The Research Triangle Institute (RTI), an independent research organisation with headquarters in North Carolina, has been routinely offering HIV counselling and testing to patients and their family members at 10 health centres in eight districts of Uganda since 2004. About 99 percent of people have agreed to be tested.

"We provide a health talk to all patients that includes the basic facts about HV; then an HIV test is offered, with the patient being given the choice to opt out," RTI's Jennifer Namusobya explained to delegates at the recent HIV Implementers' Meeting in Kampala, Uganda's capital. "There is no coercion and they are informed of the confidential nature of the test."

People who test positive for the virus are offered further counselling and referred to the centre's HIV clinic. Those who test HIV-negative are counselled on risk reduction, given condoms and advised to test again in three months if they have recently engaged in behaviour that may have exposed them to the virus.

By March 2008, the 10 health centres had tested more than 124,000 people for HIV, 30 percent of them non-patients. An estimated 13 percent tested positive, of which 8,525 have been enrolled on antiretroviral (ARV) treatment.

Figures estimating that only about 12 percent of men and 10 percent of women in sub-Saharan Africa know their HIV status, led the World Health Organisation to revise its testing guidelines in 2007. HIV testing in the region has mainly been done on a client-initiated voluntary counselling and testing (VCT) basis, but fear of stigma and discrimination, the perception by many people that they are not at risk as well as a lack of VCT services in many areas has resulted in low uptake. The WHO urged a move towards provider-initiated testing whereby health care providers begin routinely recommending an HIV test to patients attending their facilities.

According to Uganda's Ministry of Health, about 85 percent of the population has never tested for HIV, although 70 percent report they would like to know their status. In 2004, the ministry revised its HIV policy to include provider-initiated counselling and testing, but only in settings where comprehensive HIV care and treatment was available.

Namusobya noted, however, that most Ugandan health facilities were still ill-equipped to start provider-initiated counselling and testing, and that much more investment in the public health sector would be necessary before it could be introduced countrywide.

In addition to upgrading hospitals without fully-fledged HIV services, she said an intensive training programme would be necessary.

"We have trained more than 1,000 health workers in routine counselling and testing, as well as volunteers," she pointed out. Health centres would also need to set up several routine testing points around their various wards and departments instead of relying on one central point as with VCT, she added.

Moses Isabirye, an HIV counselling and testing coordinator with the Makerere University Walter Reed Project (MUWRP), which has been piloting provider-initiated HIV testing at four government health centres in the central Ugandan district of Kayunga, described to delegates at the Kampala meeting how health workers had approached patients, family members accompanying them and other visitors with information about HIV and the offer of a free test.

"We were able to identify HIV-positive friends and family, as well as target couples on the male ward when wives came to visit their husbands," he said.

Isabirye noted that routine counselling and testing had the additional benefit of freeing up staff usually dedicated to carrying out VCT. These staff members could then assist in dealing with the increased number of patients identified as in need of ARV medication.

"It also reduced costs for patients and their families, who struggle to meet transport costs to come to the clinic; now they are able to make one visit and kill two birds with one stone," he added.

www.aegis.org