Voluntary Counselling and Testing ( VCT ) Services on HIV / AIDS in Private Hospital of Yogyakarta

Background: Data Yogyakarta AIDS Commission in 2016 stated the total number of people living with HIV/AIDS was 4,648 cases consisting of 3,334 HIV cases and 1,314 AIDS cases. Based on the data of PKU Muhammadiyah Hospital, Yogyakarta, in October 2016 to October 2017, there were 35 patients with HIV / AIDS. Regulations carried out for any action in the hospital must be following standard operating procedures (SOP), including program counseling and testing of HIV/AIDS or Voluntary Counselling and Testing (VCT). This program is the gateway for the community to gain access to all HIV/AIDS services. This study aimed to explore the implementation of VCT services on HIV/AIDS at PKU Muhammadiyah Hospital in Yogyakarta. Methods: Descriptive qualitative using an observational approach was used in this study to describe the implementation of Voluntary Counselling and Testing (VCT) on HIV/AIDS. As many as ten informants were interviewed, namely: 1 head of VCT services in PKU Muhammadiyah Yogyakarta, 3 VCT counselors, 1 laboratory staff and 5 clients. They were selected using purposive sampling refers to inclusion criteria. Results: Implementation of pre-test counseling, testing, and post-test had been good. Improper service was identified in the number of counselors and waiting time for the VCT test results. Conclusions: Implementation of VCT at PKU Muhammadiyah Yogyakarta is running well and follow the SOPs.


INTRODUCTION
Indonesia, as a developing country, stands on the 5 th country with a high risk of HIV/AIDS in Asia. HIV/AIDS is a deadly disease because there is no medication until this time. Men Like Men (MSM) is the group who at high risk of having Sexually Transmitted Infections (STIs) that can be ended with HIV/AIDS (1). In Indonesia, the cumulative cases of HIV/AIDS in 2016 have increased. At that year, recorded HIV and AIDS cases were 232,323 and 86,780, respectively. While in 2015 was recorded 191,073 and 77,112 cases of HIV in AIDS (2). The popular risk factor for getting HIV/AIDS is unsafe sex in heterosexual (58,846) with the highest age group of 20-35 years at most infected with HIV/AIDS than other age groups (3). The high number of HIV/AIDS cases in Indonesia is partly due to the low interest of someone at risk for the VCT test. It is related to the Health Belief Model Theory (HBM) contains components that can analyze an individual's response to the prevention of disease (4).
The Indonesia government develops HIV/AIDS prevention programs in districts/cities that consist of 4 programs, namely 1) Information and Education communication program (IEC) as an effort to communicate Behaviour Change Communication, 2) Program condom 100%, 3) Voluntary Counselling and Testing (VCT) program, namely the number and quality of services for voluntary counseling and testing, and 4) care, treatment and support programs for people with HIV/AIDS (PLWHA) (5). Voluntary counseling and testing (VCT) is part of the public health strategy to provide counseling and testing for risky people of getting HIV/AIDS infection. Excellent quality of VCT improves people's access to this service and as an effective HIV/AIDS prevention (6). VCT is a reciprocal interaction between counselors and clients aimed at preventing HIV and AIDS, reducing anxiety, increasing perceptions and knowledge about HIV, and developing behavioral changes. Having early VCT could be lead client towards service programs and support including access to antiretroviral therapy, and help reduce stigma in the community (7) The primary HIV/AIDS risk factor is having free sex behavior. Accordingly, providing counseling about HIV/AIDS risk factors, especially sex behavior that can transmit HIV to others and the patient's family quickly, is needed (8). Voluntary Counselling and Testing (VCT) is counseling that provides psychological support such as information and knowledge of HIV/AIDS, preventing the HIV transmissions, promoting the behavior changes, ensuring the ARV treatment, and offering the problem solving associated with HIV/AIDS (9). This program launched by the government to prevent the transmission of HIV/AIDS Voluntary Counselling and Testing (VCT) and Provider Initiated Counselling and Testing (PICT). Program for Infant/Toddler Care (PITC), we consider a relationship-based approach to caring for infants and toddlers essential. Provider-initiated counseling and testing (PICT) have been introduced to ensure that HCT becomes the standard of care in all consultations with health providers. PICT promotes universal access to prevention, care, and treatment services for all clients by increasing the utilization and acceptance of HCT services. Health providers play an essential role in seeing the patient who has symptoms of HIV/AIDS as well as a high-risk factor exposure to HIV/AIDS (10). The health provider in VCT is a trained counselor who has received a certificate from the Ministry of Health.
The level of knowledge about HIV/AIDS and VCT, attitudes, stigma has a significant relationship to the use of VCT services. A low level of knowledge about VCT services is leading to limited access to VCT services. In addition, attitude is a very significant factor. The low acceptance of VCT services increases the higher risk of HIV/AIDS spreading, and vice versa (11).
Early case finding, immediate treatment, and increase knowledge and behavior change in HIV/AIDS prevention. To reduce the HIV/AIDS epidemic, the government has made various efforts, including free ARV treatment, static and mobile VCT, which is a prevention program from the hospital (12). Considering these problems, we researched about how the implementation of VCT on HIV/AIDS at Gemphita Clinic, PKU Muhammadiyah Hospital in Yogyakarta.

METHODS
This is a descriptive qualitative study with an observational approach, aimed to describe the implementation of the Voluntary Counselling and Testing (VCT) on HIV / AIDS. The research was conducted in Gemphita Clinic, PKU Muhammadiyah Yogyakarta, which provides services related to HIV/AIDS. There were ten persons who were interviewed, such 1 head of VCT services in PKU Muhammadiyah Yogyakarta, 3 VCT counselors, 1 laboratory staff and 5 clients. They were selected using purposive sampling refers to inclusion criteria: they were: head of VCT services, VCT counselors, laboratory staff, and clients. They are part of VCT HIV/AIDS team, they certified by the Ministry of Health of Indonesia, have knowledge of VCT service flow associated with HIV/AIDS and the clients who had received VCT HIV/AIDS in PKU Muhammadiyah Yogyakarta Data collections were obtained in 2 approaches: 1) primary data, which was divided into two interviews. We collected verbal information from 1 head of VCT services in PKU Muhammadiyah Yogyakarta, 3 VCT counselors, 1 laboratory staff and 5 clients and observation were employed to observe the VCT HIV/AIDS in PKU Muhammadiyah Yogyakarta. 2) Secondary data was taken from the patient register with VCT services to HIV / AIDS. Refer to the hospital regulation, the material, and information from the client could not be opened for publication purposes. Accordingly, the quote on this research only comes from 2 groups: counselor and laboratory staff.

a. Implementation of pre-test counseling
Implementation of Voluntary Counselling and Testing (VCT) begins with a pre-test counseling. From interviews with respondents, all VCT clients perform registration procedures beforehand, as the same procedure with other PKU Muhammadiyah Yogyakarta patients. Except for PITC services that referred from the emergency unit or inpatient unit. After the registration process, the client is recorded and registered in the medical record, and the staff will contact a counselor who is on duty at the time. Afterward, the client waits for a counselor on duty.
"VCT services, the patient begins to register at the registration desk, as there should be documentation online, in its billing system must be logged in. Enter the VCT clinic, then been confirmed with the counselors on duty " Counsellors 1 According to the counselor's information, the first step on pre-test counseling is an introduction and building the client's self-confidence and delivering information about the confidentiality of the consultation content. Subsequently, questions about the client's knowledge about HIV/AIDS and risk factors are asked to clients. If there is a wrong perception about HIV on the client, it will be corrected by the counselor.
"The first step is counseling pre-test; it is technically we approach the patient, communication with patients to improve their self-confidence. We start with an introduction, build trust and relationship first with the patient. We are listeners about the information they provided. Usually, he/she will tell us about the particular incidence, risk factors. After that, we come to the essence of counseling " Counsellors 2 From interviews with counselors about the constraints experienced in the implementation of pre-test counseling is about knowledge of the client, and they not open to the counselor.
"We face time constraints since, for us, this service is our secondary job, we still have other duties. We come here only if there is a patient. In the counseling process, we face barriers such as the ability of the patient, the patient's ignorance, patient education: patients with low education give inaccurate information. But surely, we always use easy language that can be accepted by patients. We adjust it based on patient originality " Counsellors 3

b. Implementation of VCT test
Our results indicate that the implementation of VCT tests at PKU Muhammadiyah Yogyakarta voluntarily from clients. In a VCT test, informed consent is given to the client to be filled out regarding the test to be taken. Prior to the action, the client will be given information and make sure the client understands the instructions provided. After that, the client will be asked to choose to accept or refuse to have a VCT or PITC test. If the client is accepting, then the test will be carried out.
"Client needs to signing the informed consent here; it comes together with the form. If they sign in, meaning they agree to take the test. " Counsellor 3 Based on the interview with the laboratory staff delivery, he/she said that the test result handed over to the counselor or doctor. Laboratory staff responsible only blood sample acquisitions and release the result.

"For his SOP, all HIV test results gave to the counselors or doctors who refer patients.
Explanation about the result will be delivered by the counselor or doctor, not by the laboratory staff "Laboratory staff.

c. Implementation of the post-test counseling
The counselors said the implementation of the post-test counseling is done after a client undergoes the pre-test counseling and testing of HIV / AIDS. Test results remain in a sealed envelope and should only be opened in front of the client with the client's approval. In the post-test counseling, the counselor should be explaining the results when the client is ready to hear the result. Because the client's psychological condition is influencing the course of post-test counseling.
"We should handle the laboratory test, because if the client opens on their way. They can be shocked by the result. Hence, the results put in the sealed envelope. The counselor asks do they ready to accept the results, otherwise not be forced and the result will deliver when they ready on another occasion" Counsellors 1 When an unexpected result is raising from the test, counselors said that they have to support the client to accept the consequences.

"So, before a test, we give explanations about HIV/AIDS, the risk factors, the hazards. We have to make sure that the client ready with the result. " Counsellors 2
The counselor's challenge in the post-test is when a patient does not come for post-test counseling, or they could not accept the results. In addition, some of the clients complaining about the duration of the whole process.
"Time is an obstacle for the counselor. Because the counselor is not from the counselor himself but other health workers, so this is a side service, so it does not focus on handling.
If the obstacle for the counseling process is the patient's ability, patient ignorance, low knowledge. But of course, we use language that is acceptable to patients; the important thing is obviously" Counselor 1

DISCUSSIONS
The research was conducted in Gemphita Clinic, PKU Muhammadiyah Yogyakarta, which provides services related to HIV / AIDS. The service in Gemphita clinic of PKU Muhammadiyah Yogyakarta delivered not optimal yet because the counselor has dual tasks, and as the counselor is an additional task only. Our finding is not alone; a study of Mujiati (2013) at the VCT services in Bandung reported that similar problems occurred in this place (13).
According to the Minister of Health Regulations No. 1507 / Menkes / SK / X / 2005 is stated the counselor in the hospital should be at least two persons with minimum holds senior high school education. Counselors may come from health or non-health background who have been trained VCT, and counselors should deal with 5-8 clients per day divided between the client pre-test counseling and post-test counseling clients.

a. Implementation of pre-test counseling
In delivering VCT services are not allowed to write the results in any place, even in the medical records, this note should only be coded to maintain confidentiality. Accordingly, in this case, a standard operating procedure (SOP) is needed to handle several forms used such as confidentiality statement form, client visit form for HIV testing, daily VCT form, pre-testing VCT form, test request form of VCT to the laboratory, document VCT client, reference form, service receipt, HIV test request form in the laboratory and daily / monthly reports of VCT antibody tests (13).
Regarding the stigma and discrimination against VCT clients, in the principle of VCT services, it has to be professional, respect the rights and dignity of all clients (14). The confidentiality of VCT service has to be maintained by doing the service in the close and specific room, according to the hospital regulation. It is also referred to as the research of Lawrence (2015) that stated the implementation process of the counseling is part of building trust (15). This study found that implementation of the pre-test HIV counseling has followed the regulation. However, some were not, such as for inform consent. According to the United Nations, VCT implementation begins with pre-test counseling and any voluntary counseling, including the informed consent statement before blood tests for HIV, confidentiality, and post-test counseling (13). The counselor is one of the critical factors in the succeeds of the VCT implementation. Counselor knowledge and quality are also waiting times are determining the VCT quality. Widiyanto's research reported (2009) that Women Sex Workers (FSW) in Sunan Kuning, Semarang, show that long waiting periods and language affected the WPS motivation to participate in the VCT (16).
Waiting time for the counselor takes about 15 minutes, due to the counselor might not ready in place related to the other duty. While waiting time for the laboratory result is 1 to 2 hours. Indonesia's Ministry of Health states that the counselor could come to both health practitioners or not as long they certified. This policy is taken because of the insufficient counselor, in term of the number. Some clients have complaints about the quality of VCT services, such as long waiting times, and the counselor not in place.

b. Implementation of testing VCT
Based on the research shows that HIV testing is done after the counseling process. Implementation of VCT is voluntary because clients come with their initiative to take a blood test without enforcement. The client put their signature on the informed consent form before taking blood sampling as well as when they refused to take a blood test. In this case, laboratory staff and all people involved should maintain client confidentiality. When patients agree to take blood sampling, they have to state informed consent, the same procedure for the client who refuses blood test. The decision to accessing the VCT test depends on client decisions. The task of the laboratory staff is to take the blood sample following the hospital procedure (SOP) (16).

c. Implementation of the post-test counseling
This research found that service in the Gemphita clinic is good and conducted following the SOP, such as it is done after the client takes blood sampling. Counsellor first asks the client's readiness before delivering the test result. When the pre-test counseling goes well, it can be built up a good relationship between counselor and client. From the results of research conducted at PKU Muhammadiyah Yogyakarta, constraints experienced in post-test counseling among other clients do not come, the results of old tests or long waiting times, and pre-test counseling that failed. A trusting relationship already established between the client and the counselor will make more meaningful post-test counseling.
The research found the equipment, facilities, and infrastructure available in the clinic Gemphita to support VCT services in counseling rooms to meet the standard. Facilities and infrastructure will be very influential in the process of voluntary counseling and testing; VCT is a service that promotes comfort and privacy and comfort.
The post-test counseling on the research location seems already running well. The counselor delivers the test result when the client ready to listen (17). In case there is a reactive result, the counselor would suggest the client meet with the doctor to get treatment CST (ARV). According to Gardner (2011) conducted an ongoing ARV treatment aimed to reduce the virus population. ARV treatment is only successful if the patient complies with the role of medication, which is twice a day. Otherwise, the treatment effectivity will reduce significantly (18). The symptoms are headache, fatigue, anemia, itching, nausea/vomiting, diarrhea, lipodystrophy, skin rashes, skin discoloration, neuropathy, and sleep disorders. The problem that could arise on the antiretroviral drugs was reported by previous research such as headache, fatigue, anemia, itching, nausea/vomiting, diarrheal, lipodystrophy, skin rashes, skin discoloration, neuropathy, and sleep disorders (19).
The good pre-test counseling is influencing the post-test result, due to the chemistry between the client and counselor. The main challenge during the post-test counseling is when the client is not coming for the result consultation, long waiting time for the test, and the failure of pretest counseling. In addition, the comfort room for counseling also affects the quality of the counseling. Generally, the post-test section is important in this cycle of counseling because this stage will confirm the client is negative or positive HIV/AIDS (20). Meanwhile, if the client receives negative results, it can lead them to avoid unfavorable behavior (5).

CONCLUSIONS
The counseling process in the pre-test and post-test has been running well and the following SOP from the hospital. However, some challenges still faced by the terms counselor (a division of labor), the waiting time while waiting for the results of tests VCT. VCT services, in general, has been running quite well, but some challenges need to be attentive, such as long waiting time to the associated service.