HTC Tanzania 2013

THE UNITED REPUBLIC OF TANZANIA
MINISTRY OF HEALTH AND SOCIAL WELFARE
National Comprehensive Guidelines

for HIV Testing and Counselling
February, 2013
February, 2013
February, 2013
. Ministry of Health and Social Welfare
National AIDS Control Program (NACP)
P.O. Box 11857,
Dar es Salaam.
Website:www.nacp.go.tz
e-mail: info@nacp.go.tz
ISBN: 978-9987-650-80-4
Any part of this guidelines can be used provided that the source which is the Ministry of Health
and Social Welfare Tanzania is acknowledged.
Page ii National Comprehensive Guidelines for HIV Testing and Counselling in Tanzania
Table of Contents
Forward…………………………………………………………………………………....……vii
Acknowledgement……………………………………………………………………......….…viii
Abbreviation……………………………...…………………………………………….…..……ix
Chapter 1: Introduction ................................................................................................................1

1.1 Background on HIV and AIDS services in Tanzania ...................................................... 1

1.2 Defining HIV Testing and Counselling ........................................................................... 1

1.3 Justification for Comprehensive National HTC Guidelines ............................................ 2

1.4 Purpose of Guidelines ...................................................................................................... 2

1.5 Scope of Guidelines ......................................................................................................... 3

Chapter 2: .......................................................................................................................................4

Core Principles of HIV Testing and Counselling........................................................................4

Preamble ..................................................................................................................................... 4

2.1 Confidentiality ................................................................................................................. 4

2.2 Counselling ...................................................................................................................... 5

2.3 Consent ............................................................................................................................ 6

2.4 Correct Test Results......................................................................................................... 7

2.5 Connecting Clients and Patients to Follow-up Services .................................................. 8

Chapter 3: .......................................................................................................................................9
HIV Testing and Counselling Approaches ..................................................................................9

Preamble ..................................................................................................................................... 9

3.1 Provider-Initiated HIV Testing and Counselling............................................................. 9

3.3 Home-Based HTC.......................................................................................................... 10

3.4 Other HTC Approaches ................................................................................................. 12

3.4.1 Mandatory HIV testing ......................................................................................... 12

3.4.2 HIV testing of blood and tissue donations............................................................ 12

3.4.3 HIV testing for research or surveillance ............................................................... 12

3.4.4 Self-testing ............................................................................................................ 12

Chapter 4: .....................................................................................................................................13
HIV Testing and Counselling Settings .......................................................................................13

Preamble ................................................................................................................................... 13

4.1 Health Facilities ............................................................................................................. 13
4.1.1 Co-located HTC site ............................................................................................. 13
4.1.2 Integrated HTC ..................................................................................................... 13
4.2 Community-Based Settings ........................................................................................... 15

4.2.1 Stand-alone Voluntary Counselling and Testing Sites ......................................... 15

4.2.2 Mobile or Outreach Settings ................................................................................. 15

4.2.3 Home-Based Settings............................................................................................ 16

4.2.4 Workplace Settings ............................................................................................... 16

National Comprehensive Guidelines for HIV Testing and Counselling in Tanzania Page iii
Chapter 5: .....................................................................................................................................17

Populations Receiving HTC ........................................................................................................17

Preamble ........................................................................................................................................17

5.1 General Populations ....................................................................................................... 17

5.1.1 Women and Men................................................................................................... 17

5.1.2 Couples ................................................................................................................. 17

5.1.3 Infants, Children, Youth and Adolescents ............................................................ 20

5.2 Key Populations at Higher Risk for Infection................................................................ 25

5.2.1 Persons who Inject Drugs (PWID) ....................................................................... 26

5.2.2 Sex Workers (SW) ................................................................................................ 26

5.2.3 Men who have sex with Men (MSM) ................................................................... 26

5.3 Other populations at higher risk of HIV exposure ......................................................... 26

5.3.1 Persons abusing alcohol and other drugs .............................................................. 27

5.3.2 Mobile populations ............................................................................................... 27

5.3.3 Uniformed services ............................................................................................... 27

5.3.4 Prisoners................................................................................................................ 27

5.3.5 Refugees, displaced persons and migrants............................................................ 28

Chapter 6: .....................................................................................................................................29
HIV Testing and Counselling Service Package .........................................................................29

Preamble ................................................................................................................................... 29

6.1 Pre-test Session .............................................................................................................. 29

6.2 HIV Testing ................................................................................................................... 30

6.3 Post-test Counselling ..................................................................................................... 30

6.3.1 Re-testing Messages.............................................................................................. 31

6.4 Linkages from HTC to Follow-up Services................................................................... 32

6.5 Integration with other health services ............................................................................ 34

6.5.1 Condoms & lubricant............................................................................................ 34

6.5.2 Post-exposure Prophylaxis.................................................................................... 34

Chapter 7 ......................................................................................................................................35
Human Resources ........................................................................................................................35

Preamble ................................................................................................................................... 35

7.1 Requirements for HTC Providers .................................................................................. 35

7.2 Task Shifting.................................................................................................................. 35

7.3 Ethical Standards ........................................................................................................... 36

7.4 Training Requirements................................................................................................... 36

7.4.1 VCT Training........................................................................................................ 37

7.4.2 PITC Training ....................................................................................................... 37

7.4.3 HIV Rapid Testing Training and Certification ..................................................... 37

7.4.4 Additional HTC Training Curricula...................................................................... 37

7.5 HTC Provider Certification............................................................................................ 39

7.5.1 HTC Provider Recertification ............................................................................... 39

Page iv National Comprehensive Guidelines for HIV Testing and Counselling in Tanzania
7.6 Comprehensive Supportive Supervision and Mentoring ............................................... 39

7.7 HTC Providers Professional Growth and Development................................................ 40

7.8 Occupational Health and Safety..................................................................................... 40

Chapter 8: .....................................................................................................................................41
Quality Assurance and Improvement ........................................................................................41

Preamble ................................................................................................................................... 41

8.1 Quality Assurance for HIV Testing ............................................................................... 41

8.1.1 Internal Quality Control........................................................................................ 42

8.1.2 External Quality Assessment (EQA) .................................................................... 42

8.2 Quality Assurance for HIV Counselling........................................................................ 43

8.3 Quality Improvement for HTC ...................................................................................... 43

8.4 HTC Services Quality Assurance .................................................................................. 44

8.5 HTC Site Certification and Accreditation...................................................................... 44

Chapter 9: .....................................................................................................................................45
Logistics Management .................................................................................................................45

Preamble ................................................................................................................................... 45

9.1 Required HTC Supplies ................................................................................................. 46

9.1.1 HIV Test Kits........................................................................................................ 46

9.2 Forecasting..................................................................................................................... 47

9.3 Procurement ................................................................................................................... 47

9.4 Storage and Maintenance............................................................................................... 47

9.5 Distribution .................................................................................................................... 48

9.6 Accountability Systems ................................................................................................. 48

9.7 Stock Outs...................................................................................................................... 48

Chapter 10: ...................................................................................................................................49
Laboratory....................................................................................................................................49

Preamble ................................................................................................................................... 49

10.1 Training and Training Materials .................................................................................... 49

10.2 Quality Assurance measures for HTC laboratory services. ........................................... 49

10.3 Infection, Prevention and Control.................................................................................. 49

10.4 HIV Testing Technologies............................................................................................. 50

10.4.1 HIV Rapid Tests Kits (HRTK) ........................................................................... 50

10.4.2 Enzyme-Linked Immunosorbent Assay (ELISA)............................................... 50

10.4.3 HIV Molecular Tests........................................................................................... 51

10.5 National HIV Testing Algorithm ................................................................................... 51

Chapter 11: ...................................................................................................................................54
Monitoring and Evaluation.........................................................................................................54

Preamble ................................................................................................................................... 54

11.1 Data collection ............................................................................................................... 54

11.2 Data reporting ................................................................................................................ 54

11.3 Data analysis and interpretation..................................................................................... 56

National Comprehensive Guidelines for HIV Testing and Counselling in Tanzania Page v
11.4 Data use.......................................................................................................................... 56

11.5 Data Storage................................................................................................................... 57

11.6 HTC targets.................................................................................................................... 57

11.7 National Level Support for M&E .................................................................................. 57

11.7.1 Monitoring routine data on HTC sites ................................................................ 57

11.7.2 Monitoring routine data on individual service providers.................................... 58

11.7.3 Data Quality Assurance ...................................................................................... 58

Chapter 12: ...................................................................................................................................59
HTC Promotional Activities........................................................................................................59

Preamble ................................................................................................................................... 59

12.1 Mass Media Campaigns................................................................................................. 59

12.2 Information, Education, and Communication Materials................................................ 59

12.3 Community Advocacy, Sensitization, and Mobilization ............................................... 60

12.4 HIV Testing and Counselling Campaigns ..................................................................... 60

Chapter 13: ...................................................................................................................................61
Implementation Framework .......................................................................................................61

Preamble ................................................................................................................................... 61

13.1 National level ................................................................................................................. 61

13.2 Regional level ................................................................................................................ 62

13.3 District Level ................................................................................................................. 62

13.4 Facility Level ................................................................................................................. 63

13.5 Community level............................................................................................................ 63

References.....................................................................................................................................65
Appendices....................................................................................................................................67
Page vi National Comprehensive Guidelines for HIV Testing and Counselling in Tanzania
FOREWORD
HIV Testing and Counselling was adopted globally as a core intervention for responding to HIV
and AIDS soon after the emergence of the AIDS pandemic in 1981. During the initial two
decades of responding to HIV and AIDS, the content and approaches for delivering HIV testing
and counselling service package witnessed a wide range of changes.
In Tanzania, HIV Testing and Counselling was introduced for the first time in 1989.To begin
with, the intervention was delivered as Voluntary Counselling and Testing where clients who
desired to know their HIV status, voluntarily visited a health facility to have their blood tested
for HIV under strict confidential terms. During the roll out and scale up of this service package,
extensive implementation experience was accumulated and new scientific knowledge emerged.
These developments led to the evolution of other new testing and counselling approaches
including mobile counselling and testing in 2004, Provider Initiated Counselling and Testing in
2007, and Home Based Testing and Counselling in 2008.
Infection with the immunodeficiency virus represents a major challenge to health care workers at
all levels of the health system. In order to provide practical guidance to service providers and
managers on specific issues of Testing and Counselling services, the Ministry of Health and
Social Welfare developed several national guidelines. The first National Guidelines on Voluntary
Counselling and Testing were issued in 2005 and were followed by the National Guidelines on
Provider Initiated Counselling and Testing (PITC) in 2007. Having multiple guidelines which
cover specific issues and approaches in counselling and testing is a right step towards
standardization and ensuring the quality of services. However, this arrangement poses a
challenge to the health care providers who are forced to consult multiple sources of documents
when attending clients on HIV testing and counselling services.
The 2012 National Guidelines for HIV Testing and Counselling (HTC) are meant to provide a
comprehensive guidance that covers all testing and counselling approaches. The guidelines set
out to provide practical guidance on key technical and policy issues related to all approaches of
counselling and testing in health care facilities and in community settings. The guidelines define
the HTC service package as well as the key population that will benefit the services. Guidance is
also provided on promotional issues related to uptake of HTC services. Issues of human
resources related to HTC, laboratory issues as well as Quality Assurance and Improvement
issues are given a special emphasis. In order to ensure uninterrupted supply of all HTC
commodities, practical logistical guidance at all levels of health facilities are also provided.
The Health Care Providers and managers at all levels are required to make extensive use of these
guidelines. They are also urged to provide to the Ministry of Health and Social Welfare any
feedback that might be useful for the improvement of future editions of the guidelines.
Regina Kikuli
Ag. Permanent Secretary
National Comprehensive Guidelines for HIV Testing and Counselling in Tanzania Page vii
ACKNOWLEGEMENTS
The intent of these guidelines is to provide a comprehensive guidance addressing all HIV Testing
and Counselling (HTC) service delivery approaches and emphasizes the importance of standards
to ensure quality across these approaches.
The Ministry of Health and Social Welfare (MOHSW),through the National AIDS Control
Programme (NACP), provided leadership in the process for review and development of the 2013
HTC Guidelines. The development of these guidelines was a collaborative effort involving
various stakeholders including a number of Individuals, Institutions, Organisations, Development
Partners and interested groups. These stakeholders, consulted various National and International
policy documents and emerging scientific evidence that are relevant for the Tanzanian HTC
Guidelines.
The MOHSW thanks all individuals, Organizations and Agencies that contributed financial and
technical support to the development of these guidelines. In particular, we wish to mention the
following:
. U.S. Centers for Disease Control and Prevention (CDC)
World Health Organization (WHO)
African Medical and Research Foundation (AMREF) and
Japan International Cooperation Agency (JICA)
Members of the core guidelines development team included:
Dr. Angela Ramadhani, Programme Manager NACP
Dr. Charles Massambu, Assistant Director, Diagnostic Services, MOHSW
Dr. Fausta Mosha, Director NHLQATC, MOHSW
Dr. Rowland Swai, Retired NACP Programme Manager
Ms. Patricia Maganga, Principal State Attorney, MOHSW
Dr. Marylad Ntiro, NACP
Ms. Peris Urasa, NACP
Mr. Khalid Hassan, Retired NACP
Dr. Godfrey Mtey, Regional Medical Officer –Morogoro.
Dr. Ernest Mhando, Regional AIDS Control Coordinator, Lindi.
Dr. Salli Mwanasalli, CDC Tanzania
Dr. Benedicta Mduma, AMREF
Dr. Beati Mboya, AMREF
Mr. Nobuhiro Kadoi, JICA Tanzania
Dr. Ruth Lemwayi, Public Health Specialist,
The following provided technical assistance to the guideline formulation;
Ms. Kristina Grabbe, CDC,Atlanta,
Ms. Catherine Nichols, CDC, Atlanta,
Dr. Miriam Taegtmeyer, London School of Tropical Medicine Liverpool , UK
Dr. Donan W. Mmbando

Ag. Chief Medical Officer
Page viii National Comprehensive Guidelines for HIV Testing and Counselling in Tanzania
ABBREVIATIONS
AB Antibodies
AIDS Acquired Immune Deficiency Syndrome
ANC Antenatal Clinic
ART Antiretroviral Therapy
ARV Anti Retro Viral
CBO Community Based Organization
CCHP Comprehensive Council Health Plan
CD 4 Cluster of Differentiation 4
CIMCI Community Integrated Management of Child Illnesses
CITC Client-Initiated HIV Testing and Counselling
CHMT Council Health Management Team
CTC Care and Treatment Clinic
DACC District AIDS Control Coordinator
DMO District Medical Officer
DNA DeoxyriboNucleic Acid
EIA Enzyme Immunosorbent Assay
EID Early Infant Diagnosis
ELISA Enzyme-Linked Immunosorbent Assay
EQA External Quality Assessment
FBO Faith Based Organization
FP Family Planning
HEID HIV Early Infant Diagnosis
HSHSP Health Sector HIV and AIDS Strategic Plan
HIV Human Immunodeficiency Virus
HAPCA HIV and AIDS (Prevention and Control) Act,
HRTK HIV Rapid Test Kit
ILS Integrated Logistic System
IDU Intravenous Drug Use
IQC Internal Quality Control
GPS Global Positioning System
TTI Transfusion Transmissible Infection
MMAM Ministry of Health Primary Health Services Development Programme
MMC Medical Male Circumcision
PHLB Private Health Laboratory Board
OPD Out Patient Department
PPE Personal Protective Equipment
P24 Protein 24
RHMT Regional Health Management Team
SMS Short Messages Service
THMIS Tanzania HIV Malaria Indicator Survey
TDHS Tanzania Demographic Health Survey
VMMC Voluntary Medical Male Circumcision
HIV Human Immunodeficiency Virus
HTC HIV Testing and Counselling
IEC Information Education and Communication
National Comprehensive Guidelines for HIV Testing and Counselling in Tanzania Page ix
IMCI Integrated Management of Childhood Illness
IPC Infection Prevention and Control
L&D Labour and Delivery
M&E Monitoring and Evaluation
MARPs Most At-Risk Populations
MAT Methadone Assisted Therapy
MCH Maternal and Child Health
MC Male Circumcision
MOHSW Ministry of Health and Social Welfare
MSD Medical Stores Department
MSM Men who have Sex with Men
NACP National AIDS Control Programme
NBTS National Blood Transfusion Services
NGO Non-Governmental Organization
NHLQATC National Health Laboratory Quality Assurance Training Centre
NHLS National Health Laboratory Services
NSP Needle and Syringe Programme
OVC Orphans and Vulnerable Children
PCR Polymerase Chain Reaction
PEP Post Exposure Prophylaxis
PHDP Positive Health, Dignity and Prevention
PITC Provider-Initiated HIV Testing and Counselling
PLHIV People Living with HIV
PMTCT Prevention of Mother-to-Child Transmission of HIV
PWD Persons with Disabilities
PWID Persons who Inject Drugs
QA Quality Assurance
QC Quality Control
QI Quality Improvement
R&R Report and Request (form)
RACC Regional AIDS Control Coordinator
RMO Regional Medical Officer
RTI Reproductive Tract Infections
SOP Standard Operating Procedures
SRH Sexual and Reproductive Health
STI Sexually Transmitted Infections
SW Sex Worker
TACAIDS Tanzania Commission for AIDS
TB Tuberculosis
TTI Transfusion Transmissible Infection
VCT Voluntary Counselling and Testing
WB Western Blot
WHO World Health Organization
Page x National Comprehensive Guidelines for HIV Testing and Counselling in Tanzania
Chapter 1: Introduction
1.1 Background on HIV and AIDS services in Tanzania

It is estimated that approximately 5.3% of people aged 15-49 years in Tanzania Mainland are
living with HIV (Tanzania HIV/AIDS and Malaria Indicator Survey, (THMIS) 20011/2012).
HIV prevalence is higher among women than men, at 6.2% and 3.8%, respectively, and is
highest among persons between the ages of 15-49 years and people living in urban areas.
Furthermore, among couples who are married and/or living together in the same household,
approximately 2% are concordant HIV-positive (both partners are living with HIV) and
approximately 5% are HIV discordant (one partner is HIV-positive and the other partner is HIV-
negative).
In 2002, the National AIDS Control Programme (NACP) of the Ministry of Health and Social
Welfare (MOHSW) estimated that 2.2 million people in Tanzania Mainland were living with
HIV and AIDS, and approximately 20% of these people (440,000) were in need of life-saving
AntiRetroViral medications (ARV).
The Second Health Sector HIV and AIDS Strategic Plan – II (HSHSP) 2008 – 2012 outlined
among its goals, the identification of all persons living with HIV and enrol them in appropriate
services including care and treatment. HIV Testing and Counselling (HTC) are essential to this
goal and must be expanded as core interventions in the comprehensive national response to the
epidemic. In recent years, there has been a general increase in the number of persons who know
their HIV status from 2 million ever tested in 2007 to 20 million ever tested by Nov 2013. The
MOHSW supports the continued rapid scale-up of quality HTC services using both client-
initiated Voluntary Counselling and Testing (VCT) and Provider- Initiated HIV Testing and
Counselling (PITC) approaches in health facilities and the community to increase access to HTC
for all Tanzanians. Although there has been a general increase in recent years in the number of
persons who know their HIV status, still only 63% of women and 47% of men aged 15-49 in
Tanzania have ever been tested for HIV and received their results (Demographic and Health
Survey, 2010. Overall, 64 percent of women who gave birth in the two years preceding the
survey received HIV counselling during antenatal care, and al-most all of these women also
received post-test counselling (63 percent). Over half of the women (55 percent) had pretest
counselling and then an HIV test, after which they received the test result (Tanzania
Demographic and Health Survey,(TDHS) 2010).
The Ministry of Health and Social Welfare (MOHSW) recognizes the need to scale-up quality
HTC services throughout Tanzania in order to increase access for persons who have not
previously been tested, as well as to identify PLHIV and discordant couples and link them to
appropriate follow-up services.
1.2 Defining HIV Testing and Counselling

HIV Testing and Counselling is a service that allows persons to learn their HIV status and make
informed decisions about their health, based on their HIV status. HTC includes a confidential
dialogue between an HTC provider and an individual, couple or family. This dialogue helps
persons understand and make informed decisions about HTC, understand the results of their HIV
test, and facilitate future planning. HTC serves as an entry point for clients and patients into care,
National Comprehensive Guidelines for HIV Testing and Counselling in Tanzania Page 1
treatment, support services and reinforce HIV prevention efforts by providing clients and
patients with key messages on risk reduction and behaviour change. The key components of all
HTC services are pre-test session, HIV test, post-test session, linkage to follow-up services and
on-going support (see Chapter 6). The three primary approaches to HTC in Tanzania include:
 Client-Initiated HIV Testing and Counselling (CITC) mean that the client is the one that
seeks out the services. The knowledge of one’s HIV status, and the counselling that
accompanies it, can be a powerful catalyst for behaviour change, particularly for HIV-
positive people and persons in HIV discordant relationships.
 Provider-Initiated HIV Testing and Counselling (PITC) mean that HIV testing is offered
to all patients as part of routine health care services. The provision of PITC in health
facilities can improve diagnosis and may identify persons living with HIV earlier in their
stage of disease, ultimately saving lives.
 Home-Based HIV Testing and Counselling (HBHTC) bring HTC services into the home.
Services are initiated by HTC providers who may go from house to house in a community,
or who may target specific homes of clients or patients who voluntarily consent to have the
provider offer testing to their family members. By bringing HTC to communities and
households, home-based HTC aims to increase uptake of this important service.
1.3 Justification for Comprehensive National HTC Guidelines

The HTC services were initiated in Tanzania in 1989 as client-initiated Voluntary Counselling
and Testing, or VCT. Guidelines for this approach were developed in 2005, and this remained
the primary HTC service delivery approach for many years. In order to expand access to HTC
for various populations throughout Tanzania and reach more people earlier in the stage of
infection, approaches to HTC service delivery have expanded to include, mobile HTC in 2004,
PITC in 2007, and home-based HTC in 2008 . PITC guidelines were introduced in 2007, but to
date there are no national guidelines for home-based HTC, mobile HTC, and other emerging
service delivery approaches.
These comprehensive national HTC guidelines bring together standards for HTC that are
common to all service delivery points and approaches, and also highlight specific issues unique
to each approach.
1.4 Purpose of Guidelines

This document presents comprehensive guidelines for CITC, PITC, and HBTC approaches in
health facilities and community settings. These guidelines were developed with reference to
various international and national HTC services, policies, guidelines and strategies, and are
meant to replace and update the following national HTC documents:
 National Guidelines for Voluntary Counselling and Testing. Ministry of Health and Social
Welfare, National AIDS Control Programme. 2005.
 Guidelines for HIV Testing and Counselling in Clinical Settings. Ministry of Health and
Social Welfare, National AIDS Control Programme. April 2008.
 Standard Operating Procedures (SOP) for HIV Testing and Counselling (HTC) Services.
Ministry of Health and Social Welfare, National AIDS Control Programme. 2009.
Page 2 National Comprehensive Guidelines for HIV Testing and Counselling in Tanzania
These national HTC guidelines seek to operationalize and reinforce key HTC issues that are
highlighted in the following legal policy documents:
 HIV and AIDS (Prevention and Control) Act, (HAPCA) 2008.

 HIV and AIDS (Counselling and Testing, Use of ARVs and Disclosure) Regulations, 2010.
Furthermore, these guidelines complement other HIV prevention, care, and treatment technical
guidelines, such as the National Policy Guidelines for Collaborative TB/HIV Activities (2008),
the National Guidelines for the Management of HIV and AIDS (Forth Edition, 2012) and the
Prevention of Mother to Child Transmission of HIV National Guidelines (2011) and among
others.
All HTC services provided throughout Tanzania shall be conducted in accordance with the
guidance outlined herein, regardless of approach, setting, or population reached with HTC. These
guidelines shall also be observed by everyone providing HTC services, whether public sector,
non-governmental organizations (NGOs) or private sector.
1.5 Scope of Guidelines

These national HTC guidelines reflect evidence from recent scientific and programmatic
advances, with particular focus on the following key technical areas:
Practical considerations for home-based HTC, paediatric HTC, and couples or partner HTC
Services for discordant couples and role of treatment-centred prevention
Re-testing recommendations for HIV-negative persons
Strengthening and monitoring linkages from HTC to follow-up services
Role of various cadres of HTC personnel including Non Health Care Provider counsellors
Strengthening quality assurance and quality improvement systems
Strengthening commodities management systems
These guidelines provide direction for HTC programmers, supervisors, health care workers,
implementing partners, and other staff at the local, regional, and national levels involved in HTC
programmes in Tanzania. Refresher trainings may be required to ensure that HTC providers are
aware of the important topics and emerging issues updated in these guidelines.
The Ministry of Health and Social Welfare, through the National AIDS Control Programme, in
collaboration with other key stakeholders in HIV and AIDS control in Tanzania are actively
engaged in establishing systems to enforce these new national guidelines for HTC in Tanzania.
As new information about HIV and AIDS becomes available, these guidelines shall be updated
to reflect such developments and ensure that HTC services provided in Tanzania are of the
highest quality and consistent with international and national standards. All persons engaged in
HTC in Tanzania are hereby tasked with reading understanding, and implementing these
guidelines.
Chapter 2:
Core Principles of HIV Testing and Counselling
Preamble
In line with National and International standards for health care service delivery and human
rights principles, HIV testing and counselling (HTC) services shall be conducted with the best
interests of clients and patients in mind, and shall respond to the needs and risks of clients/
patients. In view of that, all HTC services must adhere to the following five core principles of
HTC:
1. HTC services are Confidential, meaning that anything discussed between the client(s) or
patient(s) and the HTC provider may not be shared with another person, with the
exception of situations described below in section 2.1
2. HTC services must include accurate and sufficient Pre and Post-test Counselling that
addresses the needs and risks of the HTC clients or patients and the setting in which they
are receiving services.
3. HTC clients and patients must be provided with sufficient information about HIV testing
and counselling, so that they may give their explicit and voluntary informed Consent to
receive services.
4. HTC services must adhere to standard operating procedures and quality control measures
for testing to ensure the provision of Correct test results to all clients and patients.
5. It is the responsibility of HTC programme and providers to ensure that HTC clients/
patients are Connected with appropriate follow-up services following HTC. This
includes prevention, care, treatment, support and other clinical services, as well as non-
clinical services within the community.
2.1 Confidentiality
The HTC services are confidential, meaning that anything discussed between the client(s) or
patient(s) and the HTC provider may not be shared with another person, unless the client(s) or
patient(s) explicitly give consent to share this information. Exceptions to these terms of
confidentiality are described below.
2.1.1 Confidentiality within Couples

In a couple or family HTC session, both partners agree to keep one another’s HIV test results
confidential, until they decide together to disclose their results to another person or persons. This
is referred to as shared confidentiality among the HTC provider and both partners in the couple.
2.1.2 Confidential Record Keeping

Confidentiality in HTC maintains the same underlying principles as confidentiality of other
medical information and records, and is meant to protect the privacy and dignity of clients and
patients. Health facilities and HTC sites must establish operational procedures to ensure
confidentiality. All personnel with access to client or patient medical records shall be trained in
procedures to maintain confidentiality of HIV test results. Client and patient records – for
example reporting forms, referral forms, and HIV test results, among others – shall be stored in
lockable cabinets or rooms, and shall not be left unattended. Only staff with a direct role in the
client or patient’s management, or specific data management staff, shall have access to these
medical records. More information on data management is provided in Chapter 11.
2.1.3 Disclosure
Disclosure refers to the process of an HTC provider sharing client or patient’s HIV test results
with the client or patient, or with a third party (under certain conditions); or the process of
client(s) or patient(s) sharing their HIV test results with someone else. Test results may be
disclosed to individuals receiving HTC alone and couples or families who agree to receive their
results together.
In most cases HTC providers may only disclose a client or patient’s HIV test results to the
client(s) or patient(s) receiving HTC. However, in some circumstances HIV test results may be
reported to someone other than the client(s) or patient(s). Disclosure to a third party is
permissible in the following circumstances:
1. For children less than 18 years who are not deemed to be “mature minors”, an HTC
provider may share the child’s HIV test results with that child’s parent, guardian, or legal
representative. Disclosure of a child’s HIV status to that child is a process, and is
discussed further in Chapter 5.
2. For persons who are unable to comprehend the results because they are mentally unfit or
unconscious, HTC providers may disclose that persons HIV test results to his or her
spouse or recognized guardian or caretaker.
3. Where HIV testing is mandated by a court of law, the HIV test results of the person being
tested may be disclosed for use in the legal case. However, the person being tested shall
also be given basic information about the test, and shall have access to the results in an
appropriate and supportive setting.
4. A health care provider may notify another health care provider of a client or patient’s HIV
test results if they will be directly involved in the care of that client or patient (this is
referred to as shared confidentiality between health care providers in clinical settings).
5. An HTC provider may inform a third party with whom an HIV-infected client or patient
has engaged in exposure-related contact (such as the sexual partner or spouse of the client
or patient, or a needle-sharing partner in the case of persons who inject drugs). HTC
providers may inform the third party that they may be at risk for HIV:
 If the HIV-positive client or patient has had sufficient opportunity and support to
disclose their HIV status to their sexual partner(s) on their own but has not done so;
 And the client or patient has also not accepted provider- or counsellor-facilitated
disclosure to their sexual partner(s) or couples HTC.
6. If an HTC provider has sufficient reason to believe the client or patient is planning
immediate harm or death to him/herself or another person, the HTC provider can notify
someone to assist them.
7. If a person has died due to AIDS-related causes, their death certificates shall be properly
completed with accurate reporting of the reason for death.
2.2 Counselling
All HTC services must include accurate and sufficient pre and post-test counselling sessions. The
post-test counselling must address the unique needs and risks of the HTC clients or patients and
is based on their HIV test results. Appropriate and effective counselling can be an important
catalyst for encouraging behaviour change as a result of learning one’s HIV status, and for
supporting clients to seek referrals to other HIV prevention, care, treatment and support services.
2.2.1 Counselling Procedures

Basic pre-test information/counselling shall be given to all clients/patients before HIV testing.
While the HIV test is developing, HTC providers may assess the client or patient’s knowledge
about HIV and AIDS, and discuss their specific risk behaviour. More extensive post-test
counselling shall be done during the post-test session, and shall be based on the client or
patient’s HIV test results. These procedures are discussed in more detail in Chapter 6, and are
outlined in the HTC Protocol/Tool for HTC Service Package in Appendix A.
2.2.2 Tailored Counselling

Counselling shall take into account the language and level of understanding of the person(s)
receiving HTC. For example, adults and children will require different communication skills, as
will persons with different levels of education. It is important to communicate clearly and
effectively with your clients/patients. The HTC providers shall respond appropriately to the
individual, couple, or family counselling needs.
Additionally, the extent of the counselling required may vary depending on the HTC approach or
setting in which HTC is provided. For example, provider-initiated HTC in a health facility
setting may warrant less post-test counselling than other approaches, and couples may have
different counselling needs than individuals.
2.2.3 Quality Counselling

Counselling provided to clients/patients shall be of the highest quality. The MOHSW has
developed protocols and tools to ensure that all HTC providers offer HTC services of the highest
quality. Quality assurance and improvement systems for HIV counselling are discussed in more
detail in Chapter 8.
2.3 Consent
All clients/patients receiving HTC services must be provided with sufficient information about
HIV testing and counselling so that they may give their explicit and voluntary informed Consent
to receive these services. The information that HTC clients / patients require in order to give
their informed consent may vary based on service delivery approaches and settings, but should
generally include:
 Benefits and implications of knowing one’s HIV status and/or the reasons for
recommending HTC
 Recognition of the client’s right to withdraw consent at any time
 Availability of follow-up treatment, care and support, and prevention services
 Importance of disclosure and partner testing and availability of couples HTC services
 HTC process and procedures
2.3.1 Consenting Couples

When counselling couples for HTC, HTC providers shall also ensure that both partners agree to:
 Be counselled together and receive their test results together
 Keep each other’s test results private/confidential
 Make decisions about disclosure to other persons together
 Discuss HIV risk concerns together and support one another
2.3.2 Age of Consent
Any person above 18 years of age, or any mature minor less than 18 years of age may give
consent to receive HTC services. A mature minor is defined as any person below 18 years of age
who is married, pregnant, sexually active, or otherwise believed to be at risk for HIV infection. A
young person below 18 years of age who does not meet the definition of a mature minor may
receive HTC services with a written consent of their parent or legal guardian. All children or
youth who receive HTC services shall be supported to disclose their results to their family as
appropriate, in order to receive necessary care and support, treatment assistance, and/or to
facilitate HIV prevention.
2.3.3 Consent Procedures

In accordance with the Tanzania HIV and AIDS Prevention and Control Act (2008) and its
regulation, each client/patient shall sign the HIV Informed Consent form. In-case a person is
unable to write, a thumb print shall substitute the signature on the said consent form. For
persons with auditory or visual impairment and those who cannot write, consent shall be given
with a thumb print. HTC providers shall make every effort to recognize and promote the rights of
persons who may have difficulty giving consent, for example due to age and/or mental
impairment
2.3.4 When HTC is declined

Any client or patient that does not give consent for HTC services shall still be provided with the
best possible care, and may not be denied access to other health services. Clients or patients
declining an HIV test shall be offered assistance to access HTC in the future. The decision to
decline shall be noted in their medical record so that a discussion of HTC can be reinitiated at
subsequent visits to the health facility.
2.3.5 When Consent is not necessary

Consent shall not be required in very specific situations, namely:
 When HIV testing is ordered by the court of law;
 For human organs and tissues that have been donated; and
 For sexual offenders.
Furthermore, Medical Practitioners may conduct HIV testing for patients without their consent
if:
 The person is unconscious and unable to give consent; and
 The health care worker reasonably believes that the HIV test is clinically necessary or
otherwise in the best interest of the patient.
2.4 Correct Test Results

The HTC services must adhere to Standard Operating Procedures (SOPs) and Quality Assurance
(QA) measures for testing to ensure the provision of correct test results to all clients / patients.
It is absolutely critical that test results given to clients and patients are accurate, reliable and
every effort must be made to ensure this is the case. Ensuring correct test results will not only
facilitate access to appropriate follow-up treatment, care , support, and prevention services for
HTC clients and patients based on their test results, but it will also facilitate improved trust in the
health care system and providers.
2.4.1 Procedures for Ensuring Correct Test Results
Standard Operating Procedures for HIV rapid testing outline the steps that must be taken to
ensure the accuracy of HIV rapid test results. SOPs were first published as a separate document
in 2009, but have been updated and included throughout this document and specifically in
Appendix B. Key amongst these points are that:
 HTC providers shall perform HIV tests using the nationally approved HIV rapid test kits
and in accordance with the National testing algorithm(s).
 HIV test kits package instructions provided by the manufacturer shall be referred to on a
regular basis for additional information and up-to-date SOPs for each test.
 All specimens must be clearly and correctly labelled.
 Test results must be read during the timeframe specified on the testing package
instructions,
 Timers must be used to ensure appropriate timing is adhered to. It is critical to read the
final result at the end of recommended reading time
 HTC providers shall only use the correct viable (not expired) buffer supplied by the
manufacturers for that particular test kits
 Swapping of buffer between test kits is not allowed
 Expired HIV test kits must never be used.
 HTC providers shall implement the Quality Assurance measures as outlined in Chapter 8
and Appendix B.
2.5 Connecting Clients and Patients to Follow-up Services

It is the responsibility of HTC programme and providers to ensure that HTC clients and patients
are connected with appropriate follow-up services following HTC. HTC alone is of limited
value unless it is linked with other services. The expansion of HTC must be supported by
effective and efficient linkage to HIV prevention, care, treatment and support services. These
services include, but are not limited to pre-ART care, CD4 testing, antiretroviral therapy (ART),
Tuberculosis (TB) services, screening and treatment for Sexually Transmitted Infections (STI),
Prevention of Mother-to-Child Transmission (PMTCT), Family Planning(FP), Voluntary
Medical Male Circumcision, Home-Based Care, and community support including legal and
spiritual care.
In order to ensure that clients/patients are connected to and enrolled in follow-up services,
additional efforts may be needed by HTC programme staff and providers, in collaboration with
services providers from other programme areas. Additional information, including strategies for
ensuring and monitoring linkages, can be found in Chapter 6.
Chapter 3:
HIV Testing and Counselling Approaches
Preamble
There are many approaches and settings where HIV Testing and Counselling (HTC) services are
currently offered in Tanzania. The three primary approaches for providing HTC in Tanzania are:
 Client-Initiated HIV Testing and Counselling (CITC)
 Provider-Initiated HIV Testing and Counselling (PITC)
 Home-Based HTC (HBHTC) - a hybrid of Client- and Provider-Initiated HTC.
3.1 Provider-Initiated HIV Testing and Counselling

Provider-Initiated HIV Testing and Counselling (PITC) refers to situations in which an HIV test
is recommended and offered to individuals, couples, families, or groups attending clinical
services in the public or the private sector. By recommending HTC to all patients in a health
facility as standard component of medical care, health care providers can make specific medical
decisions that would not be possible without knowledge of a patient’s HIV status. Additionally,
PITC contributes to increased rates of HIV testing and early identification of persons living with
HIV (PLHIV).
3.1.1 PITC Service Package

PITC providers shall give clients/patients basic pre-test information, in an individual, couple,
family, or group setting. This shall be done even when the HIV test is being recommended for
diagnostic purposes. Testing may be done by the provider in the consultation room, by a
designated HTC provider, or in the laboratory. Results shall be given to patients, along with
appropriate post-test counselling and linkage to follow-up services. Given the high demand of
PITC settings, post-test counselling in PITC may be streamlined, and patients shall be referred to
a counsellor or support group for on-going counselling and support as needed.
PITC is not mandatory, and patients who decline to receive PITC shall still be provided with
high quality medical care for their presenting illnesses.
3.1.2 PITC Service Delivery Points

In Tanzania, the PITC shall be offered to all patients attending Outpatient services, Inpatient
wards, and other settings within the health facility, irrespective of whether they show signs and
symptoms of HIV infection. At a minimum, HTC must be offered to all patients presenting to a
health facility with signs or symptoms of HIV infection, and in specific health-facility settings as
described in section 4.1.2 including, but not limited to, Antenatal Care (ANC), Prevention of
Mother-to-Child HIV Transmission services (PMTCT), Reproductive and Child Health (RCH),
Tuberculosis (TB) clinics, Family Planning (FP) and Voluntary Medical Male Circumcision
(VMMC) clinics. PITC may also be offered via outreach or mobile HTC and in workplaces.
3.2 Client-Initiated HIV Testing and Counselling
In this approach, also known as Voluntary Counselling and Testing (VCT), client(s) voluntarily
make the decision to learn their HIV status as an individual, couple, or family, in settings where
these services are available.
3.2.1 CITC Service Package

In CITC settings, HTC providers deliver pre-test counselling, conduct a rapid HIV test, and
conduct post-test counselling, as outlined in Chapter 6. However, different from PITC settings,
in CITC there may be opportunities during post-test counselling for more personalized risk
assessments and client-centred behaviour change counselling. This type of motivational
counselling can help client(s) identify a plan for the prevention of HIV acquisition or
transmission and linkage to appropriate follow-up services based on test results, and may be
especially relevant for discordant couples, populations at higher risk of HIV exposure and other
persons with high-risk behaviours.
3.2.2 CITC Service Delivery Points

In Tanzania, client-initiated VCT services are offered in health facilities, through stand-alone
sites outside health facilities, through mobile or outreach services, and in the home or
workplaces. These settings are described in Chapter 4 below. The protocol for the HTC service
package can be found in Appendix A and operational issues pertaining to HTC can be found in
Appendix C.
3.3 Home-Based HTC

Home-based HTC refers to a situation whereby an HTC provider visits a household and offers
HTC services to individuals, couples, and families within the household setting. Alternatively,
clients or patients may request HTC providers to visit their home to conduct HTC with
themselves or their family members. Thus, home-based HTC testing includes aspects of both
PITC and CITC.
3.3.1 Home-Based HTC Service Package

As with other approaches, home-based HTC includes the pre-test session, HIV testing, post-test
counselling, and linkage with appropriate HIV care, treatment, prevention and support services
based on the client or patient’s HIV test results. Since home-based HTC services are provided in
the community, providers shall give extra attention to linking patients with follow-up services,
and may wish to spend more time on post-test counselling to ensure adequate understanding and
support for clients and patients. Additionally, programme managers or providers shall visit
referral sites within the home-based HTC community in advance, and shall ensure that they have
the capacity to absorb additional clients and patients.
3.3.2 Home-Based HTC Models

There are two primary models for conducting home-based HTC in Tanzania: door-to-door and
via an index-patient.
 With the door-to-door model, HTC providers aim to provide HTC services in all homes
within a specific, pre-defined geographic area. This approach is best utilized in areas with
high population density (for obtaining access to a large number of people and ease of
getting around within the community), low numbers of people previously tested (to
increase access to persons who don’t know their HIV status), or to areas with high HIV
prevalence (to increase identification and referral of PLHIV and discordant couples). This
model requires strong community linkages and advance preparation to ensure acceptance
into the community and homes.
 The index patient model is when trained health care professionals or HTC providers visit
the home of someone known to be HIV-infected (e.g. a patient currently enrolled in pre-
ART care or treatment) with their consent, and offer HTC services to their partner(s),
spouse(s), or family member(s). The index patient model may be most effective for
facilitating disclosure of HIV status among couples, and for increasing identification and
referral of adults and children living with HIV and discordant couples.
3.3.3 Integrating Home-Based HTC

Home-based HTC shall be integrated with other community health services, or other health
services may be added to home-based HTC. Examples of integrated services with home-based
HTC include home-based HIV care, TB screening and treatment, immunization, malaria
screening, or other community care or health education services. One advantage of this approach
is that it shall build upon the community health platform and facilitate linkages with other health
services. However, it shall also require additional training and extended roles for HTC,
community health, or other health care providers. Programmes implementing community health
services shall consider integrating home-based HTC to maximize access to HTC services and
linkage to follow-up care, treatment, prevention and support services. However, HTC providers
must undergo the relevant trainings to empower them to provide the services.
3.3.4 Personnel Conducting Home-Based HTC

All HTC providers must be certified in MOHSW approved HTC trainings.
HTC providers conducting home-based HTC shall work in pairs, with teams ideally comprised
of one male and one female HTC provider. It shall also be useful to have a community
gatekeeper or mobilizer to accompany the providers, show them around the community, and
introduce them to local leaders and households. There shall also be an experienced team leader
or senior counsellor available on-site or in the area nearby in case they are needed.
3.3.5 Planning Home-Based HTC

Home-Based HTC requires strong planning and supervision in order to gain acceptance by the
community and ensure high quality service delivery. Organizations planning to implement home-
based HTC shall seek support from key stakeholders in the community, including local or district
officials; popular opinion leaders such as elders, religious leaders, and chiefs; administration
officials such as the police; and other key community groups and gatekeepers. Networking with
these groups can provide critical access to, information about, and protection within the
community.
Home-Based HTC programmes shall also coordinate with other service providers in the area to
reduce duplication of efforts and ensure clients and patients are linked with appropriate services.
Before implementing home-based HTC, programmes shall conduct mapping exercise to
coordinate their activities with other services provided in the area, ensure they are aware of
referral services in the area, and to document the location and inhabitants of individual
households for tracking purposes.
3.3.6 Home-Based HTC Data
HTC providers shall record physical address and other identifier as specified in HIV Testing and
Counselling Register. The Global Positioning System (GPS) coordinates may be used to provide
the description of the location where HTC occurred. They shall record whether a follow-up visit
is planned, and whether the session was for individual, couple, family, or group HTC. HTC
providers shall take extra precaution to ensure data are safely and securely stored in a
confidential manner.
3.4 Other HTC Approaches

There are some approaches for HTC that do not fit within CITC, PITC, or Home-Based HTC.
These include self-testing, mandatory testing, testing of blood and tissue donations, and testing
for the purposes of research or surveillance. These approaches are further described below:
3.4.1 Mandatory HIV testing

Under normal circumstances, mandatory testing is not permitted in Tanzania. According to the
HIV and AIDS [Prevention and Control Act] (2008), the only situations in which mandatory
testing are permitted are:
1) By court order;
2) For donors of human organs and tissues;
3) To sexual offenders;
4) If the person is unconscious and unable to give consent; and
5) The medical practitioner reasonably believes that such a test is clinically necessary or
desirable in the interest of that person.
3.4.2 HIV testing of blood and tissue donations

According to the National Blood Transfusion Practice/Policy Guidelines (2006), all blood for
transfusion must be screened for blood Transfusion Transmissible Infections (TTIs) including
HIV],. according to blood screening standard operating procedures (SOPs). All blood donors shall
be given general information about HIV testing, and shall have access to their test results if they
so wish and referrals to other services and support as appropriate. Furthermore, low-risk HIV-
negative clients, including HIV concordant negative couples, shall be encouraged to be regular
blood donors, as appropriate.
3.4.3 HIV testing for research or surveillance

HIV testing conducted for research or surveillance purposes requires the informed written
consent of study participants. Research and surveillance studies shall be done in line with
specifications stipulated in respective research protocols and ethical clearances.
3.4.4 Self-testing
Studies have revealed the potential benefits of self-testing for increasing knowledge of HIV status,
especially for health care providers (Mavedzenge, et. al. 2011). Advances in HIV testing
technologies, including the availability of oral HIV rapid tests, may make this a feasible option
in the future, at which time it will be instituted that persons acquiring HIV test kits for the
purposes of self-testing must be given information about how to perform the test and where to
access HIV care, treatment, and prevention services depending on the results of their test.
Currently Tanzania does not permit self-testing, and HIV test kits shall not be used for this
purpose.
Chapter 4:
HIV Testing and Counselling Settings
Preamble
HIV Testing and Counselling (HTC) services may be provided in a variety of settings. A mix of
settings is necessary in order to reach clients and patients with appropriate services and increase
the numbers of people who receive HTC and know their HIV status. The two primary settings
for the provision of HTC services in Tanzania are health-facilities and the community.
4.1 Health Facilities

As mentioned in Chapter 3, HTC shall be recommended for all patients attending health
facilities, regardless of whether they show signs or symptoms of HIV infection. When possible,
trained health care providers shall provide HTC services to patients themselves or with the
assistance of another counsellor, as this may facilitate improved linkages to follow-up services.
The following are examples of health-facility based HTC settings:
4.1.1 Co-located HTC site

Co-located HTC sites are stand-alone HTC sites co-located on the grounds of health facilities.
These sites have the core function of providing HTC services to clients and patients and
facilitating linkages to follow-up services based on client/patient test results. The co-located
HTC site may be a separate building on the grounds of the health facility, or it may be embedded
within the health facility, such as a designated room or group of rooms for this purpose. All co-
located HTC sites shall continue to provide basic HTC services as well as supportive follow up
counselling services.
4.1.2 Integrated HTC

HTC services shall be integrated into existing health services in all health facilities. Integration
of HTC services into the following settings and services is considered a standard of care in
Tanzania. This includes outpatient services, as well as inpatient wards and specific clinical
services as described below.
Tuberculosis (TB) clinics

As outlined in the National TB and Leprosy Guidelines (2006), HTC shall be offered to all TB
patients, suspects, their sexual partners and other persons suspected of having TB, including
family members. Similarly, TB screening using the standard National TB Programme screening
questionnaire shall be offered to all HTC clients and patients.
Services for Sexually Transmitted Infections and Reproductive Tract Infections (STIs/RTIs)
Due to the strong correlation between STIs/RTIs and HIV, all patients receiving STIs/RTIs
services (screening and/or treatment) shall be offered HTC during their initial visit to the clinic.
If the patient tests HIV-negative but is treated for an STI/RTI, s/he should be offered re-testing
for HIV two to four weeks from the initial test in order to identify or rule out acute HIV
infection. In the meantime patients should be advised on safer sex practises including consistent
correct use of condoms. Persons attending STI/RTI services shall be offered HIV testing with
each new STI/RTI diagnosis, and partner treatment for STI/RTI and HIV testing shall be
recommended.
In-Patient Department (IPD) and specialized clinics

In-patient wards and specialized clinics have been seen to have high concentration of patients
with HIV. HTC shall be prioritized and recommended to all patients admitted to inpatient
facilities. A separate room shall be set up in inpatient wards for the provision of confidential
HTC as needed. HTC shall also be recommended to partners/couples and family members of
inpatients in this setting.
Out-Patient Department (OPD) health services

Outpatient department receive patients presenting with a wide variety of medical conditions.
HTC services in form of PITC shall be prioritised and recommended as a standard of care. HTC
shall be recommended to partners/couples and family members of all out patients.
Sexual and Reproductive Health (SRH) services

As outlined in the National Guidelines for the Prevention of Mother-to Child Transmission of
HIV (2011), all pregnant women and their sexual partners shall be offered HTC services as a
standard of care in SRH services. These services are offered in; pre-natal, peri-natal, labour and
delivery (L&D), postnatal care, family planning and under five children immunization clinics.
Additional details on the specific services offered as part of PMTCT are provided in the National
PMTCT Guidelines.
Pregnant women and their sexual partners shall be offered HIV testing as early as possible in
their pregnancy to prevent mother-to-child transmission of HIV. Women who initially test HIV-
negative shall be offered a re-test during the third trimester. If that is not possible, testing shall be
done during L&D or as early as possible after delivery (WHO, delivering HIV Test results and
Messages for Retesting and Counselling in Adults 2010).
Care and Treatment Clinics (CTC)

All care and treatment clinics shall have at least one trained HTC provider in their team. This
shall facilitate point-of-care HTC service delivery to partners of PLHIV and couples. This is a
standard component of Positive, Health, Dignity and Prevention (PHDP) interventions with
PLHIV.
Voluntary Medical Male Circumcision (VMMC) Clinics

Voluntary medical male circumcision can reduce HIV acquisition in HIV negative males by 60%
(Auvert, et al, 2005). The MOHSW has developed a strategy for VMMC services with HTC as
one of the VMMC package. The strategy emphasizes on ensuring appropriate messages around
behaviour change, active STI/RTI screening and condom use as part of the package of services.
HTC providers shall ensure that:
 All persons receiving VMMC shall be offered HTC, however, HTC shall not be a
precondition to access VMMC services
 HIV negative male clients shall be informed about the benefits of MC for HIV prevention
and referred to an appropriate MC site if they wish to undergo the procedure.
Child health services
All children who show signs and symptoms of HIV infection, all paediatric inpatients, all HIV-
exposed children, and all children whose mothers’ HIV status are not known shall be offered
HIV testing with the consent of their parent(s) or legal guardians. This includes children
accessing child welfare services, under-five clinics, immunisation clinics, vitamin
supplementation campaigns, as part of community Integrated Management of Childhood Illness
(IMCI) and school health programmes.
4.2 Community-Based Settings

Community-Based HTC services are important venues that offer HTC to individuals, couples
and families outside of health facilities. Community-based HTC programmes play a critical role
in providing outreach to clients and in normalizing HIV testing in communities and within
workplaces. Examples of community-based settings offering HTC services are listed below and
additional information on this topic can be found in the Ministry of Health and Social Welfare
Primary Health Services Development Programme (MMAM 2007-2017).
4.2.1 Stand-alone Voluntary Counselling and Testing Sites

Stand-alone voluntary counselling and testing (VCT) sites are located within the community with
the sole primary function of providing HTC services to individuals, couples, or families within
the community. These are not attached to a health facility.
 With appropriate training for HTC providers, stand-alone VCT sites shall integrate other
health services in order to maximize the benefits of these sites, such as TB and STI
screening and referral, family planning services, CD4 testing and cotrimoxazole provision
for persons testing HIV-positive.
 Stand-alone centres and VCT sites provide services to the general population, or can be
tailored to meet the needs of specific populations, such as persons with visual, auditory,
and/or other disabilities, youth, or populations at higher risk of HIV exposure
 Where conditions permit, stand-alone VCT sites shall consider supplementing their
services by offering mobile, outreach, or home-based services in addition to HTC at the
centre.
4.2.2 Mobile or Outreach Settings

Mobile or outreach HTC is provided in the community to increase access to HTC for hard-to-
reach populations such as rural communities, men, mobile populations or other populations at
higher risk of HIV exposure
 With this model, HTC services may be provided in a variety of settings, including mobile
vans, tents, schools, workplaces, churches, mosques, bars, prisons, or bus stations.
 Mobile or outreach HTC requires strong collaboration with local health care workers,
community leaders, and other influential community persons. This includes advance
preparation such as identifying a venue, conducting community mobilization, identifying
sites and services for follow-up and referral.
 District Health authorities shall be informed, involved and coordinate all planned HTC
activities within the districts.
 The community leaders and the nearby health facility leadership shall help with prior
arrangements. Some mobile/outreach sites incorporate drama, choir, or other forms of folk
media in order to draw large crowds to these sites and educate them about HTC services.
 Mobile services may also be very important to the success of national HTC campaigns,
during World AIDS Day or national testing events, and can be provided at night for
specific target populations.
As with any HTC model or approach, mobile/outreach home based HTC providers must adhere
to MOHSW SOPs for HTC as outlined in this document and accompanying resources.
Mobile/outreach services are inherently not facility based. Implementation of this model shall
require increased attention to planning and supervision by health managers in order to ensure
high-quality HTC services are provided and linkages to follow-up services are successful.
4.2.3 Home-Based Settings

As discussed in Chapter 3, HTC services may also be provided in a person’s home or homestead.
 HTC providers must carry all necessary HTC supplies and equipment with them, and
adhere to the standards and quality assurance systems outlined in these guidelines.
 Home-based HTC also requires advance preparation and engagement with local leaders to
gain access to the community and peoples’ homes.
 Testing environment is less controlled in the home, particular attention shall be paid to bio
safety and waste precautions, appropriate lighting, allowing tests to develop for the
appropriate amount of time, ensuring appropriate temperature of the test kits and supplies,
ensuring confidentiality, and maintaining high quality services under sometimes harsh
conditions.
 Home-based HTC services may be combined with mobile or outreach sites to increase the
reach of services.
 As with any HTC model or approach, home based HTC providers must adhere to MOHSW
SOPs for HTC.
4.2.4 Workplace Settings

HTC services shall be offered in public and private sector work places as part of routine,
comprehensive workplace HIV programmes. Managers of all public and private sector
workplaces in Tanzania shall strive to incorporate HTC as part of their welfare strategy for
employees and their families in line with HIV and AIDS (Prevention and Control) Act 2008.
 Workplace HTC may be provided on-site through a workplace clinic or in coordination
with a nearby HTC centre. HTC providers may visit the workplace and offer HTC services
there, either in an office room, a mobile van, or in tents. HTC services may also be
introduced into a workplace on an ad hoc basis, for example during an annual family day or event.
 Workplace HIV programme may offer education about HTC and refer employees to a
nearby HTC site to receive services.
 Persons who receive HTC in the workplace shall have access to appropriate prevention,
care, treatment and support services following HTC.
 Employees shall have sufficient information to make informed decisions about HTC
services, and services must be accessed voluntarily; that is, workers or their families shall
not be forced to be tested by their employer.
 All personal data relating to an employee’s HIV status or other personal information shall
not be disclosed to the employer unless the employee provides written consent to do so.
 Employees shall not be subjected to discrimination on the basis of real or perceived HIV
status at any time.
 As with any HTC model or approach, workplace HTC providers must adhere to MOHSW
SOPs for HTC.
Chapter 5:
Populations Receiving HTC
Preamble
In order to achieve Tanzania’s goals of universal access to HIV prevention, care ,treatment and
support services, HIV Testing and Counselling (HTC) services in Tanzania shall be made
available to individuals, couples/partners, and families of all age groups and populations. It is
considered a fundamental human right for all Tanzanians to know their HIV status if they so
wish. Key considerations for the following populations are outlined below:
 General populations;
 Populations at higher risk of HIV exposure
 Other vulnerable populations.
5.1 General Populations

All persons have the right to access HTC services in order to learn their HIV status and to assist
them in preventing transmission to others or acquiring HIV themselves. Due to the high numbers
of persons living with HIV (PLHIV) who do not know their HIV status and may not be receiving
essential prevention, care, treatment and other support services, every effort shall be made to
reach these persons by providing HTC services in communities with known high HIV prevalence
or low numbers of people tested.
5.1.1 Women and Men

Currently, more women access health services than men in Tanzania, and so more women
receive HTC services (Tanzania Demographic and Health Survey, 2010). Special efforts shall be
made to encourage male involvement in health care, and to reach men through the provision of
couples HTC and targeted services such as VMMC, mobile, home-based, or workplace HTC.
Some women may experience particular vulnerabilities, for example, when disclosing their HIV
status to their partners. In particular, HIV-positive women may fear negative consequences such
as violence, abandonment, or discrimination when disclosing their HIV test results. There is a
relationship between intimate partner violence and HIV that providers shall be aware of. HTC
providers shall be trained on the potential for negative outcomes, particularly for women, and
shall understand how to screen clients for intimate partner violence and provide appropriate
support and referral to follow-up services as necessary.
In order to achieve the goals of involving men in HTC, innovative strategies are needed to
engage more men in health care services. Male involvement refers to engaging men to participate
in health services together with their partners, especially in programmes that conventionally
serve only women such as ante natal, post natal services and under five clinics.
5.1.2 Couples
Two or more persons who are in, or are planning to be in, a sexual relationship are considered a
couple. These may be pregnant women and their male partners, persons attending CITC services,
persons reached through home-based HTC, PLHIV enrolled in CTC and their partners, casual
National Comprehensive
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esting and Counselling
Testing in Tanzania
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partners, or other key populations at higher risk of HIV exposure such as men who have sex with
men (MSM) and their sexual partners. For persons who inject drugs, the definition of “couple”
may also be expanded to include persons who share needles, syringes, or other injecting drug use
equipment that puts them at high risk of HIV transmission.
About 80% of HIV transmission in Tanzania occurs between persons in a heterosexual

relationship, often among married couples (Ministry of Health and Social Welfare HIV/AIDS/
Surveillance Report number 22 NACP 2010). Additionally, 5%of couples tested for HIV are
discordant (Tanzania HIV/AIDS and Malaria Indicator Survey, THMIS 2011-2012) that is, one
partner is HIV-infected and the other is uninfected. Disclosure of HIV status among sexual
partners can be challenging. Many people do not share their HIV status with their partners and
when they do it is usually delayed (Fimbo et al 2008).
Providers shall be trained to deliver couples HTC services and respond to the needs of various
couple types in Tanzania, including:
 Pre-sexual
 Pre-marital
 Married
 Cohabiting
 Casual
 Non-cohabiting
 MSM, injecting drugs users and lesbians
Couples HTC
In order to facilitate disclosure, identify discordance, and prevent HIV transmission between
couples/partners, persons who are in or are planning to be in a sexual relationship shall be
encouraged to receive HTC services together. This includes pre- and post-test counselling, HIV
testing, and receiving their test results together. This approach is highly effective for reducing
HIV risk behaviour and risk of HIV transmission among couples especially among discordant
couples. Couple HTC provides an opportunity for easing tension and diffusing blame that can
sometimes occur when individuals learn their HIV test results separately. Separating couples
may imply distrust between the couple, and confidential information from individual counselling
sessions will not aid HTC providers when couples are brought back together. In couples HTC
sessions, both partners shall be encouraged to talk equally and openly. Discussion of risk issues
shall be done using abstract/hypothetical language and focusing on the present and the future.
In some instances, where the HTC provider has reason to believe that one partner may have been
coerced to attend couples HTC or that there may be underlying partner violence, the provider
may wish to separate the couple for individual counselling, or may recommend individual HTC.
Provider-Assisted Mutual Disclosure

This occurs when an HTC provider assists a client or patient with disclosing his or her HIV
status to a partner or spouse. Provider-assisted mutual disclosure of HIV status is an effective
way to facilitate the process of disclosure for persons who may have concerns about doing so
themselves. Individuals who attend HTC alone shall be informed of the possibility of
discordance with their sex partner(s), the importance of knowing their partner’s HIV status, and
the benefits of couples HTC. They shall be encouraged to bring their partner to the HTC site for
provider-assisted mutual disclosure where the provider will also clarify any HIV related
information, and offer HIV testing for the partner.
Follow-up Services for Couples

All couples shall be linked with appropriate follow-up services based on their HIV test results
Figure 1: Potential Benefits ofCouples HIV Testing and Counselling
Increased uptake and HIV prevention within Safe contraception /family

adherence to PMTCT. couples. planning.
Decreased numbers of • Condoms Safer conception.
infants with HN. • ART
Increased marital cohesion. HIV prevention to external

Reduced IPV. partners.
....aii.... • Condoms
CHTC ~ .ART
I
Male circumcision
Decreased stigma
Normalization
Some couples may require on-going counselling support from the HTC site in order to accept
their HIV status and plan on how to live positively with HIV as couples.
Due to the high risk of HIV transmission among HIV discordant couples, HTC sites shall
emphasize linking discordant couples with appropriate services and providing on-site follow-up
counselling and support as needed. With the support of appropriate services and uptake of risk
reduction behaviours such as correct, consistent condom use and adherence to antiretroviral
therapy (ART), discordant couples can remain discordant for many years. Follow-up services
that shall be provided to all couples, in particular to discordant couples, include:
• Partners who are living with HIV shall be linked with care, treatment and support
programmes.
• HIV-infected pregnant women shall be linked with Prevention of Mother-to-Child
Transmission (PMTCT) services.
 HIV-uninfected male partners shall be linked with medical male circumcision programs.
 HIV-uninfected partners in discordant relationships shall be retested for HIV four weeks
after the first discordance result, then each year, or 4 weeks after a potential exposure has
occurred (e.g. unprotected sex).
 On-going risk reduction counselling and linkage to support groups.
 Condom demonstration, distribution and explanation of where to access more condoms as
needed.
 Family planning counselling and distribution of contraceptives as appropriate.
 Pregnancy counselling and safer conception to couples who want to conceive.
The Ministry of Health and Social Welfare shall strengthen HTC programmes and systems to
successfully link discordant couples with these follow-up services, and shall explicitly establish
and/or strengthen data systems to track these linkages and ensure couples enrol in and receive
follow-up services.
Box 1: Treatment as Prevention for Discordant Couples

Recent evidence suggests as much as a 96% (reference) reduction in transmission among
discordant couples when the HIV-infected partner is on antiretroviral therapy (ART). In
the same study, extra pulmonary tuberculosis (TB) was also significantly reduced among
the HIV-infected persons receiving ART. This demonstrates that ART has not only
substantial benefits for the health and well-being of PLHIV, but also for preventing
transmission to HIV-uninfected persons in a discordant couple.
All discordant couples shall be given information on the benefits of ART for preventing
transmission to the HIV-uninfected partner. Programmes shall strengthen systems to
successfully link discordant couples with care and treatment services, and PLHIV in a
discordant couple should receive treatment according to Tanzania’s national ART
guidelines and support for treatment adherence.
5.1.3 Infants, Children, Youth and Adolescents
For the purposes of this document an infant is defined as anyone below the age of 18 months,
and a child, youth, or adolescent is defined as anyone who is older than 18 months and younger
than 18 years.
Early initiation of ART can save lives for infants, children, youth and adolescents that are living
with HIV. However, many HIV-infected infants and children die from HIV without their HIV
status being known or entering HIV care. It is critical to strengthen HTC services for these
populations to identify HIV-infected infants, children, youth and adolescents before they develop
clinical disease, and to link them with appropriate care, treatment and support services. For HIV-
exposed infants who are HIV-negative, HTC provides an opportunity to discuss appropriate
infant feeding with parent(s) and/or guardian(s), and to establish plans for reducing the risk of
future infection (e.g. from breastfeeding) while maintaining the child’s health.
All health care workers and HTC providers who work with infants, children, youth and
adolescents shall receive standardized training in providing HTC for these populations, so that
they can deliver high-quality HTC services that meet their specific needs. HTC providers shall be
aware that testing an infant, child, or adolescent may reveal the HIV status of the child’s
parent(s) or guardian by default, and some parents may refuse to have their children tested
because of this. Although parents and guardians have the right to refuse an HIV test for their
infant, child, or adolescent, they shall be made to understand that if their child is HIV-positive,
early identification of their HIV status and linkage to care, treatment and support services is
critical to their health. Referral or follow-up visits with the parent(s) or guardian(s) may be
necessary to reinforce the importance of HIV testing if they initially refuse.
HTC providers shall always seek to conduct HTC services when it is in the best interest of the
infant, child, youth or adolescent. HTC providers shall also seek to reach beyond the exposed or
infected infant or child and test the siblings of that exposed individual as well as other family
members, as appropriate.
5.1.3.1 Infants
HTC shall be recommended as a routine component of follow-up care at 4 weeks after birth for
all infants who have been exposed to HIV; that is those who are born to known HIV-positive
women. Additionally, all HIV exposed infants who missed their appointment at 4 weeks, shall be
recommended for an HIV test at their first contact with health services, For all infants with
unknown HIV exposure status attending clinical services (including immunization clinics), and
those who are malnourished or otherwise show signs of suboptimal growth, HTC shall be
recommended.
Consent for infants

Parents or guardians must give their consent to have infants tested. This consent shall be
documented in the infant’s file.
Where to test infants

HIV Testing and Counselling services for infants may occur in any health facility or other setting
where the infant and parents or guardians receive services, including:
 Maternal health services such as Antenatal Clinics (ANC) or postnatal services for the
Prevention of Mother to Child Transmission (PMTCT);
 Child health services such as under-5 clinics, immunization clinics and inpatient units and
Community Integrated Management of Childhood Illnesses (CIMCI)
 Adult care and treatment services that offer testing for infants of HIV-positive adults;
 Home-based testing initiatives;
 Child immunization campaigns in the community
 Other outpatient department settings within a health facility.
 Orphanages
Testing procedure for infants

Infants exposed to HIV perinatally, may take up to 18 months to shed the mother’s HIV
antibodies from the child’s blood. HIV antibody tests may reveal a positive result for HIV
exposed infants up to 18 months, even though they may not actually have HIV. (National
Guidelines for the Prevention of Mother-to-Child Transmission of HIV, 2011).
National Comprehensive Guidelines for HIV Testing and Counselling in Tanzania
 HIV Early Infant Diagnosis (HEID) using Polymerase Chain Reaction (PCR) or other
virologic testing shall be offered to all HIV-exposed infants below 18 months, as early as
possible (starting at 4 weeks).
 If HIV status or exposure is unknown and PCR or other virologist tests are not available,
HIV antibody tests may be used for infants between 9-18 months old to assess HIV
exposure and the need for referring for PCR testing.
o If the infant is antibody negative and they have not been breastfed for at least 6 weeks,
they are truly HIV-negative. If they are still breastfeeding (exposure), they will need to
be retested 6 weeks after the last possible exposure.
o If the infant is antibody positive and still less than 18 months, they will need to be
referred for retesting with PCR, or re- test with an antibody test at 18 months. This is
consistent with the National Guidelines for the Prevention of Mother-to-Child
Transmission of HIV (2011).
o Refer to Chapter 10 for the EID testing algorithm for infants less than 18 months.
5.1.3.2 Children, Youth, and Adolescents

Testing children can be challenging for HTC providers, given the broad range of issues that
children may have within this age group, and differences in child development. If a parent or
guardian brings a child to an HTC site for testing, the HTC provider shall discuss the reasons for
testing and determine that HIV testing is in the best interests of the child. The health care
provider and the parent(s) or guardian(s) shall determine the child’s capacity to understand the
HIV test results, and shall facilitate the HTC session in an age-appropriate manner. Generally
speaking, the level of engagement with children in the HTC session will depend on the child’s
age and developmental stage. Some general guidelines for young children and older children are
provided below:
Young Children (less than 10 years old)

 Young children who are able to comprehend the HTC provider may participate in the
session, but much of the information for the session will be provided by the parent or
guardian.
 Some young children may not understand that they are being tested for HIV, but if they are
positive, they will need to understand the importance of taking their medication and
staying healthy.
 Some young children will understand that they are being tested for HIV, and HTC
providers shall be prepared to facilitate disclosure to children, if applicable.
 Disclosure of a young child’s HIV status shall be handled in an age appropriate manner,
and is a process that develops over time. Typically this process will occur in the paediatric
care and treatment clinic, and shall involve the provider and the parent(s) and/or
guardian(s).
 Particularly when disclosing HIV-positive results to children, providers may wish to
disclose a child’s results to the parent or guardian before disclosing to the child. This may
allow parents or guardians time to process the test results, initiate discussion about follow-
up care and treatment for the child, and decide the best time and method for disclosure to
the child.
 Together, providers and parents or guardians shall consider the level of cognitive
development and emotional maturity of the child, and the child’s ability to handle difficult
situations, when deciding how and when to safely disclose.
 In general, it is recommended that providers and parents or guardians introduce age-
appropriate information regarding HIV as early as possible, in order to be transparent and
potentially reduce HIV/AIDS related stigma.
 If a child is HIV-positive, it is recommended that full disclosure of a child’s HIV status
take place by the age of 10 years.
Older Children (above 10 yrs and below 18 years)

 For older children, once their parents or guardians have consented for them to be tested,
they shall agree with their parent or guardian and HTC provider on how they want to
receive their results. HTC providers shall support the family in this decision-making,
recognizing the rights and sensitivities that may arise for both parents and older children.
 Older children are generally capable of understanding the HIV test and test results, and the
HTC session will generally be directed at the older child and the parent(s) or guardian(s) if
they are present for the session. In some situations, where parents/guardians agree, it may
be preferable to conduct the HTC session with older children alone, giving them their HIV
test results first, and then inviting the parent or guardian in for provider-assisted disclosure
and additional supportive counselling.
 Provider-assisted disclosure of the child’s HIV test results to the parent or guardian may
help facilitate access to care and treatment, and may open lines of communication between
parents/guardians and children.
 Parents and guardians should be encouraged to support their youth or adolescent in their
health-seeking behaviours, regardless of HIV status.
 Older children are generally becoming (or are already) aware of their sexuality, and may
have special counselling needs around HIV and relationships, sexuality, and risk reduction,
in addition to care and treatment support.
 HTC providers shall also be aware of the differences in counselling and support needs for
older children who have been living with HIV since birth, and those that became infected
in their youth.
 Educational messages and materials that address the prevention care and treatment of HIV
shall be developed specifically for older children.
 Since children might not want to receive services in the same place where adults are also
receiving HTC, “youth-friendly” HTC services and providers shall be made available, and
expanded, where feasible, to meet the needs of older children.
Consent for Children, Youth and Adolescents

Parent or guardian consent is required for children, youth and adolescents to receive HTC
services. Children, youth and adolescents should also give their assent to be tested; that is, they
also confirm that they are willing to receive this service. Consent shall be documented in the
child’s file in writing. Consent for other conditions shall be provided as outlined below;
 Youths less than 18 years who are legally married may give their own consent for HIV
testing.
 For youth and adolescents less than 18 years and who are sexually active, or otherwise
believed to be at risk for HIV infection, the medical practitioner shall provide HTC
services without consent of the parent/guardian if he reasonably believes that the HIV test
is clinically necessary or desirable in interest of that person.
National
Comprehensive Guidelines
Guidelines for Hfor
IV THIV Testing
esting and Caounselling
nd Counselling
in Tanzania
in Tanzania Page 23
 Youth and adolescents less than 18 years who wish to voluntarily access HTC services
shall be encouraged to bring a parent or guardian to attend the HTC session to ease
disclosure and for support. This may help to enrol such individuals in treatment, care and
support, or prevention services as necessary.
 Youths less than 18 years who are pregnant, shall be referred to ANC services for PMTCT
services.
HTC programmes shall establish, strengthen and promote systems that facilitate post-test support
services for youths and adolescents including youth friendly Services and recreational facilities.
The Ministry of Health and Social Welfare shall create/build capacity at all levels to enable
delivery of quality HTC services to children, youth and adolescents.
5.1.3.3 Special Considerations

There are some unique situations that may arise when providing HTC for infants, children, and
adolescents. These include, but are not limited to the following populations:
Orphans and vulnerable children

In Tanzania, by the year 2009 more than 1.3 million children less than 18 years were orphaned
due to HIV and AIDS (The State of the World’s Children (2009). Some of these orphans and
vulnerable children (OVC) may be living with HIV themselves, while others are rendered
vulnerable due to the loss of family members who have died from HIV and AIDS.
 OVC living with family members or other legal guardian(s) shall have access to health care
services, including HTC, and shall receive appropriate treatment, care and support, based
on their HIV status.
 OVC shall not be forced to take an HIV test, but shall be supported to do so when it is in
their best interest, i.e. for their own health and well-being.
 Guardians shall talk to OVC in an age appropriate manner about the risk of HIV infection
and the benefits of treatment, care and support, and shall disclose the child’s HIV status to
him/her as appropriate (see above).
Children and youth living in the street may also be vulnerable to HIV infection, and may not
have a guardian to look after them or support them with decisions around HTC or seeking health
care. In collaboration with social welfare services, HTC providers shall address the risks and
needs of children living in the street, and shall support them to develop risk reduction plans, and
linkage to appropriate follow-up services.
Children who have been sexually abused

Children who have been sexually abused are at an increased risk for acquiring HIV. Children
presenting to the facility, clinic or health centre within 72 hours of an alleged incidence of sexual
assault shall be offered post-exposure prophylaxis (PEP) according to the National PEP
guidelines, and referred to the proper social welfare services, medical and legal aid support as
necessary. HTC services may be provided with or without parent or guardian consent.
Child-headed households
Children whose parents or guardians are deceased or missing can be considered as head of
household if there is no other adult present in their lives to supervise and support them. HTC
should be provided only if it is in the best interest of the child and/or clinically indicated.
5.2 Key Populations at Higher Risk for Infection

Persons who engage in socially stigmatized behaviours, including sex work, injection drug use
and male-to-male sexual behaviours are at disproportionately higher risk for HIV infection. HIV
may spread rapidly in these populations, due to more frequent participation in high risk
behaviours such as unprotected anal and vaginal sex with partners of unknown HIV-status and
sharing of injection drug mixtures and equipment. The risk of HIV infection among these groups
is augmented because persons who engage in these behaviours often overlap. (e.g. sex workers
who use drugs, men who have sex with men who sell sex, a female injection drug user engaging
in receptive anal sex). In addition, since these populations are often hidden due to political and
socio-cultural discrimination and systematic marginalization, they are often harder to reach, and
less likely to have access to services, or to use services whey they are available, due to fear of
being stigmatized or criminalized. The key populations at higher risk of HIV exposure are:
 Persons who inject drugs (PWID);
 Sex workers (SW) and their clients
 Men who have sex with men (MSM).
HTC Training for Key populations at higher risk of HIV exposure
All health care workers and HTC providers shall receive standardized training on providing HTC
to key populations at higher risk of HIV exposure so that they can deliver HTC services that are
appropriately tailored and sensitive to the specific needs of these populations (e.g. make every
effort to provide same day rapid results, use non-venous blood draw, etc.). This training shall be
incorporated into the general HTC training for new providers. Practising HTC providers shall
receive refresher training.
All providers shall routinely ask clients about their risk taking behaviours to determine if they
are engaged in these high risk behaviours and conduct appropriate risk reduction counselling and
linkage to follow-up services. HTC providers shall aim to reduce stigma and discrimination
associated with key populations at higher risk of HIV exposure by providing high-quality,
confidential, non-judgemental, and non-coercive HIV services that are friendly to key populations
at higher risk of HIV exposure.
HTC Service Delivery Approaches

HTC delivery approaches shall extend beyond traditional provider-initiated HIV testing and
counselling (PITC) and stand-alone client-initiated voluntary counselling and testing (VCT) sites.
Thoughtful delivery points and approaches shall aim for co-location of services for key
populations at higher risk of HIV exposure and reach them in their natural environments and
therefore reducing access barriers. HTC shall also prioritize reaching key populations at higher
risk of HIV exposure together with their sexual partners, where appropriate. This may include
sexual and injecting drug use partners of PWID, clients and long term partners of SWs, and
partners of MSM.
National
Guidelines forTHIV
for HIV Testing
nd Counselling
in Tanzania
in Tanzania Page 25
Suggested HTC sites for reaching key populations at higher risk of HIV exposure include:
 Needle and Syringe Programme (NSP) sites
 Methadone Assisted Therapy (MAT) sites;
 Home-based HTC sites
 Mobile or outreach HTC at key populations at higher risk of HIV exposure hotspots;
 Drop-in centres with convenient hours;
 Bars, parks, or other areas or venues frequented by key populations at higher risk of HIV
exposure
 Other closed settings such as prisons.
Outreach or community-based HTC is often an entry point for key populations at higher risk of
HIV exposure to health care services and shall be optimized as a critical link to treatment, care
and support, and prevention services. As much as possible, referrals and linkages for additional
services shall address the individual’s medical, psychological, social, vocational and legal
challenges.
5.2.1 Persons who Inject Drugs (PWID)

Injecting drug use puts persons at high risk for HIV infection due to the sharing of drug mixture
and injection equipment such as needles, syringes, cookers, and other paraphernalia. Dual risk
may also come from unsafe sex practices (unprotected vaginal or anal sex) due to sexual
disinhibition or exchange of sex for money or drugs.
5.2.2 Sex Workers (SW)

Sex work includes female, male, transgender adults and young people who receive money or
other goods in exchange for sexual services. Exchange of sexual services for cash or other goods
can put a sex worker or his/her partner(s) at high risk for acquiring HIV infection because they
often engage in sex with multiple and sometimes concurrent partners. There are other aspects of
sex workers’ lifestyles and occupation that increases the vulnerability of their partners and them
to HIV infection including client refusal to use condoms via physical coercion or threats, drug
use by either party that can decrease an individuals’ ability to negotiate safe sex, and a lack of
available support networks.
5.2.3 Men who have Sex with Men (MSM)

Male-to-male sex puts men and their male or female partners at high risk for HIV infection due
to transmission during unprotected incentive or receptive anal sex. Some MSM may be at higher
risk due to multiple and concurrent partners, or overlapping risks such as drug and alcohol use
which can impair judgement or reduce one’s ability to negotiate and effectively practice safe
sex.
5.3 Other populations at higher risk of HIV exposure

In addition to key populations at higher risk of HIV exposure, there are other populations that
may also be vulnerable to HIV infection or that may have difficulty accessing equitable health
care services, including HTC. A concerted effort shall be made to reach these populations, and
provide them with high quality HTC. Where appropriate, these persons shall be encouraged to be
tested with their sexual partners. Every effort shall be made to reduce stigma and discrimination
among these populations. These groups include, but are not limited to:
5.3.1 Persons abusing alcohol and other drugs
There is a strong correlation between alcohol and drug use and HIV infection. Persons who
abuse alcohol or other drugs may participate in high HIV risk behaviour due to lowered
inhibitions as a result of drug use. Additionally, alcohol or other drug use may be a “gateway” to
experimental or long-term use with more dangerous and addictive hard drugs. Therefore;
 Alcohol screening shall be incorporated into counselling during the HTC session (see
Chapter 6), and clients/patients shall be assisted to establish risk reduction plans that may
include decreasing alcohol intake or drug use.
 HTC providers shall discuss the risks associated with alcohol and drug abuse with all
clients/patients, and make appropriate referrals as necessary.
 Persons who are high under the influence of alcohol or other drugs at the time they present
for HTC shall be requested to return when they are sober.
5.3.2 Mobile populations

Long distance truck drivers, bus drivers, taxi drivers, mine workers, fishermen, plantation
workers and frequent travellers, may be at increased risk for HIV infection due to engagement in
risk behaviours during periods of time spent away from home. These persons may engage in high
risk behaviours, and provision shall be made for ensuring they and their sexual partners have
access to HTC services and appropriate follow-up services.
5.3.3 Uniformed services

Uniformed forces members may be at particularly high risk due to long periods of time spent
away from their home or spouse, at times in other countries. Specific health care services,
including HTC, shall be made available to uniformed service members and their families,
including sexual partners. The following shall be considered:
 Establishing and promoting HTC services in all uniformed forces health facilities that
provide services to uniformed personnel their partners and families.
 Providing outreach and mobile HTC services where stand-alone services are unavailable.
 Integrating Voluntary Medical Male Circumcision (VMMC) with HTC where possible.
 Effectively linking uniformed services to appropriate care, treatment and support services.
 Providing couples/partner HTC for uniformed service members.
5.3.4 Prisoners
Prisoners may either enter the prison with unknown HIV infection, or may acquire HIV infection
through high-risk behaviour while in prison. Prison and jail wardens shall ensure that prisoners
have access to health care services including HTC, and that they are informed of the availability
of these services upon admission to the prison system, and regularly thereafter, including before
their release.
 Prisoners shall be offered HTC as part of all regular medical screening, and specifically
when they are showing signs or symptoms of underlying HIV infection. However, it shall
be emphasized that HTC for prisoners is voluntary, and they have the right to decline HTC.
 HTC for prisoners shall be strengthened and scaled up as part of comprehensive HIV
programming which includes prevention, care treatment and support services.
 The rights of inmates are the same as for any individual requesting to receive HTC, with
the exception of convicted rapists where a judge has ordered HIV testing to be done.
 Prison HTC sites shall ensure the safety of providers during HTC sessions.
National
Guidelines for Hfor
IV THIV Testing
nd Counselling
in Tanzania
in Tanzania Page 27
 All prisons shall ensure that Post Exposure Prophylaxis (PEP) is provided following sexual
abuse in prisons or work place HIV exposure according to the national protocol.
5.3.5 Refugees, displaced persons and migrants

Refugees, displaced persons and migrants may be vulnerable to HIV infection because they are
separated from family members or loved ones, and they may have language barriers that inhibit
their ability to communicate with health care providers. Additionally, among the main risk
factors for HIV transmission among refugees are sexual abuse, rape, coercion in the form of
exchanging sex for food, and prostitution. Refugees, displaced persons and migrants may be
unfamiliar with the health care system in their new location, and/or they may not have adequate
support for health care decision-making.
 Refugees, displaced persons and migrants shall have access to comprehensive health care
services, including HTC services and follow-up prevention, treatment, care and support
services.
 The HTC services shall be provided through: health facilities, mobile/outreach or home-
based.
 HTC providers shall be aware of the vulnerabilities of refugees, displaced persons,
migrants and therefore provide appropriate support and referrals as needed.
 Partners/ Programmes serving these populations may need to train additional providers
who speak the language of the population or hire interpreters/translators to assist with
language barriers.
5.3.6 Persons with Disabilities (PWD)

Persons with disabilities include anyone with physical, sensory, or mental limitations. They are
vulnerable to HIV infection not only because of a clinical condition, but also because they may
not have equitable access to information, education and other public services due to
communication, attitudinal and infrastructural barriers. Therefore;
 Ministry of Health and Social Welfare shall develop appropriate IEC materials for PWD
and partner programmes shall support their production and distribution.
 Provisions shall be made to address the barriers for persons with disabilities to access HTC
services in a manner that meets their specific needs.
 HTC providers may be required to attend client or patient in their homes or other
appropriate setting
 HTC service providers shall assess the client and their ability to comprehend the testing
process, give informed consent and understand their results.
 HTC providers working with PWD will be provided with appropriate training (including
sign language and psychology of PWDs) to empower them.
Other populations at higher risk of HIV exposure that shall require considerations for specific
interventions include students in higher learning institutions, domestic workers, people caring for
HIV positive and AIDS patients, survivors of gender based violence, traditional healers, birth
attendants and health care workers.
Chapter 6:
HIV Testing and Counselling Service Package
Preamble
HIV Testing and Counselling (HTC) implemented via all approaches and settings in Tanzania
shall include four key components as part of the minimum package of services. These are:
 Pre-test session
 HIV testing
 Post-test counselling session
 Linkages and referrals
These four components are described in summary below, and are outlined in Figure 2.
Figure 2: HIV Testing and Counselling Service Package Flow Chart
A description of the HTC protocol, including suggested information and counselling messages to
be delivered, can be found in Appendix A. Appendix C has additional operational considerations
for HTC.
6.1 Pre-Test Session

Once a client(s) or patient(s) has/have completed registration they shall receive basic pre-test
information or counselling that will help them understand the reasons for testing, HTC processes
and procedures, and the possible test results they may receive.
 Pre-test information/counselling shall be provided to individuals, couples, families, or
groups. Couples shall be encouraged to receive pre and post-test counselling together, to
encourage mutual disclosure and to support couples communication.
 The minimum messages that shall be provided in individual, couple, or group pre-test
information or counselling sessions can be found in the Protocol for HTC Service Package
provided in Appendix A.
 When group pre-test information is provided, client(s) or patient(s) shall still have the
opportunity for an individual pre-test session with an HTC provider to address any personal
concerns or questions.
 Additional counselling and condom demonstration shall be conducted while the HIV test is
developing.
After receiving pre-test information or counselling, clients or patients give their consent to
receive HTC services. Each individual shall give written consent for receiving HTC services as
required in the HAPCA 2008, regardless of whether the pre-test session was conducted with an
National
Guidelines for Hfor
IV THIV Testing
nd Counselling
in Tanzania
in Tanzania Page 29
individual, couple, family, or group. If a client or patient declines to receive HTC services, this
information shall be documented in their medical record and other relevant HTC data tools.
6.2 HIV Testing

HIV rapid testing shall be conducted according to the National HIV Testing Algorithm and
procedures outlined in Appendix B. Protocol/Tool for HIV rapid Testing.
 Only test kits that are approved by the MOHSW shall be used for providing HTC services.
 HIV Rapid testing must follow the MOHSW approved national HIV rapid testing
algorithm. The current testing algorithm can be found in Chapter 10.
 Information about appropriate procedures for specific HIV rapid test kits and other details
is found on information inserts included in the test kit package. These inserts contain vital
information about how to accurately conduct HIV testing, and shall be adhered to.
 In order to ensure accurate and reliable test results, providers shall also adhere to good
laboratory practices and quality assurance standards as outlined in Chapter 8 and infection
control measures as outlined in the MOHSW National Infection Prevention and Control
Guidelines for Healthcare Services in Tanzania (2007).
 Additional information about laboratory roles and responsibilities regarding HIV testing
are provided in Chapter 10.
 Risk assessment and condom demonstration using models may be conducted while the HIV
test is developing, and may help HTC providers determine a client or patient’s level of risk.
This information can then be used to inform risk reduction counselling messages based on
the client or patient’s test results, and recommendations for retesting, if necessary.
6.2.1 Repeat HIV Testing for Discordant Test Results in an Individual

 If a person’s first two HIV test results are discordant that is, the first test result is HIV-
positive and the second test result is HIV-negative,
 Testing shall be done by a different HTC provider immediately by repeating the two-test
algorithm from the beginning. If not possible to get a different HTC provider, the same
provider can repeat the testing following the SOP carefully and documenting the procedure
step by step. If discordant results still persist, the client or patient should be advised to
return for a re-test in 2-4 weeks, and shall be counselled on the possibility of acute
infection and the need for using condoms.
 If after 2-4 weeks the results are still discordant the client/ patient shall be referred to
higher level health facility
6.3 Post-Test Counselling

After performing the HIV test and allowing time for the test to develop in accordance with
Standard Operating Procedures, the HTC provider will deliver the HIV test results and conduct
post-test counselling.
 Post-test counselling shall be client-centred and focus on the specific risks and needs of the
client or patient, based on their HIV test results, stated risk behaviours, and prior
knowledge about HIV/AIDS.
 Post-test counselling may be delivered to individuals, couples or families, depending on
what they agreed to during pre-testing counselling. However, couples shall be encouraged
to receive post-test counselling together, when possible, to encourage mutual disclosure
and to support couples communication.
 Post-test counselling shall be done only after performing HIV testing according to national
HIV testing algorithm.
 Post-test counselling messages can be found in the Protocol for HTC Service Package
found in Appendix A.
6.3.1 Re-testing Messages

Not all people who test HIV-negative need to be re-tested unless they are exposed to HIV or
have continuous high risk of infection. Providers shall need additional training to change
previous counselling messages around re-testing in the context of window period to align with
international re-testing recommendations (WHO, Delivering HIV test results and messages for
re-testing and counselling in adults 2010) and these National guidelines for HTC.
 Post-test counselling messages should accurately target re-testing messages to persons who
need re-testing, and to reduce unnecessary re-testing among low-risk HIV-negative
persons. HTC providers shall focus on risk-screening to identify clients or patients who are
with high risk of HIV exposure or who may have experienced a recent HIV exposure and
who might be in the acute phase of HIV infection, when HIV antibodies may not yet be
present.
 More frequent re-testing may be important for persons at increased and continual risk of
infection, such as:
o Populations at higher risk of HIV exposure,
o Pregnant women who tested in 1stand 2nd trimester
o HIV-negative partner in a sero-discordant couple. .
 Health managers shall ensure that additional training to HTC providers is provided to cope
with new WHO guidelines on re-testing
Additional information on who should be offered re-testing is found in Table 3 on the following
page (Page no. 32).
National
Guidelines for Hfor
IV THIV Testing
nd Counselling
in Tanzania
in Tanzania Page 31
Table 3: Indications for HIV Re-testing
Persons testing HIV-negative who: When to re-test? Future re-testing?

Have indeterminate HIV status Immediately If still indeterminate status, retest
repeat the test in 2 weeks
following testing
instructions.
OR immediately
repeat test by
another HTC
provider/Lab
technician
Are pregnant women in 1st trimester 3rd trimester or With each new pregnancy
or early in pregnancy Labour &
Delivery
Have specific incident of HIV 4 weeks With each new known exposure
exposure in last 3 months
Have on-going risk of infection (SW, 4 weeks Every after 6 months
IDU, MSM)
Have a spouse or partner with 4 weeks Every after 6 months
unknown HIV status or known HIV-
positive
Have an STI 4 weeks With each new STI
Have clinical indication of HIV 4 weeks With new exposure
infection
Are victims of sexual violence/rape As per PEP As per PEP guidelines
or experience occupational exposure guidelines
6.4 Linkages from HTC to Follow-up Services

HTC is an important gateway to other essential HIV services and is critical for attaining
prevention goals, and receiving care, treatment and support services. In order to strengthen the
impact of HTC programmes and provide higher quality services, increased emphasis is needed to
ensure not only referral from HTC, but linkage of clients/patients from HTC to treatment, care
and support, and prevention services.
 In all HTC approaches and settings, HTC providers must take responsibility for ensuring
that all clients and patients are connected to and enrolled in appropriate follow-up services,
based on their test results.
 HTC programme shall strengthen systems to monitor successful linkages from HTC to
follow-up services. Follow-up clients/patients who do not follow through on
referrals/linkages.
 Follow-up services include facility-based services such as care and treatment, as well as
community-based services such as support groups and legal support.
Figure 3: Comprehensive referral options for persons receiving HTC
Interventions to strengthen linkages include:

 Integrating point-of-care CD4 testing, provision of isoniazid and cotrimoxazole preventive
therapy, or other relevant services at the HTC site including TB screening and referral to
TB clinic.
 Strengthen partnerships between HTC sites and HIV prevention, care, treatment and
support services including Positive Health Dignity and Prevention (PHDP) (both Clinic-
Based and Community-Based).
 Improving HTC provider understanding of and engagement with referral sites through:
o Developing a comprehensive list of local referral services;
o Conducting visits to the referral sites; and/or,
o Establishing personal contacts at the referral sites.
 Providing additional counselling or social support services at the HTC site by an expert
client or PLHIV who can share their experience with HIV care and treatment, offer
practical guidance, and help clients overcome real and perceived barriers to care; ( These
services are co-shared between HTC and CTC sites)
 Seek consent to continue tracking patients that do not enrol in or remain in HIV
care/treatment through short messages reminders, making phone calls or conducting
home-visits (with informed consent) to clients or patients to follow-up on referrals that
were given at the HTC site.
Guidelinesfor HIV
forTHIVesting and Caounselling
Testing in Tanzania
nd Counselling
in Tanzania Page 33
 Training providers to create an enabling environment within the HTC site, particularly for
key populations at higher risk of HIV exposure and other vulnerable populations who may
not follow through on referrals/linkages because of any reason including stigma and
discrimination.
 Strengthen M&E systems to track linkages.
6.5 Integration with other health services

HTC sites shall incorporate other health services into HTC in order to maximize the health
benefits of these services and utilize the skills and time of HTC providers as detailed in Chapter
Four. The following services shall be prioritised for integration into HTC:
 Reproductive, Infant and Child Health Care
 Tuberculosis screening
 STI/RTI Prevention and Control
 Family Planning
 Alcohol and substance abuse screening
 Screening for high-risk HIV-negative clients or patients
 Voluntary Medical Male Circumcision
 Care and treatment services
 Gender Based Violence
6.5.1 Condoms& lubricant

HTC providers shall encourage the use of male and female condoms for all sexually active HTC
clients/patients. The Ministry of Health and Social Welfare shall distribute sufficient supply of
condoms to all HTC clients/patients as needed. HTC clients will be enabled to understand correct
use of both male and female condoms and their use shall be demonstrated. Water-based lubricant
will be recommended for use to clients /patients to help ensure the condom does not break.
6.5.2 Post-exposure Prophylaxis

Health care providers who become accidentally exposed to HIV in the course of providing care
shall follow appropriate steps as described in the MOHSW Infection Prevention and Control
Guidelines (2007) and shall have access to Post-Exposure Prophylaxis (PEP). The exposed
providers shall be appropriately supported by their employers. It is the responsibility of each
employer to ensure that PEP services are available and appropriately used at the workplace. PEP
service shall be available in all health facilities for occupational exposure to HIV and rape/sexual
assault. PEP shall be provided within 72 hours post exposure.
Chapter 7
Human Resources
Preamble
Well trained human resources are critical to the provision of high-quality HIV testing and
counselling (HTC) services. HTC providers are required to be compassionate, dedicated, caring
individuals, who have the very challenging and rewarding task of informing persons of their HIV
status. In order to support HTC providers to give the best possible services to clients and
patients, HTC providers shall be adequately trained and receive on-going, supportive
supervision, mentorship, and refresher training. Additional considerations for HTC human
resources are provided below.
7.1 Requirements for HTC Providers

With the release of these guidelines, HTC providers must meet two requirements ; be trained as
HTC counsellor using national HTC training curricula and be certified by Tanzania Health
Laboratory Practitioner Council to perform HIV testing.
Other requirements for HTC providers include:
 At least Ordinary (O) Level education;

 Received additional training or certification in health or a related field;
 Trained and certified in national HTC training curricula, with both didactic and practical
components. Skill-based proficiency test must be passed in order to be certified as a HTC
provider.
 Licensed by Laboratory with MOHSW as HIV testers, before providing services.
Training for counsellors will be developed by the National AIDS Control Program (NACP) and
Laboratory Diagnostics Unit, Ministry of Health and Social Welfare (MOHSW).
Anyone who meets these qualifications may provide HTC services. This includes health care
workers as well as non-health care workers, counsellors or PLHIV.
In addition to receiving high-quality training, HTC providers must participate in quality

assurance procedures as outlined in Chapter 8. Supervision and mentorship HTC providers shall
be undertaken on a regular basis. When possible, training materials may need to be translated
into Kiswahili so that terminologies are well understood by all HTC providers.
7.2 Task Shifting

The WHO has established that community health workers, lay counsellors, and persons living
with HIV (PLHIV) when appropriately trained, certified, and supervised can provide high-
quality HTC services. The inclusion of lay counsellors and PLHIV in the HTC workforce may
relieve some of the burden on the strained health care system for providing these services.
National
Guidelines for Hfor
IV THIV Testing
nd Counselling
in Tanzania
in Tanzania Page 35
Task-shifting, or moving health-related tasks to less specialized health workers, is critical to
make the most efficient use of available human resources in light of the current shortages of
health care professionals in Tanzania. With the availability of HIV rapid tests, which use finger-
prick sample collection, less specialised health workers can perform this simple technology. This
frees up health care workers and specialized laboratory staff for other, more complex health-
related duties. Given the innovation of this concept the MOHSW will explore the best way to use
it to alleviate the problem of human resources for health. (WHO. Task Shifting to Tackle Health
Worker Shortages. Geneva. 2007).
7.3 Ethical Standards

In all HTC approaches and settings, HTC providers shall adhere to professional and ethical codes
of conduct. Breaches of these standards (for example, a breach of confidentiality, sexual
misconduct with clients or patients, or accepting money or gifts from clients or patients), will
result in disciplinary action as provided in The HIV and AIDS (Prevention and Control) Act
2008.
When a decision to introduce non health professionals in the delivery of HTC services is made,
the MOHSW shall formulate a code of conduct to regulate the conduct and performance of these
non-health cadres.
HTC providers shall be encouraged to go through HIV testing and counselling for understanding
their own personal risks for HIV and AIDS and develop plans to address them. This will also
give them deeper understanding of perspectives and feelings of the clients and patients they
serve.
7.4 Training Requirements

There shall be two main types for training HTC providers
Pre placement training:
This shall be provided for identified HTC counsellors based on curriculum developed by
MOHSW prior to their engagement in HTC services. This includes; Voluntary Counselling and
Testing (VCT); Provider-Initiated Testing and Counselling; PMTCT as well as HIV Rapid Test.
In addition to the didactic training courses, practical, hands-on training with supportive
supervision and mentorship shall be provided as a pre-requisite to licensing.
The MOHSW shall provide a mechanism that will facilitate identification and accreditation of
institutions (zones) NGOs and FBOs to empower them to provide all kinds of HIV testing and
counselling training. It shall also identify a list of accredited training institution and team of
trainers to carry out all counsellors training.
 Counsellor trainers must be qualified counsellor themselves
 National curricula and training materials shall be used in all HTC counsellor training to
ensure standardisation and quality
 The training materials to be used for the different courses shall be developed on the basis
of curriculum and shall be coordinated by the MOHSW.
MOHSW will engage higher learning institutions for health care or related fields incorporate
HTC into pre-service curricula.
On-going training /Refresher training:
HIV and AIDS are evolving epidemic that brings different challenges. The needs for different
counselling knowledge and skill are also rapidly changing and counsellors need to keep abreast
with these changes. Continuing education in HTC setting is inevitable.
 HTC providers shall participate in refresher training at least once a year to upgrade their
counselling skills and address issues of burn out
 The training content shall be based on new developments in the area of HIV and AIDS
with specific identified needs
 Mentorship and supervision shall be guided by Ministry of Health and Social Welfare
Manual for Comprehensive Supportive Supervision and Mentoring on HIV and AIDS
Health Services 2010
 All managers must ensure that HTC counsellors, supervisors and trainers shall undergo
refresher course in counselling and other HIV related aspects
Other programmes that wish to also train their work force on HTC shall adhere to these HTC
guidelines.
7.4.1 VCT Training

Any counsellor providing HTC in an integrated or stand-alone VCT site, mobile/outreach, home-
based, work-place, or health facility HTC settings shall be trained in HTC according to MOHSW
training curriculum.
7.4.2 PITC Training

All certified health care professionals providing PITC in a health facility or community setting
shall be trained according to MOHSW training curriculum. This training supplements the skills
that health care workers already have in basic health care, communication and counselling with
additional skills in HTC service delivery.
7.4.3 HIV Rapid Testing Training and Certification

HIV rapid testing training and certification shall be provided to all Non-Laboratory Health care
workers performing HIV rapid testing. HIV Rapid test training provides HTC providers with the
necessary skills to draw blood samples, conduct HIV rapid tests and read HIV rapid test results,
according to the national HIV testing algorithm. Additionally the training equips providers with
the skills to conduct quality assurance measures for HIV testing.
Persons who have attended VCT or PITC training shall receive rapid testing certification before
they can perform HTC services. Trainers authorized by the National Health Laboratory Quality
Assurance Training Centre (NHLQATC) shall provide the HIV Rapid Test certification. They
will also provide on-going support and supervision to HTC providers as outlined in Chapter 10.
7.4.4 Additional HTC Training Curricula

Additional training curricula that supplement HTC provider skills are listed below. HTC
providers can take these trainings in their entirety or as refresher trainings.
 Couples HIV Testing and Counselling training shall offer HTC providers the additional
skills necessary to identify their HIV risk and develop joint risk reduction plan. Other skills
include provider-assisted disclosure of HIV status, explanation of the concept of shared
National
Guidelines for
for H IV HIV Testing
Testing and aCnd Counselling
ounselling in Tianzania
n Tanzania Page 37
confidentiality, HIV discordance, couples’ unique issues and concerns. Additionally the
training shall impart skills to provide test results and linkage to follow-up services for
concordant negative, concordant positive and discordant couples, couple communication
and negotiation skills.
 Child and Paediatric HIV Testing and Counselling training shall address the importance
of testing children, when to offer an HIV test, where testing should take place, issues
around consent for children, disclosure of test results to children, and child testing
procedures. Additionally, special circumstances for child testing (such as orphans and
vulnerable children or child-headed households), quality assurance, and linkage to services
for children should be addressed.
 HTC for Key Populations training shall equip providers with the skills to understand and
appropriately respond to the risk behaviours and needs of key populations at higher risk of
HIV exposure. This HTC training shall also address how to serve these populations with
accurate, non-judgemental information that addresses their risk behaviours, re-testing need,
and risk reduction strategies.
 HTC for persons with disabilities (PWD)
HTC providers shall be equipped with knowledge and skills to understand the use of sign
and brail language and psychology of PWDs. The intention is to provide comprehensive
accessibility of HIV and AIDS services and information to PWDs.
 Machine-based HIV test training for laboratory technicians and technologists who
perform machine-based HIV tests, such as standard enzyme-linked immunosorbent assays
(ELISA or EIA), polymerase chain reaction (PCR), western blot (WB), or viral culture
tests. These trainings should provide the skills necessary to operate, care for, and maintain
these machine-based HIV tests, and to accurately read the results of these tests. This
training will provide necessary skills to Lab technologists to support HTC services
 Refresher training shall be provided to all HTC providers periodically, in order to provide
accurate up-to-date information to clients and patients. HTC providers shall receive at least
annual refresher training. Refresher training needs may vary depending on current
evidence, testing technologies, strategic priorities, or quality assurance needs, may address
topics such as:
○ Monitoring and evaluation
○ Strategies for strengthening linkages across HIV programs;
○ Re-testing messages for HTC clients and patients;
○ The benefits of treatment for preventing transmission among discordant couples and
follow-up services for discordant couples;
○ Home-based HIV testing and counselling operational issues;
○ New testing technologies and algorithms; or
○ Quality assurance approaches and indicators.
○ Positive Health Dignity and Prevention(PHDP)
○ New emerging issues/science
The MOHSW will develop one national HTC training curriculum as an umbrella document that
will incorporate all the HTC approaches.
Finally, in addition to HTC service providers, additional staff that supports HTC services may
require training in order to provide accurate up-to-date information to community members,
clients, and patients, about HTC and associated services. This may include programme
managers, laboratory staff, data managers, community mobilizers, receptionists, or other persons
that support HTC service delivery.
7.5 HTC Provider Certification

Persons completing national VCT or PITC and HIV rapid test training curricula, provided by
MOHSW approved trainers, will receive certificates of competence issued by the MOHSW after
successful completion of practical/ hands-on training
Non laboratory medical personnel shall present their Rapid HIV testing training certificates to
Tanzania Health Laboratory Practitioner Council for licensing.
Non-medical HIV testers shall undergo in-depth training using special curriculum for a minimum
of six weeks and shall be licensed before practising.
7.5.1 HTC Provider Recertification

Periodic recertification is necessary to ensure HTC providers have the most accurate up-to-
date information, and that they are providing high-quality HTC services.
 Persons currently conducting HTC services shall be recertified as HTC providers every two
years.
 Persons who have not conducted HTC for more than 12 months are required to be
recertified before they begin practicing HTC again.
 Persons who have not provided HTC for more than 24 months are required to be retrained
and issued with a new certificate of competency.
The requirements for recertification are:

 Attending at least one refresher training per year;
 Participating in supportive supervision programmes at least quarterly; and,
 Conducting a proficiency panel testing at least once per year with 100% concordance as
approved by the national reference laboratory.
7.6 Comprehensive Supportive Supervision and Mentoring

Regular and appropriate comprehensive supportive supervision shall cover among other things
HTC services to ensure high quality service provision and support providers with difficult issues
and prevent burn out.
During supportive supervision, supervisors shall;
 Identify issues/challenges
 Facilitate development of the action plan to address the identified problems
 Empower health workers to improve on their performance by enhancing skills and
knowledge and abilities.
 Identify gaps that require mentors intervention for further technical support
 The supervisors shall make sure through higher authority that a mentor is identified and
provides mentorship
 Make follow up on the implementation of the previous action plan
Comprehensive 39
During mentorship, the mentors shall;
 Asses the mentees performance and provide couching as necessary
 Support application of theoretical learning to clinical /practical care
All HTC providers shall participate in regular supportive supervision activities and implement
the agreed action plan as per the National manual and tools for Comprehensive Supportive
Supervision and Mentoring on HIV and AIDS Services
7.7 HTC Providers Professional Growth and Development

As with any profession, HTC providers shall have opportunities for professional growth and
development to ensure an active and competent workforce. This may include attending training
courses related to their work that may enhance their technical skills and areas of interest. HTC
site managers and supervisors shall engage HTC providers to determine their areas of
professional growth and development, and facilitate their participation in gaining additional
skills, as appropriate.
7.8 Occupational Health and Safety

All HTC programmes, facilities, and organizations have an obligation to care for their workers.
HTC providers are at risk of occupational exposure to HIV through needle stick injuries and
other workplace accidents. It is the responsibility of the workplace managers to provide adequate
training to all employees so that all HTC is conducted in accordance with SOPs, minimizing risk
of needle stick injury, and to provide adequate disposal of sharps and contaminated waste.
Post exposure prophylaxis (PEP) shall also be made available to persons who have an
occupational exposure, and PEP guidelines shall be posted at all health service delivery sites. All
sites conducting HTC shall have basic first aid materials. All areas used for HTC must be well
ventilated, and HTC providers shall receive routine preventive health screening, especially for
TB. HTC Site managers and supervisors shall also encourage periodic medical screening for all
HTC providers, as they may be exposed to other diseases in the course of their work.
The MOHSW shall provide guidance on the safety of working environment, upgrading of
infrastructure and introduction of preventive medicine services for health care workers working
in various risky environments.
Chapter 8:
Quality Assurance and Improvement
Preamble
Quality Assurance (QA) and Quality Improvement (QI) are essential components of all HIV
Testing and Counselling services. These measures help to ensure that HTC programmes conform
to set requirements and standards. HTC managers and service providers must have a systematic
and planned approach to monitor and assess the quality of their services on a continuous basis.
They shall also seek to consistently modify programmes in a way that improves the effectiveness
and quality of all HTC services offered. More details on Quality Assurance and Quality
Improvement can be found in the National Laboratory Quality Assurance Framework (2010) and
National Guidelines for Quality Improvement of HIV and AIDS services (2010)
8.1 Quality Assurance for HIV Testing

The availability of HIV rapid tests with high performance characteristics does not guarantee
accurate test results. Errors can occur at each step of the testing process, and measures must be in
place to assure the quality of HIV testing. QA helps to ensure that the final test results that are
delivered to the client or patient are accurate and reliable. Internal Quality Control (IQC) and
External Quality Assessment (EQA) systems must be in place at all HTC sites, and QI systems
shall be established to continually improve the quality of HTC service delivery. All HTC
providers conducting rapid testing are responsible for ensuring that they take part in QA
measures.
There are a number of basic QA components that shall be in place to ensure the accuracy of HIV
test results in a HTC site. These include the following:
 Persons performing HIV rapid tests must complete rapid test training, including a practical
component and awarded a certificate of competence;
 Standard operating procedures must be available onsite and adhered by all HTC providers
(see Appendix B);
 Person performing HIV rapid testing must validate every new batch of test kit before using
it for HIV testing.
 Person performing HIV rapid testing must follow SOP and document all testing
procedures. (see Chapter 10);
 Routine supervision shall be conducted by site supervisors, regional HTC coordinators,
and authorised lab supervisors;
 Site supervisors must conduct regular competence assessment to the testers, identify gaps
and take corrective measures for quality improvement.
 HTC providers must follow standard safety precautions as outlined in IPC guidelines
including personal safety and waste management;
 Visual aids shall be available for HIV testing procedures;
 A higher level laboratory shall be responsible for QA backstopping and to address rapid
testing problems when they arise.
National
Guidelines for Hfor
IV HIV
Testing and aCnd
Testing ounselling in Tanzania
Counselling
in Tanzania Page 41
In addition to these QA components, HTC programmes shall ensure the quality of logistics
management. In particular, staff at HTC sites shall make sure that test kit stocks are rotated and
monitored regularly so that First in HIV test kits are used first to avoid expiring of test kits. Site
in-charge shall ensure that staff at HTC sites record data accurately and timely, to ensure high
quality data management (see Chapter 11).
8.1.1 Internal Quality Control

There are two types of internal quality controls:
 Controls built into the testing device – each test kit has Manufacture’s guidance on
ensuring that the test result is valid. HIV testers must strictly make sure that the inbuilt
control line in the test device is reactive before giving results to a client/patient. Testers
must adhere to the approved National HIV testing algorithm.
 Periodic control tests on known samples – each site shall validate their HIV test kits daily
by running tests using Standard Operating Procedures on known HIV-positive and
negative samples, to be sure the tests give accurate test results. Samples may be obtained
from the laboratory supervisor within the health facility, or may come from the blood
donation site. Controls should be conducted:
o At the beginning of every day (recommended only for high-volume sites);
o Every time a new batch of test kits is used;
o Every time a test kit may have been exposed to potentially damaging conditions such
as extreme heat or sunlight; and,
o Every time a new HTC provider starts at a site.
8.1.2 External Quality Assessment (EQA)

All HTC sites and laboratory training institutions must have specific EQA systems in place,
including:
8.1.2.1. Proficiency panel testing

HTC sites shall receive a panel of blood specimens, known as a proficiency panel, once per
quarter (every 3 months) from the National HIV Reference Laboratory. HTC providers shall
perform HIV testing on the samples on a rotational basis, and they shall record the test results on
a standard form. The test results are returned to the National HIV reference laboratory, and are
crosschecked for accuracy. Any errors or mistakes are reported back to the site, so that
corrections can be made. HTC providers shall be trained in proficiency testing by National HIV
reference laboratory, with the assistance of zonal and regional referral laboratories. All HTC
providers shall participate in a proficiency panel at least every two years in order to maintain
their certification. All sites shall receive the results of their proficiency panel testing within one
month, and facilities that do not pass shall receive technical support from the National HIV
reference laboratory.
8.1.2.2. Supportive Supervision, including site assessment and observed practice

Supportive supervision occurs in a tiered approach and involves collaboration at the national,
regional, district and site levels:
 The national supervisory team conducts supportive supervision at the regional level and
includes members from the MOHSW and, laboratory regulatory authorities
 The regional supervisory team conducts supportive supervision at the district level and
includes members from the RHMT and a regional hospital laboratory personnel
 District level representatives provide supervision to the health facilities and includes
CHMT and district hospital laboratory personnel
 During supervisory visits at the site level, supervision teams shall carry known samples and
ask HTC providers to perform HIV testing on these samples for competence assessment.
 If samples are not available, the supervisory team shall conduct direct observations of an
HTC session,
 The supervisory teams shall identify any issues that arise and address them directly during
the site visit.
8.1.3 National HIV Logbook

The HIV logbook is used for recording specific results of each individual HIV Rapid test kit
performed, and allows for easier monitoring of the lot number, type and number of HIV test kits
used. The HV logbook also facilitates HTC providers to address test kit problems, such as
expired test kits or inconclusive results. They shall also be used to monitor HTC sites
participation in EQA activities. Every HTC provider shall complete the HIV logbook
immediately following the performance of HIV rapid tests with clients or patients. This shall be
checked regularly by HTC site supervisors.
8.2 Quality Assurance for HIV Counselling

The counselling component of HTC provides the client or patient with important information
regarding HIV prevention, care treatment and support. There are basic conditions that must be in
place to ensure that high quality counselling services are being delivered:
 All persons performing HIV counselling must complete appropriate nationally recognized
trainings, as listed in Chapter 7;
 HTC providers shall engage in routine de-briefings with other HTC providers on-site (i.e.
weekly meetings);
 Supervisors shall facilitate regular supportive supervision sessions with HTC staff,
including observing HTC providers in sessions, with the permission of the client or patient;
 All health managers and programmes shall establish supportive networks for all staff to
minimise staff burn out.
 HTC providers shall be regularly assessed through site accreditation or supervision visits;
 Client/patient exit interviews shall be conducted quarterly to assess their level of
satisfaction with HTC services.
 Self-reflection tools shall be used regularly by HTC providers;
 Observed practice and mentorship tools shall be available at the HTC site.
 All certified HTC counsellors shall take counsellors oath.
8.3 Quality Improvement for HTC

HTC site managers and providers shall seek to use QA monitoring data to identify areas of HTC
service provision that are performing well and areas that need improvement. Staff at the HTC
sites shall work together to prioritize the problems, seek to analyse and understand the cause of
the problems. They shall also collectively recognize what is working well and develop clear
action plans to address the problems. In the final step of QI, HTC focal person and providers
should test and implement the solution.
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forTHIV
Testing in Tanzania
nd Counselling
in Tanzania Page 43
8.4 HTC Services Quality Assurance
All HTC sites shall participate in Quality Assurance monitoring and evaluation. The national
HTC quality indicators shall be collected regularly at all HTC sites and can inform program staff
of achievements and gaps in quality.
Health managers shall ensure that the following minimum standards are met;
o HTC sites abide by national standards for HTC site set up

o Client exist interviews are conducted quarterly
o All new batches of HRTK are validated before use.
o All HIV tests are conducted according to national HIV testing algorithm and SOPs.
o HTC sites take part in regular EQA activities
o HTC sites report stock outs of more than ten days.
o All HIV positive HTC clients are linked to care and treatment clinics
8.5 HTC Site Certification and Accreditation

Regional and District Health Management Team will assess HTC sites prior to their provision of
services to ensure the competency, preparedness and credibility of the site to deliver quality HTC
services. The standard checklist shall be used to ensure that the HTC site has the set standards in
place, in order to be certified by the Ministry of Health and Social Welfare (MOHSW). Only
certified HTC sites shall be allowed to operate HTC services.
In addition to the process for certification, the MOHSW will annually coordinate the process for
accrediting HTC sites. This annual assessment shall be undertaken by a District/Regional team
and shall establish whether the minimum standards for a functioning HTC site have been met.
The MOHSW shall issue a de-certification to a HTC site if it no longer meets the standards of
national criteria. Where a de-certification has taken place, the HTC site shall no longer be
permitted to provide services.
Chapter 9:
Logistics Management
Preamble
The delivery of high quality HIV testing and counselling (HTC) services relies in large part on
developing and maintaining systems for the quantification, procurement, storage, distribution,
and monitoring of essential commodities and supplies, such as HIV test kits, latex gloves,
lancets, and other items, including those that are used for Infection Prevention and Control (IPC).
This chapter outlines these required supplies and the logistics management systems for their
quantification, procurement, storage, distribution, and monitoring these supplies.
Figure 4 outlines the flow of HTC supplies and other materials from Medical Stores Department
(MSD) to the HTC sites. Additionally, it highlights the way that forecasting data flows up the
chain to MSD, which is used for procuring HIV rapid test kits and other supplies.
Figure 4: Logistics Management Flow chart for HTC Supplies
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9.1 Required HTC Supplies
The types and quantities of supplies needed at each HTC site will depend on the volume of
clients and patients, and the specific services offered at the HTC site. In general, the following
supplies are needed for the provision of HIV rapid testing in all approaches and settings:
 HIV rapid test kits and its accessories as specified by the National
testing algorithm (see Chapter 10)
 Lancets and capillary tubes
 Timer or watch for ensuring test kits are read within recommended time frame
 Needles and syringes
 Other medical consumables, such as swabs, spirit, disinfectants, sodium hypochloride
 Gloves and other supplies needed for universal precautions
 Sharps disposal containers / safety boxes
 Contaminated waste disposal containers
 Foot operated waste containers and their liners
 PEP protocol displayed.
 ARVs for Post Exposure Prophylaxis (PEP)
 Registers for record keeping
 Reporting forms (logbook)
 Condoms – both female and male
 Penile and pelvic models for demonstration of condom use
 Adequate information and education communication (IEC) materials
In addition to the standard HTC supplies, the following supplies shall be used by HTC providers
during home-based, outreach and mobile HTC services:
 Boxes for carrying test kits and ensuring that the temperatures do not
exceed standard recommendations for test kits
 Plastic sheets that can be spread out on a flat surface or an alternative
testing surface such as a plastic cutting board
 Portable sharps disposal containers and biohazard waste containers
 Torches, umbrella, rain coat, gum boots
 Soap and/or hand sanitizer, paper towels
 Hand washing equipment and water
 Backpack for carrying supplies
 Water bottle for storing drinking water
 Mobile phone for each Home-based HTC team in case of an emergency
 Job aids and home-based HTC protocols
9.1.1 HIV Test Kits

All HIV tests procured and used for HTC services in Tanzania must be approved and registered
by the Private Health Laboratory Board. Only HIV tests approved by MOHSW and included in
the National HIV Testing Algorithm shall be used for HIV testing. The MOHSW shall establish
a mechanism of ensuring quality of HIV test kits including validating every new batch before
distribution to the sites. This requirement applies to all sites providing HTC both public and
private health facilities. Public facilities and approved private and faith based facilities may
receive HIV rapid test kits from MOHSW through the MSD.
9.2 Forecasting
Realistic forecasting for HIV rapid test kits shall be based on the HTC programme’s capacity to
provide HIV testing services. Accurate forecasting shall be based on the capacity of the HTC site
to ensure adequate and on-going supply of HIV test kits and other consumables needed for
meeting the demand of HIV testing services.
Forecasting for tests and other supplies depends on accurate and timely reporting from all HTC
sites. HTC sites shall report the requisite consumption data to the District Medical Officer
(DMO). This information shall include the number of test kits used each month and the number
of test kits expired each month, HTC sites shall also note if there is need for greater number of
kits in a particular month due to planned outreach HTC events, other mass HTC services, or
increased capacity for providing HTC.
HTC sites shall bear in mind the lead period between ordering and delivery of supplies, and are
strongly recommended to submit orders for HTC supplies early enough to avoid stock outs. HTC
sites shall observe the established maximum and minimum levels for inventory.
DMOs shall compile monthly reports from all HTC sites in the district and shall send a final
report to the regional and then National Authorities (NACP & MSD) on a quarterly basis using
the laboratory report and request form (R&R). DMOs shall also note if there is need for greater
numbers of test kits due to planned events or increased capacity for test kits utilization.
The National AIDS Control Program (NACP) shall work with MSD to assess the total number of
test kits requested, consider the capacity of HTC sites and laboratories, and estimate the total
number of test kits needed for the next one year. This includes forecasting and planning for all
special campaigns.
The Regional and District Health Authorities shall ensure proper adherence to inventory
management protocol including maintenance of quality records, timely reporting, accurate
forecasting, prompt ordering, proper storage and distribution to ensure adequate supply of tests
and other essential commodities in all HTC sites in order to prevent the disruption of HTC
service provision.
9.3 Procurement
All HIV tests and related commodities are procured centrally through the MSD. Following the
reporting procedures outlined above, sites will request test kits and other HTC supplies from the
DMO. The DMO requests supplies directly from the MSD. Medical officers, and in-charges of
the regional and district hospitals order their supplies.
9.4 Storage and Maintenance

At the national level, HIV test kits are received centrally and distributed to the nine zonal MSD
stores. The nine zonal stores and all facilities/sites providing HIV testing services shall keep an
accurate inventory of their supplies and commodities. They should also ensure that HIV test kits
and other commodities are stored properly and used before their expiry date. HIV tests and
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commodities must be stored as specified in the manufacturers recommended storage conditions
inserted in the HIV test kits and standard operational procedures (SOPs).
At every facility where commodities are stored, a designated person shall ensure an accurate and
timely ordering of HIV testing supplies, appropriate storage, including accurate stock rotation,
records keeping and reporting. This person shall be accountable for maintaining quality HIV
testing supplies, and shall promptly report any problems with the management of commodities to
the site supervisor or in-charge of the facility.
9.5 Distribution
MSD is responsible to distribute test kits and other supplies to all health facilities in accordance
to Integrated Logistic System (ILS) Protocol and as indicated in figure 4.
9.6 Accountability Systems

NACP shall conduct yearly audits of the logistics management systems for HIV test kits and
other essential supplies. This will enable to determine the effectiveness of the process and to
prevent mismanagement of HTC commodities and supplies. Monitoring and Evaluation systems
for tracking the distribution and use of HIV rapid test kits and other commodities shall be made
functional and used at all levels.
9.7 Stock Outs

Personnel at every level of the logistics management process for HTC commodities shall strive
for high quality logistics management in order to avoid stock outs altogether. In the event that
any HTC supplies, including HIV rapid tests, are out of stock at the HTC site, the DMO shall be
informed in order to mobilize test kits or supplies from other sites in the area. Rarely, after
consultation with MSD, emergency procurements may be required to fill the stock out gaps and
ensure continuous provision of HTC services. This procurement should be coordinated by the
MSD
Chapter 10:
Laboratory
Preamble
The National Health Laboratory Quality Assurance and Training Centre NHL-QACTC) lays a
critical role in supporting HIV Testing and Counselling (HTC) programme. This Laboratory
works hand in hand with the National AIDS Control Programme (NACP) to ensure high quality
HIV testing services. The NHLQATC serves as the National HIV reference laboratory for HIV-
related testing. Other roles includes, assisting the programme with assessment of new HIV
testing technologies before their adoption for national use, development of EQA materials, and
high quality HTC training materials. The lab also provides oversight and support supervision for
HTC providers. In order to support the scale up of HTC in Tanzania, this chapter offers an
overview of the important roles and responsibilities of the laboratory health services, with
particular reference to HIV rapid testing. Additional information on the role and functions of
NHLQATC can be found in the National Health Laboratory Strategic Plan of 2009 – 2015.
(2009)
10.1 Training and Training Materials

In collaboration with NACP and the national trainers, the NHRL personnel shall provide training
for HTC providers on the appropriate procedures for providing HIV testing. Laboratory staff
ensures that trainees have an adequate understanding of laboratory safety precautions and
standard operating procedures (SOPs) for HIV testing. NHRL personnel serve as an important
source of knowledge and experience during the trainings, and verify participants’ competency in
HIV testing at the end of trainings. NHRL also develop and review HTC training materials and
job aids on a regular basis, and provide recommendations for quality improvement in terms of
the procedures for HIV testing.
10.2 Quality Assurance measures for HTC laboratory services.

In collaboration with MOHSW staff and regional staff, NHLS personnel shall participate in
external quality assurance of HTC laboratory services. Specifically during these visits,
supervisors shall administer proficiency testing panels, check and record temperature, storage
conditions, stock expiry dates and on-site standardized National HIV logbook (see Chapter 8).
The National HIV logbook shall be assessed for completeness, compliance with the national
algorithms, and rates of discordance. Visits shall take place at least quarterly by laboratory staff
especially if there are identified issues that have not been resolved.
10.3 Infection, Prevention and Control

The NHRL personnel shall ensure that the occupational safety and health procedures as outlined
in the National Guidelines for Infection, Prevention and Control (2007) are adhered to by all
HTC providers. The following actions are important:-
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 Sharps shall be disposed of in designated sharps containers
 Used test kits and other contaminated waste shall be placed in separate closed containers
 All medical wastes shall be properly incinerated, or disposed according to the National
Infection Prevention and Control Guidelines.
 HTC providers, community and laboratory staff involved in handling and disposing
hazardous waste shall be adequately trained on infection prevention and control
procedures.
 Workplace managers shall provide Personal Protective Equipment (PPE) to HTC providers
 HTC providers must regard all blood and body fluids specimens potentially infectious and
shall take all standard precautions to protect themselves and their clients from the risk of
contracting HIV and other infections in HTC settings.[HIV and AIDS (Prevention and
Control) Act 2008]
 PEP shall be made available to HTC providers who are exposed to HIV during delivery of
the HTC services
10.4 HIV Testing Technologies

The NHLS is responsible for assessing new HIV testing technologies as they become available,
recommending HIV test kits for use in HTC services in Tanzania, and updating national HIV
testing algorithms and approaches to align with new technologies as appropriate.
The NHLS will periodically evaluate, validate and make recommendations for HIV testing
technologies for the adoption into the Government of Tanzania policy, trainings and practise in a
timely manner.
10.4.1 HIV Rapid Tests Kits (HRTK)

HIV Rapid tests kits (HRTK) are recommended for HTC because they are simple to perform,
and do not require laboratories or specialized laboratory equipment. They provide accurate
results within 30 minutes when SOPs are followed. Rapid tests may use whole blood, plasma,
serum, or oral fluid. They do not require electricity to run, and they are relatively temperature
stable (require refrigeration only in hot climatic conditions above 30oC temperature). HRTK
used in Tanzania are recommended by the World Health Organization (WHO) evaluated by the
NHRL, registered by PHLB and are in national HIV testing algorithm.
HIV Rapid testing can be conducted by Non Laboratory health care workers after training and
being licenced. HTC providers conducting HIV rapid tests should use finger prick specimen
collection as it is simple to obtain, minimally invasive, less frightening for clients and patients,
and is less costly compared to venous specimen collection. In special situations like EQA
procedures and where multiple tests are performed e.g. in antenatal clinics (ANC) or sexually
transmitted infection (STI) clinics venous blood may be collected for HIV rapid testing, since
other tests will require a blood sample as well.
10.4.2 Enzyme-Linked Immunosorbent Assay (ELISA)

Performing ELISA tests requires qualified staff and specialized laboratory equipment. It is
suitable for batch testing in laboratories or health care settings where large numbers of samples
are tested. The testing takes 2 to 4 hours and results are usually not available on the same day of
specimen collection. Therefore, HIV rapid tests are generally preferred to ensure that clients and
patients receive their test results on the same day. ELISA is commonly used in NBTS services
and recommended for rapid test indeterminate and discordant test results in the national
algorithm.
10.4.3 HIV Molecular Tests

These tests include deoxyribonucleic acid (DNA) Polymerase Chain Reaction (PCR) and HIV
p24 antigen tests. These assays are particularly useful in the diagnosis of HIV infection in
children less than 18 months of age. The tests require highly sophisticated laboratory equipment,
qualified personnel and dedicated space for properly conducting the tests.
Currently, early infant diagnosis (EID) capacity exists only at consultant and other specified
hospitals. In health facilities that do not have EID capability, specimens shall be collected and
transported to the nearest point where PCR testing capacity exists for EID. See Figure 5 for the
testing algorithm for early infant diagnosis.
10.5 National HIV Testing Algorithm

A testing algorithm describes the number, type and order of tests that need to be performed. The
first test conducted is highly sensitive, and the second test is highly specific. All HIV testing
facilities in Tanzania, whether public or private, must adhere to national HIV testing algorithms.
In Tanzania, the national HIV rapid testing algorithm utilizes a ‘serial’ testing strategy. That is,
blood sample is tested with one HIV test kit first, and a second test kit is used only when the first
HIV test kit revealed an HIV-positive test result. The actual tests used in the national HIV testing
algorithm may change from time to time, based on the availability of quality assessment results
and introduction of new technologies.
NHRL and NACP will conduct periodic or whenever necessary assessments of the HIV rapid
testing technologies and will update the national testing algorithm based on the results of these
assessments.
The current national HIV testing algorithms for early infant diagnosis (less than 18 months) and
HIV rapid testing (18 months and older) are shown. See figure 5 and 6 on the following pages
(page 52 & 53).
Page 51
Tanzania National HIV Rapid Testing Algorithm for Persons Aged 18 Months and Older
Draw Sample
First HIV
Rapid Test
Non-reactive Reactive
HIV Negative Second HIV Rapid Test (take

another sample)
Non-reactive Reactive
Inconclusive HIV Positive
Repeat First and Second HIV Rapid Test

following same algorithm from beginning
If results are still inconclusive, advice client/patient that he/she

may be in acute HIV infection period; ask to return for another
repeat HIV test in 2-4 weeks, following same algorithm or refer
to higher-level facility; advise that protection is critical until
results are known
Figure 6: Tanzania National HIV Testing Algorithm for Early Infant Diagnosis for children
less than 18 months
Child presents at clinic
Age <9 months: virological testing (PCR) Age >9 months: antibody testing
Rapid Test
Positive PCR Negative PCR Negative Ab Positive Ab
Not Still Not

breastfeed (Or recent) breastfeed <18 mo.: ≥18 mo.:
Start ART for at least breast for at least retest confirmatory
6 weeks feeding 6 weeks with PCR Ab test
<24 months: start

Negative Retest 6 Negative ART.
child weeks child If ≥24 months check
after last CD4, if clinically
possible indicated, start ART.
exposure
Chapter 11:
Monitoring and Evaluation
Preamble
Monitoring and Evaluation (M&E) is an essential component of quality HIV testing and
counselling (HTC) service delivery. It allows programmes to follow trends in HTC outcomes,
utilize programme data for strategic planning and redirection of resources, and report on key
indicators. National M&E tools shall be used at all HTC sites, and routine reporting on key
indicators shall be done. Data quality shall be regularly assessed by supervisors as part of Quality
Assurance (QA) systems (see Chapter 8), and improvements shall be made as needed.
As M&E systems are strengthened, programmes shall conduct periodic review/evaluations to

more rigorously assess HTC outcomes, impact, and effectiveness. HTC programme evaluations
may provide key information on specific elements of HTC that are successful, or where
modifications need to be made.
11.1 Data collection

Key client/patient information shall be collected for every HTC encounter in all approaches and
settings. This will enable monitoring of HTC service delivery in a standardized fashion and
allow for useful analysis of HTC data. The Ministry of Health and Social Welfare (MOHSW)
standard HTC data collection tools should be utilized in all HTC settings. These standard data
collection tools include:
 National HTC register (Appendix D) for collecting key demographic and behavioural
characteristics of HTC clients;
 National HIV logbook (Appendix E) for collecting key HIV testing information such as
results of each test performed, lot number of test kits used, and total number of test kits
used.
Accurate completion of these data collection tools is critical for monitoring performance and
identifying trends in service delivery. All HTC providers shall be trained to complete the data
collection tools for each client or patient before he/she leaves the HTC room. However, the
collection of such information shall not interfere with the counselling process. HTC clients and
patients shall be informed that all data captured on data collecting tools is confidential. HTC
providers shall be engaged in M&E processes and shall utilize programme data to identify areas
for improving their performance.
11.2 Data reporting

At the end of every month, HTC sites shall tally data from the registers and National HIV
logbooks, and enter this information into the standard monthly HTC reporting form (see
Appendix G).
 Monthly reporting forms shall be sent to the Office of the District Medical Officer (DMO),
(DACC) by the 7th day of the month, following the month of data collection.
 The DMO will receive, validate, and send data from their district to the Office of the
Regional Medical Officer (RMO) (RACC) by the 14th day of the month, following the
month of data collection.
 The RMO will receive, validate, and send the data from their region to the National AIDS
Control Program Manager Office (NACP) by the 21st day of the month, following the
month of data collection.
 NACP will receive, validate, analyse by the 21st day of the following month of data
collection.
 Reports will be developed on an annual basis and disseminated to all relevant stakeholders,
including the HTC sites.
In addition to national level reports, all reporting levels should retain their copies and utilize
them for planning purposes. Feedback on data collection, data quality, or trends in data outcomes
shall be communicated back to HTC sites, districts, and regions, as outlined in the data flow
systems in Figure 7 below. Information feedback shall be as follows:-
 Districts shall provide feedback to HTC sites;
 Regions shall provide feedback to the districts; and
 The national level shall provide feedback to the regions.
Figure 7: M&E Data Flow Systems for HTC in Tanzania
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11.3 Data analysis and interpretation
HTC data is used for monitoring and evaluating HTC programs, and for informing programmatic
and strategic planning of HTC services. NACP uses the CONTEST software for entering,
managing, and analysing data. Data summary reports and feedback shall be shared with all levels
including the implementing sites:
 DMO shall share these reports with

o HTC sites
o Local Government Authority
o District Commissioner
o District Executive Director
o Other key stakeholders in the district
 RMO shall share their reports with

o All districts within their region
o The Regional Commissioner
o The Regional Administrative Secretary
o Other key stakeholders in the region
 NACP Programme Manager shall share reports with

o TACAIDS
o Regional Medical Officers
o Other Ministries
o Implementing Partners
o Development Partners
o Other key National stakeholders
The report outputs will be aligned with national HTC input, output and outcome indicators.
11.4 Data use

Routinely collected HTC data shall be utilized at the site and community level to help guide
strategic programme planning and implementation, and for resource allocation to meet
programme goals. HTC sites shall use their data to monitor uptake of HTC services over time,
and to see which populations utilize HTC services. HTC sites shall also use data from the
laboratory logbooks to monitor the quality of HIV testing and address any problem identified.
At the district and regional levels, data shall be utilized for planning, to recognize programmes
that are successful and programmes that may need additional supportive supervision. The
National HTC programme shall also use HTC data to determine geographic areas that shall be
prioritized for HTC service delivery using different HTC approaches. Data shall also be used to
answer critical questions about Tanzania’s HIV epidemic in a local, regional, national context.
MOHSW encourages documentation of M&E data, best practices, and lessons learned.
Publication of these data is also encouraged by MOHSW. Any publications or presentations
based on HTC data must be submitted to NACP for clearance before submission for publication
or presentation. This includes abstracts for national and international conferences.
When appropriate, other national clearing mechanisms such as national HTC and AIDS
committees shall also be engaged.
11.5 Data Storage

All data collected at HTC sites is confidential, and shall be treated with the same level of
protection as all other medical records. Every effort shall be made to ensure that records cannot
be accessed by persons other than those who are authorized to do so. Data shall be stored in a
lockable file cabinet, on a password-protected, secure computer, or in other secure locations so
that the information will remain protected when the site is closed or HTC staff is not present.
Monthly data registers shall be stored at HTC sites for as long as permitted by facility archiving
systems and MOHSW. A standard system for filing HTC data registers and monthly reporting
forms shall be developed and adhered to.
11.6 HTC targets

National targets shall be developed based on contributions from the regional and district levels.
HTC sites shall establish targets as well, which may contribute to district level target setting.
Staff shall be trained to appropriately set targets, and measures shall be in place to reduce under
and over-targeting. Targets shall be realistic projections of anticipated goals. Targets shall
establish the number of persons reached with HTC services, as well as other estimations,
including:
 The proportion of new or first-time clients;
 The proportion of clients by gender;
 The proportion of clients by HIV status;
 The proportion of clients receiving couples or partner HTC;
 The proportion of new HIV-infected persons identified and effectively linked to services.
11.7 National Level Support for M&E

The NACP M&E Unit maintains a secure database with current, summary-level data based on
information received from the site, district, and regional levels. They are responsible for
analysing, interpreting, feedback and disseminating HTC reporting data and providing overall
guidance. Additionally, NACP shall assist with supportive supervision of M&E activities at HTC
sites, helping the sites interpret and use their data to guide programme development. In
collaboration with the Diagnostics Unit, NACP is also responsible for training HTC providers on
the importance of data collection, analysis, and use, including how to complete the new HTC
M&E tools and laboratory logbooks. The NACP shall also routinely review the tools and
logbooks during supervisory visits to HTC sites. NACP HTC data M&E are centred on the
following core activities:
11.7.1 Monitoring routine data on HTC sites

NACP shall maintain a database of all HTC sites that have passed a Site Readiness Assessment
visit, as well as sites that have been certified, accredited, or licensed to provide HTC services.
Using updates from the regional level, the database will record the site’s current status and date
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issued. This will be done for all VCT, mobile/outreach, home-based and health-facility based
services, and this information will be used for programme planning and implementation.
11.7.2 Monitoring routine data on individual service providers

The regional QA officers, on behalf of the NACP, shall maintain a database of individual service
providers in their regions that are certified to conduct HTC. This shall include information on
certification for counselling and for rapid testing from MOHSW-recognized training institutions.
Using updates from the refresher trainings and the annual individual proficiency testing the
database will record information on the following areas:
 Certification in HIV counselling
 Certification in HIV rapid testing
 EQA results
 Competency assessment results
 Date the provider is due for his/her next external assessment.
11.7.3 Data Quality Assurance

To ensure that there is credibility of the data that is reported, every quarter the District, Regional
and National level HIS officers will select and visit some sites for data verification. Each service
delivery point is encouraged to conduct routine quarterly data quality assessment and checks.
Chapter 12:
HTC Promotional Activities
Preamble
HTC promotional activities focus on informing communities about availability and benefits of
services, as well as sensitizing and mobilizing communities to create demand for HIV testing and
counselling (HTC). Counselling and testing promotional activities should aim at changing norms,
reducing stigma, and increasing support for and utilization of counselling and testing services. These
activities should present accurate and up-to-date information about HTC, treatment, care and
support, and prevention. This information shall be relevant to the target population, culturally
sensitive, and shall reflect current evidence and technological advances. The Ministry of Health
and Social Welfare (MOHSW), Regional Medical Officers (RMO) and District Medical Officers
(DMO) shall be consulted to provide support for the development of promotional materials and
activities. Some of the common examples of promotional activities include: Media campaigns,
development and distribution of Information, Education and Communication materials, targeted
community mobilization and advocacy and Mass HIV Testing campaigns.
12.1 Mass Media Campaigns

Mass media campaigns are used to communicate key messages about HTC and related services
to an entire population or to specific segments of the population such as couples or persons with
high-risk behaviours.
 Mass media campaigns shall be used to promote HTC services through billboards,
television, radio campaigns, newspapers, road shows and action days.
 Mass media campaigns shall be coordinated by the MOHSW, and messages for mass
media campaigns shall be approved by the MOHSW.
 Mass media campaigns shall be pre- tested to ensure that they are accurate, up-to-date and
culturally/target appropriate.
12.2 Information, Education and Communication Materials

High quality information, education, and communication (IEC) materials are an important
element of promotional activities to increase awareness and create demand for HTC and related
services.
 Printed and/or electronic materials addressing all elements of the HTC service package,
including the benefits and availability of follow-up services, shall be made available at
HTC sites.
 In order to meet the needs of the community, these materials should be made available in
Kiswahili and English or any other languages and technology as may be necessary with
appropriate illustrations and graphics.
 At times the MOHSW produce and distribute nationally relevant IEC materials to all
districts and organizations within Tanzania.
 The MOHSW shall review and approve new IEC materials before their dissemination to
the public.
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12.3 Community Advocacy, Sensitization, and Mobilization
HTC sites shall engage community leaders at all levels in the promotion of HTC services. This
may include government and private institutions officials NGOs/faith-based leaders, health care
workers, teachers, and other locally recognized opinion, community, cultural leaders in the
community who have influence, or who can advocate for HTC, sensitise and mobilise the
community.
 Health facilities shall engage community health educators to provide HTC information.
 Community leaders, peer educators, PLHIV and community health educators shall be
encouraged to share accurate and culturally sensitive messages about HTC and related
services at public community functions, or when communicating with community members
on an individual, couple, or family basis.
 Peer educators and PLHIV are also effective for providing messages and reaching specific
populations.
In order to ensure the provision of accurate and culturally sensitive messaging, these groups shall
require specific training to support their advocacy efforts.
12.4 HIV Testing and Counselling Campaigns

HTC campaigns aim to reach large numbers of people with HTC services, within a specific
geographic region or population group, over a specific period of time. Campaigns also improve
the visibility of the services thus enhancing knowledge and attitude and practise about HTC.
When organising campaigns, health managers should realise that;
 Campaigns require advance mobilization and planning with respective level of
administration and health care services in order to create demand and ensure adequate
resources and follow-up services are available.
 In order to be most effective, campaigns should target specific populations or groups of
people that may be at an elevated or continued risk of acquiring HIV.
 Campaigns may take place in established HTC sites such as health facilities or voluntary
counselling and testing (VCT) site, or may utilize mobile/outreach or home-based or any
other non-conventional areas for testing
All campaigns for HTC must adhere to quality assurance contingency plan should be in place to
minimize the impact of high client flow, long working hours, limited space and unfamiliar
surroundings. Testing must be conducted in the same high standards and level of accountability
as HTC services offered in any other setting.
12.5 Signboards
HTC sites shall be clearly marked with a signboard or other indication that HTC services are
offered with no fee at that location. It is the responsibility of the HTC site to clearly indicate their
services as well as the time table for the service offered
Chapter 13:
Implementation Framework
Preamble
Delivery of HIV testing and counselling (HTC) services in Tanzania relies on the participation
and coordination of many authorities within the Government structure, from the national level
including the Ministry of Health and Social Welfare (MOHSW) through the National AIDS
Control Programme (NACP), Medical Stores Department (MSD), Tanzania Commission for
AIDS (TACAIDS). At the Regional and District levels the key authorities include Regional
Secretariat through Regional Medical Officer (RMO) and local government authorities through
District Medical Officer (DMO).respectively. In addition to these structures, the role of Non-
Governmental Organizations (NGOs), including faith-based organizations (FBOs) and
Community-Based Organizations (CBOs) is critical to the process of improving access to quality
HTC programmes for all Tanzanians. This chapter outlines the roles and responsibilities for HTC
at different levels of implementation.
13.1 National level

The Tanzania Commission for AIDS (TACAIDS) provides overall coordination of the multi-
sectorial response to HIV and AIDS in the country. The MOHSW, through the NACP,
coordinates the implementation of technical aspects of HIV and AIDS prevention, care,
treatment and support programmes, including HTC. The MSD is responsible for procurement,
storage and distribution of HIV and AIDS commodities and supplies. The NACP convenes an
HTC technical working group comprised of technical experts from MOHSW, representatives
from regional and district health authorities, bilateral and multilateral agencies, international and
national NGOs academia and other implementing partners, which meets regularly and provides
technical support in the following key areas:
 Formulating policies and establishing strategic plans regarding HTC
 Ensuring appropriate dissemination and implementation of HTC policies
 Advising on HTC services roll out and scale up
 Managing HTC commodities, including test kits
 Coordinating, monitoring HTC performance and assessing the quality of service delivery
 Building capacity of HTC service providers and systems
 Managing of National data collection and database
 Carrying out operations and health systems research
 Working with International and National partners to develop best practices in HTC
coordination and service delivery
 Coordinating Partners involved in HTC services
 Reviewing and approving of new IEC materials before they are disseminated to the public.
National
Guidelines for Hfor
IV HIV
Testing and aCnd
Counselling
in Tanzania Page 61
13.2 Regional level
The Regional Medical Officer (RMO) is the overall coordinator of technical issues of all HIV
and AIDS services in the region on behalf of the Regional Secretariat. The RMO works with the
Regional Health Management Team (RHMT), receiving technical input from the RACC and
Regional HTC Coordinators. The RMO carries out the following roles;
 Coordinating and supervising HTC service performance;
 Capacity building, including initiation of staff deployment, training, and certification
 Monitoring and evaluating HTC services
 Facilitating reporting from district to national level and vice versa;
 Carrying out comprehensive supportive supervision and mentoring of HTC service
providers
 Laboratory support for quality assurance (QA) of HIV testing
 Networking and coordination of stakeholders at the regional level
 Resources mobilization and Accountability
 Dissemination and enforcement of MOHSW policies, guidelines and standards. Ensuring
availability of HIV testing supplies and commodities throughout the region
 Reviewing new IEC materials and forwarding to NACP for approval before they are
disseminated to the public
13.3 District Level

The District Medical Officer (DMO) is the overall technical coordinator of all HIV and AIDS
services in the district on behalf of the local government authority. The DMO works with the
Council Health Management Team (CHMT), receiving technical input from the DACC and
District HTC Coordinators. Specifically the DMO has the following roles:
 Coordinating and supervising HTC service performance
 Capacity building, including initiation of staff deployment, training, and certification
 Monitoring and evaluating HTC services
 Facilitating reporting from HTC sites to Regional and National levels;
 Carrying out comprehensive supportive supervision and mentoring of HTC service
providers
 Laboratory support for quality assurance (QA) of HIV testing;
 Networking and coordination of stakeholders at the District level.
 Dissemination and enforcement of MOHSW policies, guidelines and standards
 Ensuring availability of HIV testing supplies and commodities throughout the District
 Registration and accreditation of HTC sites
 Incorporation of HIV and AIDS interventions in Comprehensive Council Health Plans
(CCHPs)
 Resources administration and accountability
 Reviewing new IEC materials and forwarding to RMO for further review before they are
sent to NACP.
13.4 Facility Level
The HTC programme relies on the implementation of quality HTC services at the site level. HTC
may be provided by the Government in collaboration with International and National NGOs,
FBOs, CBOs, and private for-profit facilities, HTC may be provided in a wide range of settings.
The following roles are carried out by HTC sites under the accountability of the facility in
charge
 Providing quality HTC services to clients and patients as directed by the DMO;
 Practice quality assurance (QA) measures for HIV testing and counselling including
o Abiding to the national standards for HTC site set up
o Conducting client exist interviews quarterly
o Validating all new batches of HRTK before use.
o Conducting all HTV tests according to national HIV testing algorithm and SOPs.
o Taking part in regular EQA activities
o Reporting stock outs of more than ten days.
o Managing safe disposal of medical waste generated at the HTC site.
 Linking clients and patients from HTC services to appropriate follow-up services, as
needed;
 Managing site-level HTC logistics and commodities;
 Timely and accurate reporting to health facility and district levels as appropriate
 Mobilizing communities on HTC services, raising awareness, and providing HTC
education and information;
 Participating in relevant stakeholders’ forums and meetings including planning for HTC
services
 Propose relevant HIV testing and counselling IEC materials for the target population
13.5 Community level

The HTC programme relies on the implementation of quality HTC services at the outreach
site/Mobile and Home Based HTC by having contact with a nearby health facility. These
programmes are implemented by staff from a nearby health facility in collaboration with
community health providers identified from the respective locality.
The following activities are carried out at the HTC outreach site level by service providers under
the accountability of the health facility In charge;
 Providing quality HTC services to clients and patients;

 Managing outreach site-level HTC logistics and commodities;
 Timely and accurate reporting to health facility;
 Mobilizing communities on HTC services, raising awareness, and providing HTC
education and information
 Making referrals from the community to the nearby health facility
 Managing safe disposal of medical waste generated at the community HTC sites
 Participating in relevant stakeholders’ forums and meetings including planning for HTC
services and provide community perspective of HTC services.
National
Guidelines for Hfor
IV THIV
Testing in Tanzania
nd Counselling
in Tanzania Page 63
The roles of the benefiting communities are as follows;
 Adapt healthy life styles as advised by HTC provider
 Identify community focal person for HTC services
 Contribute resources towards community HTC services
 Create a conducive environment for the implementation of HTC services
 Establish networks to provide psychosocial support to HTC clients
References
Auvert B, Taljaard D, Lagarde E, Sobngwi- Tambekou J, Sitta R, Puren A. Randomized,
controlled intervention trial of male circumcision for reduction of HIV infection risk: the ANRS
1265 Trial. PLoS Med. 2005 Nov;2(11):e298. Erratum in: PLoS Med. 2006 May;3(5):e298.
Mavedzenge, S., Baggaley, R., Lo, Y. Corbett, L. HIV self-testing among health workers: a
review of the literature and discussion of current practices, issues and options for increasing
access to HIV testing in sub-Saharan Africa. World Health Organization: Geneva. 2011.
Ministry of Health and Social Welfare (MoHSW), National AIDS Control Programme
(NACP).Guidelines for HIV Testing and Counselling in Clinical Settings. April 2008.
MoHSW, NACP. The Health Sector HIV & AIDS Communication Strategy 2008-2015. 2011.
MoHSW, NACP. Health Sector HIV and AIDS Strategic Plan – II (HSHSP) 2008 – 2012. 2008.
MoHSW. National Blood Transfusion Practice Guidelines. June, 2006.
MoHSW, NACP. National Guidelines for the Management of HIV and AIDS. 2009.
MoHSW, NACP. National Guidelines for Voluntary Counselling and Testing. 2005.
MoHSW. National Health Laboratory Strategic Plan of 2009 – 2015. April 2009.
MoHSW. National Infection Prevention and Control Guidelines for Healthcare Services in
Tanzania. 2011.
MoHSW, National TB and Leprosy Programme. National Tuberculosis and Leprosy Guidelines.
2007.
MoHSW. A Practical Handbook for Improving HIV Testing and Counselling Services in
Tanzania. September, 2010.
Ministry of Health and Social Welfare Primary Health Services Development Programme
MMAM 2007-2017, (2007)
MoHSW. Prevention of Mother to Child Transmission of HIV: National Guidelines (PMTCT) in

Tanzania. July, 2011.
MoHSW. Standard Operating Procedures for HIV Testing and Counselling (HTC) Services
National Bureau of Statistics (NBS) Tanzania and ICF Macro. Tanzania Demographic and Health Survey
2010. Dar es Salaam, Tanzania: NBS and ICF Macro. 2011.
Parliament of the United Republic of Tanzania. HIV and AIDS (Counselling and Testing, Use of
ARVs and Disclosure) Regulations, 2010.
Guidelinesfor HIV
forTesting and Counselling
HIV Testing in Tanzania
and Counselling
in Tanzania Page 65
Parliament of the United Republic of Tanzania. HIV and AIDS (Prevention and Control) Act,
2008.
Tanzania Commission for AIDS (TACAIDS), Zanzibar AIDS Commission (ZAC), National
Bureau of Statistics (NBS), Office of Chief Government Statistician (OCGS), Macro
International Inc. Tanzania HIV/AIDS and Malaria Indicator Survey 2007-2008. November
2008.
Joint United Nations Programme on HIV/AIDS (UNAIDS). United Republic of Tanzania

HIV/AIDS Factsheet. 2009. Accessible at:
http://www.unaids.org/en/regionscountries/countries/unitedrepublicoftanzania/.
United Nations Children’s Fund (UNICEF). The State of the World’s Children 2011. New York.
2011.
World Health Organization (WHO).Delivering HIV Test Results and Messages for Re-testing
and Counselling in Adults. Geneva. 2010.
WHO. Guidance on Provider-Initiated HIV Testing and Counselling in Health Facilities.

Geneva. 2007.
WHO. Task Shifting to Tackle Health Worker Shortages. Geneva. 2007.
Appendices
A. Protocol/Tool for HTC Service Package
B. SOPs for HIV Rapid Testing
C. Operational Issues for HTC
D. National HTC Register
E. National HIV Logbook
F. HTC Reporting Form
National Comprehensive Guidelines for HIV
Guidelines for Testing and Counselling
HIV Testing in Tanzania
and Counselling
in Tanzania Page 67
APPENDIX A: Protocolffool for HTC Service Package
g>
-·Ill
~ I
Pre-test Session I
~ID
s:~ Individual • Couple Group
!ll • Explain benefits of knowing HIV status • Explain benefits of knowing HIV status as acouple • Brief explanation of HIV/AIDS
.,
'a- • Review client knowledge on HIV/AIDS and • Review clients' knowledge on HIV/AIDS and correct any • Explain how HIV transmission occurs to
Es correct any misperceptions misperceptions partner/sand children
-.:::: • Review how HIV is transmitted • Explain testing process • Benefits of receiving HIV test results
~ • Explain HIV testing process • Confirm that both/all partners agree to receive HTC • Explain testing process
~· • Discuss client risk issues
• Address client concerns and questions
together, including results • Explain services offered
Cl • Couple agrees to keep results confidential • Discuss right to decline
;:s
Cl..
• Obtain informed consent • Couple agrees to make decisions about disclosure • Clients can see HTC provider or
~ together clinician for more information
• Ask for questions
-~~
• Discuss couple's HIV risk concerns
:;·
I HIVTAAf I
QI
;:s
During HIV test development, discuss with client(s) and patient(s):
~ • Discuss methods for HIV prevention: abstinence, • Condom
;:s condoms, partner reduction, PMTCT demonstration
;::;·
• Explain referral process and support services that are • Explain importance of
available at the clinic disclosure
I Post-test Session: I
HIV Negative Individuals and HIV Positive Individuals and Concordant Discordant Couples Inconclusive Test Results
Concordant Negative Couples Positive Couples • Invite couple to share their
• Recommend that client return
• Explain methods to keep • Ask the client/s how they feel about feelings and concerns
for testing after 2weeks
client/s HIV negative: their results • Address immediate concerns • Address immediate concerns
abstinence, partner reduction, • Address immediate concerns of the couple • Explain methods to protect
condoms • Recommend disclosing to partner/s if • Discuss how clients can client and partner/s until client's
~ • Address immediate concerns client feels safe protect themselves and each status is known: abstinence,
g. • Recommend disclosing to • Client should protect themselves and other by: abstinence, partner reduction, condoms.
-
;:s
Cl
~
3
"l:I
partner/s
• Recommend asking all
partner/s to test •
partners by: abstinence, condoms,
partner reduction
Explain and refer to care and treatment
•
condoms, partner reduction
Explain and refer to care and
treatment services
ii!
;:so
• Recommend re-testing next services or PMTCT (if client is • Encourage utilizing community
~ year or in 4weeks if there was pregnant) support groups and/or
1:11
~·
a recent risk (past 3 months). • Encourage utilizing community support prevention services.
groups and/or prevention services.
APPENDIX B: (SOPs) for Rapid HIV Testing
HTC providers and management staff should maintain a safe environment for HTC services.
Specifically, privacy of the clients and the confidentiality of their test results should be upheld at all
times. HTC venues should be sufficiently stocked with supplies (for example an ample supply of
approved test kits that have not expired).
The table below shows a summary of the steps that a HTC provider should take when conducting HIV
counselling and testing. Please see the Standard Operating Procedures for HIV Testing and Counselling
(HTC) Services (2009) and the National Guidelines for the Management of HIV and AIDS (2009) by the
Ministry of Health and Social Welfare for additional guidance on HTC processes including information
on specimen management, environmental regulations, quality assurance and control, etc.
When conducting tests, HTC providers should abide by the following steps:
Pre-Analytic
 Check temperature of room/s and space/s
 Check inventory and test kits
 Receive requests for testing
 Set up test area
 Record pre-test data
Analytic
 Follow the biohazardous safety precaution
 Perform an external quality control (please see SOPs for a detailed description)
 Greet the client/patient, establish rapport and explain testing process
 Collect the specimen, including specimen for External Quality Assessment (EQA)
 Perform the test as directed by the manufacturer (follow Laboratory SOP for each test product)
 Utilize the algorithm to properly interpret the test results
Post-Analytic
 Check patient identifier and report results
 Properly dispose of biohazardous waste
 Package and transport EQA re-test specimens to referral laboratory, or appropriately store until
next shipment to referral laboratory, if needed
Quality Assurance and Quality Control

Quality Assurance activities in an HTC setting are essential to ensure the provision of quality counselling
and accurate and reliable HIV testing. Quality improvement processes are required for auditing adherence
to policies, protocols and procedures. It is important to use these processes to assess issues such as staff
competency/proficiency, counsellor skills, counselling protocols, the adequacy of laboratory testing and
the perspective of clients on the accessibility and acceptability of testing and counselling services.
Approaches for assessing quality of counselling include regular training, supportive supervision,
counsellor self assessment and stress management sessions, client exit interviews and suggestions to
measure client satisfaction, and regular monitoring of all activities along the workflow.
Internal Quality Assessment (IQA)/Quality Control Procedures are checks done within the HTC site by
management staff and HTC providers to ensure adequate laboratory practices, systems for managing test
kits, that test kits are performing as anticipated, etc. An external quality assessment (EQA) occurs when
an objective agency or group that is not directly affiliated with the HTC site performs an assessment of an
HTC site’s operations and performance. This can include proficiency testing, on-site monitoring and
evaluation, re-testing of specimens, etc.
APPENDIX C: HTC Operational Issues
Minimum Site Specifications for all HTC Settings:
 HTC providers and management staff should be aware of national policies and must adhere to
protocols and standard operating procedures
 HTC sites should offer free HTC services at point of delivery where possible and if costs are
associated they should be minimal
 Access to clean water for hand washing and other hygienic facilities including toilets
 Testing room/s or space/s that are well-ventilated and private
 A locked filing cabinet or space for data storage
 Should maintain an optimum, efficient flow of patients by minimizing patient wait-times, yet
offering quality HTC services
 Clear signage indicating what services are offered
 Safe disposal available for biohazard materials
Other facilities which are advisable, but not mandatory include:
 Media for example televisions for educational videos, educational pamphlets and posters, etc.
 Group room for staff meetings and interest groups such as persons living with HIV/AIDS
 If facility also offers care centre services, separate rooms with sufficient space for at least one bed
in each room
 Locakble refrigerator for storing test kits
 Bathroom, kitchen and laundry facilities
 Storage facilities
In addition to the requirements listed above, the following items are required in specific HTC
settings:
STAND-ALONE HTC HTC IN INTEGRATED OR CLINICAL
 Visible location that is accessible to all SITES
populations  A private setting such as a counselling
 At least two counselling rooms room dedicated specifically to HTC, or a
 Counselling rooms should be large enough for at nursing officer’s room that can be used for
least three chairs and a small desk HTC
 Reception area where clients or patients can wait  Office space for management duties such as
to receive HTC services reporting
 Office for management duties such as reporting  Office should contain locked refrigerator
 Office should contain locked refrigerator for for storage of test kits
storage of test kits
MOBILE HTC
 Unit should be easily accessible to patrons and located in a strategic place to maximize uptake of
targeted populations
 HTC staff should be knowledgeable about community mobilization and have proper IEC materials
available for this
 HTC staff should be knowledgeable of referral service points in the area
 HTC staff should be knowledgeable of nearby facilities offering Post Exposure Prophylaxis (PEP)
 Established plan for controlling client flow (i.e. numbered ticketing system)
70
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APPENDIX E: National HIV Logbook
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APPENDIX F: Reporting Form
73
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THE UNITED REPUBLIC OF TANZANIA

MINISTRY OF HEALTH AND SOCIAL WELFARE

National Comprehensive Guidelines

National AIDS Control Program (NACP)

P.O. Box 11857,

Chapter 1: Introduction ................................................................................................................1

HIV Testing and Counselling Approaches ..................................................................................9

HIV Testing and Counselling Settings .......................................................................................13

4.1.1 Co-located HTC site ............................................................................................. 13

4.1.2 Integrated HTC ..................................................................................................... 13

4.2 Community-Based Settings ........................................................................................... 15

HIV Testing and Counselling Service Package .........................................................................29

Human Resources ........................................................................................................................35

Quality Assurance and Improvement ........................................................................................41

Logistics Management .................................................................................................................45

Monitoring and Evaluation.........................................................................................................54

HTC Promotional Activities........................................................................................................59

Implementation Framework .......................................................................................................61

World Health Organization (WHO)

African Medical and Research Foundation (AMREF) and

Japan International Cooperation Agency (JICA)

Members of the core guidelines development team included:

Dr. Angela Ramadhani, Programme Manager NACP

Dr. Charles Massambu, Assistant Director, Diagnostic Services, MOHSW

Dr. Fausta Mosha, Director NHLQATC, MOHSW

Dr. Rowland Swai, Retired NACP Programme Manager

Ms. Patricia Maganga, Principal State Attorney, MOHSW

Dr. Marylad Ntiro, NACP

Ms. Peris Urasa, NACP

Mr. Khalid Hassan, Retired NACP

Dr. Godfrey Mtey, Regional Medical Officer –Morogoro.

Dr. Ernest Mhando, Regional AIDS Control Coordinator, Lindi.

Dr. Salli Mwanasalli, CDC Tanzania

Dr. Benedicta Mduma, AMREF

Dr. Beati Mboya, AMREF

Mr. Nobuhiro Kadoi, JICA Tanzania

Dr. Ruth Lemwayi, Public Health Specialist,

The following provided technical assistance to the guideline formulation;

Ms. Kristina Grabbe, CDC,Atlanta,

Ms. Catherine Nichols, CDC, Atlanta,

Dr. Miriam Taegtmeyer, London School of Tropical Medicine Liverpool , UK

Dr. Donan W. Mmbando

1.1 Background on HIV and AIDS services in Tanzania

1.2 Defining HIV Testing and Counselling

1.3 Justification for Comprehensive National HTC Guidelines

1.4 Purpose of Guidelines

 HIV and AIDS (Prevention and Control) Act, (HAPCA) 2008.

1.5 Scope of Guidelines

Core Principles of HIV Testing and Counselling

2.1.1 Confidentiality within Couples

2.1.2 Confidential Record Keeping

2.2.1 Counselling Procedures

2.2.2 Tailored Counselling

2.2.3 Quality Counselling

2.3.1 Consenting Couples

2.3.3 Consent Procedures

2.3.4 When HTC is declined

2.3.5 When Consent is not necessary