCT goal in the district. In view of above, following are the impact and progress indicators for your reference and perusal.
a) Process Indicators
• Achieve 95% of ANC registration against Pregnancy estimation: Accessing antenatal care so that 95% of total pregnant women are registered in Health facilities including both private and public health facilities.

• Achieve 95% of HIV and Syphilis Test against total ANC registered: Innovative strategy to reach Universal screening for HIV and Syphilis among pregnant women (95% of registered pregnant women are tested HIV and syphilis by saturating Health facilities up to VSHND level with HIV & syphilis screening).

• Achieve 100% reporting of HIV & syphilis test in HMIS, SOCH and Google Form: By ensuring 100% reporting of HIV and syphilis test both in HMIS, SOCH and Google Form through data entry operator of the facilities.

• 100% of identified HIV positive pregnant to be link with ART for treatment: Innovative strategies to ensure that every HIV positive pregnant woman is promptly Initiated on ART (95% of Identified positive pregnant women to be initiated ART treatment)

• Ensure 100% institutional delivery of HIV positive pregnant women: Any institution level denial could be averted.

• Achieve Early Infant diagnosis (EID) test among 100% HIV exposed babies right from 42 days of birth to 18 months of age:
Strategy to increase the uptake of Early Infant Diagnosis (EID) services Including DBS test with 60 days of child birth at ICTCS and minimising the Loss to follow up (100% of HIV exposed baby should complete 1" EID on 42 days to 60 days and thereafter at every 6 months. interval up to 18 months. of age).

I. 1st EID (DBS test) within 42 days to 60 days of child birth
II. 2nd EID (antibody test) at 6 months of child birth
III. 3rd EID (antibody test) at 12 months of child birth
IV. Final & confirmatory test (antibody test) at 18 months of child birth


• Ensure 100% of spouse test (HIV) of positive pregnant women:
Testing and counselling of Spouse/ partner has to be done on the periodic basis to reduce the risk of transmission. (First screening at 3 months, followed by testing every 6 month)