2006h). Conversely, if programs are not implemented with sensitivity to these issues, both women and men may drop out of care and treatment.

PEPFAR’s 5-year strategy includes a clear commitment to addressing gender issues and reducing the vulnerability of women and girls to HIV/AIDS (OGAC, 2004). However, program results for voluntary counseling and testing is the only category that is currently required to be disaggregated by gender. Much of the gender focus in counseling and testing for diagnostic purposes is in initiatives to prevent mother-to-child transmission. By the end of fiscal year 2006, OGAC reports that cumulatively 70 percent of those receiving counseling and testing services supported by the U.S. government in prevention of mother-to-child and all other settings were women (OGAC, 2007a).

Voluntary Counseling and Testing

The past 2 years has seen increasing interest in moving toward a model of counseling and testing that makes the HIV test a routine part of medical care. In 2004, both the United Nations Programme on HIV/AIDS (UNAIDS) and WHO recommended that “health care providers routinely offer HIV testing to all patients seen in clinical and community-based health service settings where HIV is prevalent and antiretroviral therapy is available (WHO, 2006, p. 11). Such provider-initiated testing also gives the patient the opportunity to refuse the test or “opt out.” While OGAC has stated that PEPFAR will promote and support routine or opt-out testing in appropriate settings, particularly for prevention of mother-to-child transmission (OGAC, 2006b), human rights advocates have raised concern as to whether people are truly able to provide informed consent and not be coerced to undergo testing. This concern appears to stem from questions about whether patients are ready for disclosure of their status and whether stigma, discrimination, and even violence against women may result from undergoing the test and receiving the results (HIV Insite, 2006). Questions also arise about how and whether expanded programs can provide the right amount of information during counseling sessions when human resources are stretched and whether marginalized populations would become more vulnerable to human rights abuses if testing became routine. Other ethical issues, raised above with respect to children and adolescents, include discerning when people are the appropriate age to give consent, when they can understand the information provided and discussed in the counseling session well enough to give informed consent, and given the potential consequences, whether it is appropriate to disclose results to the person being tested.

OGAC has reported several key barriers to counseling and testing, including a lack of routine availability of the services in health care settings, stigma and discrimination, shortages of laboratory personnel, long



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