Nicaragua | HIV Counseling and Testing Collaborative for People with STIs
The primary objective of this collaborative was to support most at-risk populations (MARPs) in HIV/AIDS and sexually transmitted infection (STI) prevention and care. These populations include commercial sex workers (CSWs) and men who have sex with men (MSM). In order to increase the access to prevention and care services for these populations, the collaborative worked with Ministry of Health (MINSA) facilities to address counseling, diagnostics, treatment, and follow up with a focus on quality of care.
Specifically, the collaborative aimed to promote counseling and voluntary HIV testing among patients who attended facilities to receive STI treatment. Among patients requesting STI treatment, a specific emphasis was placed on increasing testing among higher-risk populations such as CSWs and MSM.
The collaborative provided technical assistance to municipalities from SILAIS in Madriz, Chontales, Chinandega, Granada, Carazo, Masaya, Nueva Segovia, RAAN, Rio San Juan, RAAS, Jinotega, Boaco, Matagalpa, and Estelí to strengthen activities and recording of pre- and post-test counseling with an emphasis on increasing HIV testing provided to patients with STIs, women of reproductive age, TB patients, and the general population. Training and improvement activities were targeted towards providers who provided voluntary HIV counseling and testing and/or treatment for HIV patients.
Specifically, under the collaborative, facilities improved their procedures and care to:
- Better identify at-risk patients, especially those who present with STIs and TB
- Provide counseling to pregnant women captured in ante-natal care
- Counsel patients on HIV risk factors and testing procedures
- Obtain informed consent
- Administer rapid HIV tests
A team from each facility participating in learning sessions under the collaborative. During these sessions, teams learned about the relationship of STIs and HIV/AIDS, the clinical management of STIs, and quality improvement methodology.
In addition to the learning sessions, all doctors and nurses that provided HIV testing at participating facilities took part in a training course titled “Working with Stigma and Discrimination.” This stigma training was first part of the Anti-Retroviral Therapy Collaborative led by HCI in Nicaragua; during that work, HCI realized STI patients also faced stigma and discrimination. The training course was modified to include themes around STIs and sexual diversity. The training was delivered over 6 monthly meetings.
Under the collaborative, the manual for the technical team of the Nicaraguan Association of Positive People for Life with HIV (ANICP+VIDA) was revised. This NGO works with HIV-positive MARPs and supports many of the patients who access the services improved by this collaborative. Additionally, HCI developed activities for organizational strengthening within the CSW nework. From 2008 to 2009, HCI worked with three NGOs that worked with this population, Xochiquetzal, Clínica Bílwi, and ASONVIH-SIDA. These organizations received the same training as the MINSA health clinics so that they could improve counseling and testing for populations they served. From 2009 to 2010, additional organizations serving these populations became involved and received similar training and organizational strengthening from HCI.
The following indicators were collected for this collaborative to identify improvements in the quality of care at participating facilities:
- % of people with STI who received HIV counseling ´
- % of people with STI who got an HIV rapid test
- % of people with STI reactive to HIV
The following indicators were used as process indicators for this collaborative:
- Number of clinics providing counseling and testing according to national and international standards
- Number of individuals who received counseling and testing for HIV and received their test results
- Number of individuals trained in counseling and testing according to national and international standards
- Number of individuals trained in the provision of laboratory-related activities
- Number of individuals trained in HIV-related stigmas and discrimination reduction
HCI involved other non-governmental organizations (NGOs) that worked with MARPs in this collaborative. These populations can be difficult to identify, so it was important to involve other organizations in order to use their networks to reach these populations. As a result of the successes of this collaborative, an expansion phase was started in 2011. HCI is now working with eleven MINSA health centers in the Managua SILAIS.
74 health centers in 14 of 17 SILAIS participated in this collaborative from 2008 to 2009: participating SILAIS included Granada, Carazo, Masaya, Nueva Segovia, Chinandega, RAAN, Rio San Juan, RAAS, Chontales, Jinotega, Boaco, Matagalpa, Estelí and Madriz. From 2009 to 2010, this was reduced to 26 health units from 8 prioritized SILAIS.
HCI conducted coaching visits at all participating facilities. During coaching visits, the flow of VCT services was reviewed, which allowed QI coaches and facility teams to make specific targeted improvements for their facility.
Two intra-SILAIS learning sessions were held for participating teams. These sessions focused on clinical content about the management of STI symptoms, as well as the relationship between STIs and HIV/AIDS. This content was especially important to sensitize staff as to why it is important to offer HIV counseling and testing to patients presenting with STI symptoms. Finally, participating teams were trained on the standards and indicators used to analyze their performance in order to apply quality improvement methods to improve care.
Over the course of the collaborative, HCI found that testing became more accessible for patients, especially after providers received stigma and discrimination training. Facility staff began to see a link between STI and HIV incidence, which encouraged them to provide more HIV tests. Testing increased from 9% in 2009 to 37% by the end of collaborative activities in 2010.
When MINSA changed its data collection form, registration of patients and test improved as it was easier for providers to complete the form. Prior to the collaborative, this data form was rarely completed properly.
Adapting existing medical forms to better suit providers’ needs proved to be a key changed. By adding columns for STI tests and TB tests to the data registers at clinics, this served as a reminder and encouraged providers to offer TB and/or STI tests in conjunction with HIV tests. MINSA changed its HIV data collection forms to include STI tests and TB tests; before, HIV tests were only registered as either “general population” or “pregnant women.”
MINSA changed the HIV test that it offered in 2010, which also increased testing. Previously, the Capilus test was used, which required a veinous blood sample, centrifuge and refrigerator, was only offered at labs. Now, the Determine test is a digital blood prick test that does not need refrigeration or a centrifuge, and thus can be offered at more health clinics and posts.
Stigma and discrimination training was key to changing providers’ attitudes. This was especially important to increasing testing among MARPs. Training on the links between STIs and HIV for providers helped increase testing rates and more patients presenting for STI treatment were referred for counseling and testing.