Provider-Initiated HIV Counselling and Testing (PICT) in the Mentally Ill

By Moosa, M. Y. H.; Jeenah, F. Y. | South African Journal of Psychiatry, August 2013 | Go to article overview

Provider-Initiated HIV Counselling and Testing (PICT) in the Mentally Ill


Moosa, M. Y. H., Jeenah, F. Y., South African Journal of Psychiatry


The Joint United Nations Programme on HIV and AIDS (UNAIDS) reported that the global number of people newly infected with HIV was declining and that AIDS-related deaths were decreasing in 2010. [1] In the same report UNAIDS estimated an HIV prevalence rate of 17.8% in South Africa (SA), based on studies including the Antenatal [2] and Household [3] Surveys which reported rates of 29% and 11%, respectively. Although the prevalence rate in SA appeared to have stabilised, it was still high compared with the rest of the world. [1]

Routine HIV testing among the mentally ill in SA is not yet standard practice, despite the high prevalence of HIV, the strong association between the virus and mental illness, and the risk of acquiring and transmitting HIV. We propose that provider-initiated HIV counselling and testing (PICT) could be a tool for increasing the number of mentally ill persons tested for HIV. However, there are a number of ethical dilemmas associated with this form of testing, which this paper addresses.

Increasing HIV testing rates in the mentally ill through the PICT approach

The World Health Organization (WHO) reports that worldwide in 2005, a mere 8-20% of people living with HIV knew their serostatus. [4] According to the WHO, the number of people being tested for HIV worldwide increased to 25% of the adult population in 2009 and to 35% in 2010, [5] and a similar trend was seen in SA. The 2010 National Communications Survey included 9 728 people aged 16-55 years, from all 9 provinces and who were representative of the country's population. The survey reported that approximately 60% of men and women had been tested in the 12 months prior to the study, an increase of about 36% since the 2009 survey. [6]

Although the availability of HIV testing in public health facilities has increased in recent years, uptake of HIV testing is still relatively low. [7] Increasing these rates was the main objective of the South African National HIV Counselling and Testing (HCT) Programme, [7] which takes two approaches to testing: (i) client-initiated counselling and testing (CICT); and (ii) PICT. In CICT, also referred to as voluntary counselling and testing (VCT), individuals actively seek HIV testing and counselling at a facility that offers these services, as well as pre-test information. The process is voluntary and the 'three Cs' (informed consent, counselling and confidentiality) are observed at all times. [7] In PICT (also referred to as the routine offer of counselling and testing, or 'opt-out testing') testing is initiated by healthcare providers and recommended to all clients attending healthcare facilities, as a standard component of medical care. [4]

PICT aims at early identification of clients for whom there may be a strong likelihood of HIV infection, because of their symptoms, their high-risk sexual behaviour or their location in areas of high HIV prevalence. The 'opt-out approach' means that HIV testing is done together with all other relevant tests, unless the client actively or explicitly refuses HIV testing. Such refusal is documented in the client's clinic file. In contrast, in the 'opt-in approach' the client must specifically agree to the test rather than having to refuse it. With both approaches, the service provider recommends the testing as a standard part of medical care, and the purpose of testing 'is to enable specific clinical decisions to be made and/or specific medical services to be offered that would not be possible without knowledge of the person's HIV status'. [8] The PICT approach protects and promotes the client's right to autonomy and dignity, while recognising the duty of healthcare providers to protect the right to life and access to health services. [7] This HCT Programme has resulted in an increase in HIV testing in the general population.

However, the prevalence of HIV infection in mentally ill individuals is substantially higher than in the general population. …

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