Situational Analysis on Voluntary Counseling and Confidential Testing in HIV / AIDS Patients Referred to Behavioral Center in lmam Khomeini Hospital , Tehran , Iran

Background and aims: Behavioral counseling centers are the main health organizations which are responsible for providing treatment and care for the patients living with HIV (PLWH). HIVpositive patients receive services through a unique counseling process called voluntary counseling and confidential testing (VCCT). Although there are reports regarding VCCT evaluation from other countries, not such an evaluation was found in Iran until this study, to the best of our knowledge. The study was performed to fulfill this necessity. Methods: Using consecutive method sampling, 314 subjects were sampled from the patients referred to Behavioral Counseling Center of Imam Khomeini hospital, Tehran, Iran. A combination of process and output evaluation of VCCT was performed in the biggest Behavioral Counseling Center of Iran at Imam Khomeini hospital, Tehran, Iran. Data were analyzed using descriptive statistics (percentages and averages). Results: Participants’ response rate was 95.54%. Two shortcomings were found in the counseling process. Cronbach alpha reliability coefficient for this scale was 0.899, which was a desirable reliability for the questionnaire. As the main finding of the study, 48.33% of patients were not using antiretroviral medications regularly. An average number of patients (2.88) had HIV related stigma and fear of disclosure. In a quantitative study before testing in the study, it has been found that HIV patients did not have adequate information about their disease. Conclusion: Defects in the consultation process for the patients with HIV infection in the hospital were concluded. The quantity of consulting services for patients was in low level; therefore it is essential to improve consulting services for health promotion of the HIV patients.


Introduction
][5] During the VCCT process, individuals improve skills to cope with the occurred stress and are tested, while they are fully aware of the disease and future risks. 6VCCT is also crucial for providing available settings, emotional and psychological support, and increasing motivation to prevent high risk behaviors. 8tigma and discrimination associated with HIV occurs due to misunderstanding caused by infection or fear of clinical manifestation or death and this may lead to discourage from following the treatment. 4,5Moreover, the stigma associated with HIV is a serious barrier for VCCT, and effectiveness of prevention and care services. 7Provided services in VCCT centers can lead to early diagnosis and timely referral of patients to receive clinical care and psychological support. 6][15] Fear for test result leads to concern and fear of death in this group, and this is a more important obstacle for access to VCCT services. 7The aim of this study was to evaluate the quality of provided services for the patients living with HIV (PLWH) infection who had referred to VCCT center in Imam Khomeini hospital.Data of this research can result in proper understanding of counseling process in such a way that we could identify barriers, provide more suitable care, reduce fear of HIV testing, and increase uptake of services.

Methods
Three hundred fourteen patients of behavioral counseling referred to Imam Khomeini hospital participated in this study and their samples were used sequentially.Tools for collecting data included: part 1: demographic characteristic, part 2: questionnaire related to survey on the process and quality of patients' counseling.In other words, the process of counseling HIV positive patients about previous stages of consultation and the process of consultation was assessed.The objective of this questionnaire for seeking the first consultation included: 1) Characteristic of patient consulting 2) Characteristic of consultant 3) Methods of consulting 4) Assessment of process of consulting (before, after, follow up) 5) Assessment of environment of consulting After collecting data, to describe the characteristics of research unit, the frequency table, graph, and average was used.In the current study, the scale reliability coefficient was calculated as 0.889 using Cronbach α which represented a suitable reliability.

Results
A number of 314 questionnaires was distributed, from which 300 were completed and analyzed.Most participants were in the group age of 25-44 years, 67 (64%) were male, and 129 were high school graduates and about 50% of participants were married (Table 1).Figure 1 shows the distribution of risky behaviors have lead to HIV.Injection was the most common reason of obtaining HIV/AIDS.
The patients received treatment, care, voluntary counseling and confidential HIV testing from VCCT service, covering pre and post-counseling education (Table 2).that the results showed that 128 individuals (42.67%) stated their consent for provided precounseling education, though for post-counseling, the number of individuals increased to 241.Maintaining privacy by consultant was confirmed by 136 individuals (45.33%), and 140 individuals (46.67) stated concurrent privacy respect in our VCCT.
Table 3 has demonstrated the results of counseling using 1 5-point scale (1-5 score) for determining the satisfaction from counseling.

Discussion
In this study, we found that despite high level of knowledge about HIV transmission and the necessity of prevention, only 66% of participants had behavioral counseling.According to Programa Nacional de DST e AIDS, Ministério da Saúde 2004 report, and the study of Souza Junior et al, limited access of the health system to HIV diagnosis causes the individuals to refer to some places for HIV testing, which are not recommended by  health services, and sometimes may cause violation from ethical principles.This may also cause the individuals to perform the test in blood banks at work places or during late pregnancy or childbirth. 16,17he study of Lohn indicated that there were many negative consequences such as doubtful, risky counseling or even nonexistent counseling, 18 and the studies of Menezes Succi 19 and Segurado et al 20 showed that the decrease in the efficacy of prophylactic measures between mother and child was another negative consequence of invalid places of testing.][23][24] Studies by Bassichetto et al and Pechansky et al indicated that one of the positive aspects of the VCCT services was their capability to help to promote the unprejudiced access to HIV diagnosis, as evidenced by great number of HIV-positive individuals, with an emphasis on implementation of epidemiological and socio-demographic studies on VCCT users' profiles. 25,26ased on the study of de Almeida & Labronici, and World Health Organization/Joint United Nations Program on HIV/AIDS, primary care of most vulnerable individuals is related to the activity and organization provided by these services, to minimize stigma and discrimination and to facilitate decision making in individuals to demand the HIV testing. 27,28ome different cross-sectional studies in various regions of Brazil demonstrated that 72.7% of homosexuals, 29 34.2% of injecting drug users, 30 and 63.5% of sex workers 31 have never had an HIV testing and relevant role of VCCT on most vulnerable groups.
Leta et al stated there was established association between reported risky sexual behaviors and VCCT utilization both in rural and urban strata, whereas being married and having comprehensive knowledge of HIV/ AIDS were associated significantly with VCCT utilization in urban areas, and there was a negative association between being Muslim and VCCT utilization.Therefore, in Ethiopia, utilization of VCCT services among men was low, with a significant rural-urban difference.Despite socio-demographic variables, socio-economic position, residence, religion and age, HIV related stigma and risky sexual behavior were found as the most important determinants of VCCT utilization among the men of 15-59 year-old. 32 possible explanation for lower rate of testing in Muslims, proposed by Tesfaye et al, could be higher adherence of religious rules, which may give protection against sexual transmission of HIV. 32Gray et al stated that even though polygamy was allowed for Muslim men and divorce was relatively easy, extramarital sex was prohibited and maybe was more important for the potential risks of both former and later marriages. 33astani et al represented that alcohol consumption is forbidden in Islam and also engaging in risky sexual behavior related to alcohol is prohibited. 34According to Siegfried et al, all Muslims should be circumcised which decrease the HIV transmission. 33,35Therefore, Muslim men have a lower self-perceived HIV risk and hence are less motivated to be tested for HIV.Some literature on sub-Saharan Africa represented that generally, routine HIV testing was more accepted in most Sub-Saharan African countries.However compared to women, it seemed that fewer number of men accepted the service and HIV tests were done in areas of this new model services. 36,37 review study in South Africa by Skinner and Mfecane showed that HIV/AIDS-related stigma made the pandemic out of the view and reduced any efforts of society and individuals for behavioral changes.38 According to the report of Ministry of Health from 2003, and an article by Voluntary HIV-1 Counseling and Testing Efficacy Study Group (VCTSG), high rates of new HIV infections in men in general population of Ethiopia were among the people aged 15-34 years.Thus the most cost-effective way of reducing the HIV/AIDS epidemic is assumed to be VCCT as it has the primary preventive effects, and is focused on motivation of this age group to use VCCT services.39,40 In the study by Abamecha et al, there was a high intention to use VCCT services.Moreover, the blood test done by healthy workers themselves indicated the existence of fear of HIV status and high percent of risk for HIV infection.41 Some studies such as study of Anthony and colleagues on Ethiopian and Tanzanian people, implemented by Jimma zone health department, revealed that there was no substantial statistical association between sociodemographic factors and determination to use VCCT.[42][43][44] The study of Sherr and colleagues in Zimbabwe revealed that conceived risk was not associated with behavioral attempt.Health care workers are expected to have higher knowledge about HIV/AIDS than the other population groups which may lead to insignificant association, because it might be influenced by education and knowledge of VCT more than risk perception of this group.45 The study of Abamecha et al presented strategies to empower health professionals to resist against social pressure and target programs to change negative attitude to VCCT use, which could increase determination of health professionals to use VCCT. 41

Conclusion
There is a substantial need to promote community's awareness on provided VCCT services.With special attention to health care providers, and to decrease HIV testing fears, more accessible voluntary counseling would improve the individuals' insight about HIV, compendious

Figure 1 .
Figure 1.Distribution of High-Risk Behaviors Leading to HIV Infection.

Table 1 .
Demographic Characteristics of Participants

Table 2 .
Process of Consultation for Behavioral Patients

Table 3 .
Average Surveys About the HIV Patients' Counseling Quality