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Provider Initiated HIV Testing and Counseling / One day Training Programme
INTRODUCTION
Intended Participants
This training course is targeted to health care providers who are charged with the responsibility for establishing and implementing provider-initiated approach to HIV testing and counseling. This would include health care providers in the public, NGO and private sectors. Priority health care delivery settings include STI clinics, ante-natal clinics, TB treatment facilities, secondary care, women’s health settings, and clinics with high HIV seroprevalence rates as well as private practitioners.
It is assumed that individuals participating in this training would have a good working knowledge of HIV/AIDS basic issues, knowledge of public health system in their country, and a role in the health care delivery system where they would likely be in a position to recommend HIV testing to patients they perceive as being at risk.
Objectives
By the completion of this training, participants will be able to:
Discuss benefits of HIV testing with patients;
Provide brief, targeted health education on HIV prevention and transmission, as well as HIV treatment and care;
Identify need for confidentiality and consent and how to employ these in practice settings; and
Deliver HIV test results, including referral to treatment and care, prevention support, and partner notification.
Background and Rationale
Since HIV antibody testing first became available, WHO has advocated for persons at risk for HIV to voluntarily seek out HIV testing and counseling. The cornerstone of WHO’s guidance on HIV testing has remained constant for nearly twenty years: confidentiality, informed consent, and access to quality counseling. Throughout the World, programs offering voluntary counseling and testing (VCT) have been successful in many countries in providing individuals with knowledge about HIV, prevention measures, and in providing HIV test results to millions of individuals. Still, in many high-prevalence countries, fewer than one in ten HIV-positive individuals are aware they are infected with the HIV virus. Reaching individuals living with HIV who do not know their serostatus must clearly be a global public health priority.
In light of this, and coupled with advances in treatment and care, WHO and UNAIDS have advocated for an increase in provider-initiated HIV testing and counseling (PITC) in addition to voluntary counseling and testing. The recommendation for universal systematic offer of HIV testing and counseling is seen as an important step to achieving the goal of universal access for all persons with HIV/AIDS. This intervention--coupled with effective counseling for behavior change--provides a seminal opportunity for HIV prevention.
It should be noted that the position of WHO/UNAIDS on provider-initiated HIV testing and counseling describes two discreet categories:
• Diagnostic Testing: refers to situations where a medical condition [e.g., TB] or medical symptoms [e.g., OIs or unexplained significant weight loss] indicate a significant possibility of underlying HIV disease; and
• Routine Recommendation: refers to recommending in settings where potential benefit is especially high [antenatal settings] or where a high probability of HIV infection exists [e.g., high prevalence regions, STI treatment settings].
An important caveat in the shift to provider-initiated testing is the importance of having mechanisms in place to assure referral to post-test counseling services to all patients, and referrals to medical and psychosocial support for those testing positive. In addition, moving to an ‘opt-out’ model of obtaining consent (e.g., “Unless you object, I plan to administer an HIV test) raises concerns about whether testing is truly voluntary. Every effort must be made to ensure voluntary informed consent to HIV testing. WHO/UNAIDS have consistently refuted any benefit to mandatory testing, and ensuring consent is a principle that cannot be overlooked.
Finally, health workers should remain aware of the power--and potential status--of the health care provider in their setting and in their community. The recommendation for HIV testing will be, for some patients, tantamount to an edict. Sensitivity to patient volition and recognition of the right to refuse testing should guide a provider’s interactions in obtaining consent.
When moving to routine offer, the standard pre-test counseling components used in VCT are adapted to simply ensure informed consent, without a full education and counseling session. However, it is an expectation that every effort will be made to identify additional support within the health care setting for education and emotional support as part of the HIV testing interaction.
Finally, this course does not attempt to meet the needs of all clinicians doing routine recommendation of testing for diagnostic purposes. WHO and the U.S. CDC have jointly produced curricula that deal with testing in TB and ante-natal settings. The primary utility of the materials in this training package are for clinicians treating STIs, providing family planning services, and in general medical settings with high HIV prevalence. It is also important to acknowledge that this course does not deal with some important clinical information which would need to be part of a course on diagnostic testing for suspicion of HIV infection. The training that most closely meets that need would be the Integrated Management of Adult/Adolescent Illness (IMAI) courses developed and delivered by WHO.
Goal of course
A primary goal for this course is to increase the number of health care providers offering HIV testing to patients seeking care in private and public health facilities.
In the development of these materials, an important focus has been on adapting the model of HIV testing and counseling to:
• address health care providers’ concerns about time and staff constraints in busy health care delivery settings;
• support the implementation of an approach to ensure that a greater number of persons know their status and access treatment; and
• offer clear and direct suggestions on achieving goals for provider initiated testing and counseling.
This training has been designed to offer a model (see overleaf) of HIV testing in which the provider recommends HIV testing with ‘opt-out’ language, assures confidentiality, and obtains informed consent. The model offers a graphic comparison between a typical VCT intervention and a typical PITC intervention.
The pre-test information and education given may be offered by any member of the health care team. In this model, the education session facilitates the patient making an informed decision. The provider then confirms the patient’s desire to test. Finally, the test is performed and results are delivered with post test counseling focused on providing access to treatment and partner counseling services if positive, and with any necessary referrals. The provider-initiated opt out approach yields a high uptake in testing. Critical to this process however is providing the patient with an opportunity to opt out if they so desire, though providers should assess patient’s barriers to testing and create a plan with the interdisciplinary team to overcome this resistance.
In the Caribbean, countries decide on their national testing protocols hence a range of approaches to testing exist. Blood specimens are collected to facilitate testing using the rapid test technology or traditional lab-based Elisa testing. This has resulted in some countries being able to offer same day results or delayed results. Some offer a combination of both. The provider-initiated approach is able to accommodate both testing methodologies, though there are clear advantages from a public health perspective of parallel rapid tests per CAREC/PAHO protocol.
This course is intended to enable the provider to understand and deliver the provider-initiated approach to HIV testing and counseling. It does not provide training in quality assurance, procurement and storage. PAHO provides technical support in these areas but is not the subject of this exercise.
COMPARING PROVIDER-INITIATED AND VOLUNTARYHIV TESTING AND COUNSELING
Adapting this Curriculum
The attempt in developing this training package has been to create an easily adaptable course which might have broad utility in a number of settings. These materials do not address certain specific regional and cultural differences or specific needs of unique settings. It is anticipated that program managers working with local trainers may modify these materials to meet the unique needs in specific settings.
At the same time, this material has been created with distinct learning objectives. These make up the ‘core messages’ for a training on provider-initiated HIV testing and counseling, and altering these may dilute the intention of this course and change information about good practice in HIV testing and counseling interactions. Thus, the learning objectives should be met, whatever modifications are made to the course.
Preparing to Train
1. Selecting Trainers
The first step in preparation for training is to select the appropriate staff to act as trainers. The following criteria should be considered in making this selection:
• Expert Knowledge of HIV/AIDS
• Good knowledge and understanding of the Public Health system
• A role within the delivery of care system
• History and proven ability at training delivery.
• Thorough knowledge of CAREC Guidelines and protocol for provider-initiated testing.
• Knowledge of HIV testing strategies employed in the country they are working in.
2. Trainers Role
Trainers who utilize these materials should be familiar with the facilitator guide and the slides which will be used at the participant manual. Trainers will be asked to both lead lectures and facilitate discussion in this training. The ideal trainers for this material would be comfortable in both teaching modalities.
Finally, trainers who are preparing to train from these materials should be both organized and flexible. The preparation for this training requires a facilitator who knows their audience, who can adjust material as needed, and who is skilled at training coordination and management.
Whenever possible, pairing one trainer with an additional trainer provides benefits to learners as well as making the task of training more manageable. Using two trainers makes any educational experience for engaging for learners and is easier for trainers.
3. About the guide
The facilitator guide is designed to help trainers guide participants through lectures and exercises which are the foundation of this course. The facilitator guide is divided into four modules. At the beginning of each module, expected time needed for the module to be delivered is introduced. In addition, a narrative description of the objectives for the module and suggestions for preparation are outlined. In the course of the module, sub-modules with specific activities and content are outlined. When the content calls for didactic presentation, a numbered outline is to be followed. When prompted by a bullet with checked box, the trainer should be prompted to either engage participants in discussion or facilitate an activity.
4. The Participants’ Manual (companion piece)
The participant manual is designed to be a ‘map’ of the training for participants and also a tool for future reference in their HIV testing interactions. The participant manual has been created using Power Point. In preparing the materials, you should print copies as handouts spaced 3 per page.
The slides are designed for use as slide or overheads, but, for the most part, can easily be adapted and placed on flip charts. Again, these have been created in Power Point and have been numbered for easy reference. References in facilitator guide to slides correspond to slide numbers in the slide set. Note that the participant guides have been created with additional space for notes, so participants should be encouraged to make additional notes.
MODULE 1: INTRODUCTION TO TRAINING AND OVERVIEW
Total Time: 30 minutes
10 minutes Welcome and Introductions
5 minutes Course Objectives
15 minutes Introducing the Topic: Provider-Initiated HIV Testing
Module Objectives: Participants will be introduced to one another, and the trainer will introduce herself/himself and the training content. Overview, agenda and objectives for the course will be presented, and the rationale for provider-initiated testing and counseling will be explained. A brief overview for PITC protocol will be offered.
Preparation: Participant manuals should be prepared. If slides are to be shown, projector with back-up bulb should be ready. A flipchart and newsprint should be available for notes and lecture points. If a slide projector is not used, writing most notes from slides onto newsprint sill suffice.
WELCOME AND INTRODUCTIONS
Time: 10 minutes
Materials: Flipchart
Steps:
1. Welcome participants to the training. Thank them for their willingness to participate and openness to learning. Emphasize that HIV is an important problem, and everyone in their community is lucky to have caring health care workers willing to respond.
2. Briefly discuss logistics for the training. State that a full training day is planned, and attendance all day is necessary for participants to learn what they will need to know. Explain there will be tea breaks in the morning and afternoon, and discuss options for lunch. Make sure everyone is informed where the lavatories are, and ask that all mobile phones be turned off to minimize distractions during the day.
Introduce yourself and, if applicable, your co-trainer. Emphasize your experience in training and HIV testing and counseling as well as other relevant health care experience. Ask participants to introduce themselves briefly to the group, noting that there will be other opportunities through the day to continue finding out more about one another. Ask participants to mention the following points:
• Name
• Work setting
• Challenges associated with HIV testing
3. As participants introduce themselves, model effective listening and convey interest and empathy. If anyone takes too long, remind them that this exercise is designed to be brief.
As people are stating the challenges to HIV testing, record these on prepared flip chart labeled “Challenges”.
4. Once introductions are complete, acknowledge the important experience and compassion of participants, and advise them that they can help make this a valuable learning experience by offering solutions they have found in addressing some of the challenges which are part of HIV testing and HIV care provision. If participants disclose that they are living with HIV/AIDS, stress that they are an extraordinary resource in this training and to patients and thank them for their disclosure.
5. [Optional] You may wish to generate a list of ground rules which you will ask participants to adhere to. If you do, begin by labeling a flip chart, then ask for volunteers to suggest ground rules to be followed by you and members of the learning community during the training. As participants make suggestions, record these to newsprint. Hang these in a prominent location in the training room.
COURSE OBJECTIVES/AGENDA
Time: 5 minutes
Materials: Agenda (Slide 1), Course Objectives (Slides 2), Protocol for PITC (Slide 3)
Steps:
Reveal Slide 1, and ask refer participants to turn to the agenda in participant manuals.
1. Review structure for the day, inviting any questions about content as you proceed. Offer the suggestion that the day is a full day of training and your hope that it will be rewarding. Suggest that the curriculum has been developed to compromise one day of training factoring in an hour lunch break and morning and afternoon tea break.
Reveal Slide 2, and discuss objectives for the course. By the completion of this training, participants will be able to:
Discuss benefits of HIV testing with patients who are offered HIV tests;
Provide brief, targeted health education on HIV, transmission and prevention, and access to treatment and care;
Identify need for confidentiality and informed consent, and understand how to employ these in their practice settings; and
Deliver HIV test results, including referral to treatment and care, prevention support, as well as potential need to notify partners.
Reveal Slide 3, and suggest that this depiction summarizes one possible protocol for a provider-initiated test intervention. Quickly review the protocol making the following points:
• The intervention begins with either some form of group education or with a provider recommendation including brief HIV content. Note the traditional VCT pre-test components are abbreviated.
• Consent is obtained, assuring confidentiality.
• Sample is obtained for HIV testing.
• Results are given and interpreted.
• Post-test referrals and support provided. Counseling may or may not be offered in this setting; a referral to quality counseling may replace traditional post-test counseling in VCT.
Offer this as a BRIEF introduction to PITC, and note that this the rest of the course will explore each step in the intervention in great detail.
INTRODUCING THE TOPIC: PROVIDER-INITIATED HIV TESTING
Time: 15 minutes
Materials: Flipchart; Addressing Concerns in PI Testing (Slides 4 & 5)
Steps:
1. Remind participants of the title of the course. Ask their thoughts on why a course was developed that focused on the health care worker recommending HIV testing to a patient who has not requested the test. If they need another prompt, ask what percent of their patients are at risk for HIV. Next ask what percent of patients see themselves at risk. Listen and confirm responses. If no one has mentioned the point, be sure to emphasize that, in many health care settings, patients are probably more at risk for HIV than they acknowledge.
2. Throughout the Caribbean there is an urgent need to ensure that people living with HIV have access to treatment, care, support and prevention. This is not possible if the persons infected—and the health cares system that serves them—are not aware of their HIV status and their needs. Health Care systems need to adopt an efficient and effective system for increasing the number of persons who have the opportunity to do an HIV test. There is a need therefore to consider a shift to the Provider Initiated Approach to achieve a high uptake in HIV testing and counseling. This method has been used in public health settings to achieve this objective of high yield in cases of other health conditions; such as reducing syphilis in pregnant women, increasing immunization, prevention of various cancers.
Refer to the flipcharts with recorded participant concerns about HIV testing. Inform them that this course has been designed in hopes of addressing some of their concerns.
Show Slides 4 & 5, using the following to guide your talking points about the benefits of PITC:
Time: Begin by stressing that one important task in moving to P-I testing is recognizing the limits of physician time in busy medical settings. To address this, the recommendation is that counseling expectations in VCT be waived.
Human Resources: One option for delivering high-quality testing and counseling while addressing the time constraints for health care workers is to use other staff to assist with HIV prevention tasks. These may include existing staff and trained lay counselors.
Stigma: One important reason providers may resist offering HIV testing is patient discomfort. If patients feel ‘singled out’ or somehow stigmatized because HIV testing is offered, it may hurt the patient-provider relationship. If, on the other hand, this service is routinely offered to all or most patients in a setting, the procedure and offering of the procedure becomes normalized. This also serves to change community norms about HIV testing as a routine component of medical care.
Multiple Patient Needs: Some providers may be resistant to offering HIV testing because of a perception that they were to ‘fix’ all of the emotional and other problems facing patient. With a de-emphasis on counseling and emotional support, the testing intervention becomes a more typical medical screening procedure and linking patients to appropriate counseling and support becomes a function of effective referral not intensive individual counseling in the health care setting.
3. State that, while no intervention can address all these barriers, significant effort has been made to develop a protocol that is sensitive to concerns of health care workers and the needs of persons living with HIV who do not know their status. In addition, note that any effective HIV prevention intervention must be very attentive to patient’s issues and concerns. Inform the group that the next activity is designed to think about HIV testing from the perspective of clinic patients.
4. Invite any final questions about the agenda or objectives and proceed to the next section by suggesting the course will turn to the question of why HIV testing is recommended-and some challenges for patients who are taking HIV tests.
END OF MODULE 1
MODULE 2: BENEFITS AND BARRIERS TO TESTING Total Time: 50 minutes
10 minutes Benefits of HIV Testing
5 minutes Barriers to HIV Testing
5 minutes Patient-Centered Care
15 minutes Confidentiality and Consent
15 minutes Model for Provider-Initiated HIV Test Intervention
Module Objectives: Participants will discuss the benefits and barriers to HIV testing. Principles of informed consent, confidentiality, and counseling availability will be discussed. A model for provider-delivered HIV testing and counseling will be introduced.
Preparation: Flipcharts and markers should be available for note-taking during group exercises. Trainers should be very familiar with the four step model for P-I testing, and may choose to post this in the training room. A copy of WHO/UNAIDS policy on HIV testing and counseling may be reproduced as a supplemental handout.
BENEFITS OF HIV TESTING
Time: 10 minutes
Materials: N/A
Steps:
Quickly divide participants into two groups or, in larger groups, divide into manageable groups but instruct half the groups to focus on each of two questions.
1. Once groups are formed, explain that the task for the next 7 minutes will be to think about the benefits and barriers of HIV testing-from the perspective of patients being offered HIV testing.
Ask one half of the group(s) to think about the benefits of HIV testing. Ask, “If you were a patient thinking about taking an HIV test, what might you see as the good things about that medical information?”
To the other group(s), invite them to generate a list of barriers to HIV testing. Ask, “If you were a patient who was offered HIV testing, what might you see as the bad things about taking an HIV test?”
2. Tell groups to brainstorm as many benefits and barriers as they can in the allowed time. Give groups a two-minute notice after five minutes, and end discussions at 7 minutes.
3. Begin debriefing by asking the first group to discuss all the benefits of HIV testing they came up with. Listen and confirm responses.
If you have multiple groups, invite one group to share 2-3 ideas, and then allow other groups to add ideas until all suggestions have been offered. You should expect to hear answers like:
• early access to treatment and care
• ability to make family planning choices
• possibility to make lifestyle changes
• ability to change behavior to avoid transmission to partners
• option of making choices about child custody
• planning for possible health problems
4. Affirm all answers and thank the group for their suggestions. Add any additional benefits to HIV testing you can think of.
5. State that, particularly where time and resources may be limited, there may be reasons to prioritize patients who are ‘most in need’ of HIV testing.
When that is the case, ask participants which patients are particularly in need of provider-initiated HIV testing. If a second prompt is needed, ask what criteria they would use to determine which patients should be offered HIV testing. Expect responses like:
• STI patients
• patients with TB
• patients with symptoms of HIV
• patients with multiple risks
• women in ante-natal clinics
6. Acknowledge the group’s work, adding any priority populations not identified by the group. Invite any questions. Acknowledge their ability at understanding risk factors for HIV, and subsequent greatest benefit to HIV testing.
BARRIERS TO HIV TESTING
Time: 5 minutes
Materials: Flipchart
Steps:
1. Acknowledge that health care workers are usually very familiar with the benefits of HIV testing, and sometimes not as sensitive to the barriers to testing. Inform the group that this is the purpose for including a discussion of barriers to HIV testing.
2. Ask the second group to offer the barriers to HIV testing that they identified. Again, if there are multiple groups, alternate between groups to share reporting time.
Record these on flipchart labeled “Barriers”.
3. As before, it is important to listen attentively and affirm responses.
Once this group has finished, ask remaining participants what else they would add to the list. Confirm and record responses. You should expect responses like:
• fear of abandonment
• fear of violence
• loss of job
• loss of family support
• community rejection
• fear of illness/mortality
• denial of past HIV risk behavior
4. Conclude brainstorm by asking participants why reviewing barriers to HIV testing is important. Confirm responses. If they need a follow-up prompt, ask what might happen if providers don’t understand potential barriers. Again listen and confirm responses.
5. Write the word ‘Stigma’ on a piece of newsprint. Ask participants to think of a definition. Listen and confirm responses. Below this, write the term ‘Discrimination’ and ask for a definition. Again, confirm responses.
6. State that one of the unique features of offering HIV testing are the very real negative consequences that are associated with HIV testing and with communities discovering someone with HIV is living in their community. Make the point that many communities have responded heroically throughout the Caribbean as their countrymen and neighbors are affected by HIV. Still, prejudice, discrimination, and fear of the stigma of living with HIV are a huge barrier to utilizing HIV testing services and must be identified as a factor by health workers offering testing.
7. Summarize by saying that the rationale for this course is the absolute health benefit of persons at risk knowing their HIV status. That said, the realities of patients’ lives and the stigma and emotions associated with HIV testing remind us that the most effective testing and counseling programs will couple provider-initiated testing and counseling with comprehensive interventions, including sensitive counseling and prevention support.
8. State that any HIV testing policy which addresses human rights must include what have been called the ‘3 C’s’ of HIV testing and counseling: consent, confidentiality, and access to counseling. Point out that, while counseling should not be seen as a requirement in provider-initiated testing, a model HIV testing program would have additional staff available to augment the testing interaction where resources and time prohibit more extended interaction with primary care providers.
9. To help patients cope with the barriers to testing, careful attention must be paid to patients’ needs when recommending HIV testing. Transition to the next activity by stating that we will take a moment to explore these needs with a preliminary examination of the provider/patient relationship.
PATIENT-CENTERED CARE
Time: 5 minutes
Materials: Flipchart
Steps:
Ask participants to think for a moment about their experiences as consumers of health care. Ask, when they are patients, what they value in a relationship with a health care provider. If they need another prompt, ask what qualities would help them feel safe to trust their provider and comfortable talking honestly about their sexual behavior.
Listen carefully, and record responses on flipchart labeled “Helpful Traits”. You should expect responses like:
• compassionate
• good listener
• non-judgmental
• patient
• confidential at keeping my secrets
• knowledgeable
1. Explain that these are the types of traits you are referring to when you speak of patient-centered care. These relationship factors are important in most health care settings, but are especially critical as we think about overcoming potential barriers to HIV testing. Retain this newsprint for an activity during Module Four.
2. Remind participants of the discussion of stigma and discrimination. Point out that patient-centered care may be particularly important for persons living with or at risk for HIV because of the issues of stigma and potential lack of social support.
3. Transition to the next section by pointing out that we will spend a moment thinking about two of the three C’s in the UNAIDS guidance: confidentiality and consent.
CONFIDENTIALITY AND CONSENT
Time: 25 minutes
Materials: Flipchart
Steps:
In a matter-of-fact way, tell participants that in just a minute, they will turn to the person beside them and begin to discuss one of two scenarios: a time in which they had unprotected sex and risked HIV or STD transmission, or a time they had sex and risked an unintended pregnancy
Excuse yourself for a moment, explaining that you are looking for something in your materials. Look through your briefcase or trainer notes for a moment or two, allowing enough time for participants to reflect on what you have asked.
After this digression, return your attention to the class and lightly explain that no one will be asked--or allowed--to discuss their sexual history. Monitor group activity, and DO NOT allow anyone to disclose this information.
1. State that this was designed to help them think about what it might be like to discuss intimate information.
Ask if anyone felt uncomfortable about this possible disclosure? Listen and confirm responses. Nest, ask what other questions or issues participants had as they thought about disclosure.
2. If it is not named, it is important to ask if concern about their colleague keeping information confidential was a concern. Listen and confirm reactions.
3. State that, while all health facilities are committed to patient confidentiality, because of the significance of information shared in HIV testing, serious thought must be given to potential breaches of confidentiality and thought must be given about how to prevent problems.
Instruct participants to find a partner with whom they can work for 5 minutes. Once pairs have formed, ask partners to discuss the question: “Where are potential situations or places in the clinic when a patient’s confidentiality may be compromised?”
Advise them that they are not to mention any staff persons by name, but rather to focus on a generic discussion about potential pitfalls within the system where they work. Allow 5 minutes for discussion, and then invite the group to process the question.
Ask the group to make a list of potential breeches of confidentiality that they discussed with their partners. Record these on flipcharts labeled “Possible Problems”. Once all the potential problems have been identified, quickly divide group into smaller groups of 6-8 participants. Ask them to look at the list of potential problems and pick at least two that they can suggest possible safeguards for or strategies to implement to avoid problems.
Allow 8-10 minutes for groups to discuss, and then invite discussion. As groups offer suggestions, write possible solutions beside the problem on the flipchart. Listen and confirm all responses. If any potential problems have not been addressed, facilitate a group discussion and create suggestions for these problems. Once this process is done, review any additional points as necessary. Possible solutions may include:
• staff training about confidentiality,
• obtaining explicit permission to discuss patient’s case with colleagues
• secure record-keeping and storage and other issues which are important to a confidential encounter.
4. Once you have finished, briefly refer back to the ‘3 C’s’ and point out that the second ‘C’ is informed consent. Explain that, in many health care settings, a patient’s decision to come for care implies consent. Note that, because of the serious nature of HIV testing and counseling, it is ethically imperative that a provider determine that a patient consents to testing and is rationally able to do so. To administer an HIV test without appropriate consent would be a grave error in judgment and a violation of a patient’s rights.
5. Point out an important shift (which differs from voluntary HIV testing) in provider-initiated testing is a move to offering HIV testing with an ‘opt-out’ rather than an ‘opt-in’ philosophy. Note that this is a difference between the approach in voluntary counseling and testing (VCT).
Ask if anyone can distinguish between the two philosophical approaches. Listen and confirm responses, stressing that, in an ‘opt-out’ approach, the recommendation is made with the spirit of ‘unless you object’.
6. State that this shift may present a potential challenge for providers: the task of assuring voluntary consent while recommending HIV testing.
Ask participants to take a moment to think through possible ways to determine consent while recommending HIV testing. Listen and confirm responses. Add appropriate possible questions like:
• “Unless you object, I will get a sample for HIV testing. I think it will be important for you to know this information.”
• I want to perform an HIV test today. If that isn’t all right, you need to let me know.”
• “I think this test will help me take care of your health/baby and, unless you object, I’m going to obtain a sample. Can you agree with me?”
7. Point out that, in an ‘opt-out’ recommendation, advice is given and consent is obtained in a manner similar to ones discussed. Point out that an important additional suggestion may be to briefly include a provider’s rationale or medical reason for suggesting HIV testing.
8. Stress that, according to WHO/UNAIDS policy, the minimum amount of information required to provide informed consent includes:
• the clinical benefit and prevention benefits of testing
• the right to refuse
• the follow-up services that will be offered and
• the importance of persons who test positive informing past and future partners
NOTE: You may wish to have “WHO/UNAIDS Policy on HIV Testing and Counselling” prepared as a supplemental handout.
9. Transition to the next section of the course, stating that this step--the provider recommending HIV testing--is one component of a four step model for provider-initiated HIV testing which is the foundation for the remainder of the course.
MODEL FOR PROVIDER-INITIATED HIV TEST INTERVENTION
Time: 15 minutes
Materials: Flipchart; Protocol For Provider-Initiated HIV Testing And Counseling (Slide 6)
Steps:
Reveal Slide 6.
Quickly review the steps, using the following to guide the discussion.
• Step 1: Group Education session is given. (Optional dependent on staff and time). A brief explanation about HIV transmission, HIV testing procedure, benefits of testing and prevention measures may be done. Note that this is a simpler and shorter intervention than normal individual pre-test counseling performed in VCT. Also, in some settings, this pre-test information may be given by another worker in the clinic in lieu of group education sessions.
• Step 2: Provider engages patient individually and recommends HIV test, assures confidentiality, and obtains consent.
Remind participants about the 3 C’s, stressing that in this step the provider focuses on voluntary consent and assuring confidentiality. Note that, where group education is not delivered, the educational components about HIV transmission and testing should be covered in this step.
• Step 3: Specimen for HIV testing is obtained.
HIV testing may be done using the rapid tests or Elisa tests. The type of test used will determine whether specimens will be obtained through finger stick or whether a blood draw will be required. The national protocol will determine whether results are given to clients/patients on the same day or whether they will be asked to return for their results. In either event, all facilities are expected to follow the country’s algorithm for HIV testing.
It is anticipated that, in many settings, the primary care provider or phlebotomist may obtain specimens. In other settings, it will also be appropriate for other staff, including lay counselors, to obtain a specimen for testing.
• Step 4: HIV test results delivered to patient and referrals made
In step 4, the patient is given their HIV test results, those results are explained, and referrals for ongoing support or other needs are made. While the results may be given by other clinic staff, primary care providers are encouraged to give HIV test results when this is feasible. Note here that the test was recommended by a health care provider with a distinct medical rationale for it. It is logical that these results be interpreted--and follow up plan of care as indicated--by the primary care provider who began the process.
Invite any final questions. State that the activities will shift to the next module, focusing on the skills to achieve step 2: brief pre-test information.
END OF MODULE 2
MODULE 3: PATIENT EDUCATION STRATEGIES Total Time: 40 minutes
15 minutes Strategies for Effective HIV Education
10 minutes Key Concepts: HIV Antibodies
15 minutes Elements of Pre-Test Education
Module Objectives: Participants will be given basic information about good health education practices as they deliver HIV pre-test information. Focus will be on pertinent information related to pre-test information in provider-initiated testing intervention, including concepts of antibody development, and review of HIV testing criteria.
Preparation: Plan to use slide projector or flipcharts to augment lecture [Slide 7 and Slide 8].
STRATEGIES FOR EFFECTIVE HEALTH EDUCATION
Time: 15 minutes
Materials: Flipchart; Strategies for Effective Health Education (Slide 7)
Steps:
1. State that one important point in HIV testing will always be offering patients accurate information given by practitioners who are effective at patient education.
Reveal Slide 7. Use the following suggestions as your talking points.
• Address your patient’s chief concern first.
Ask if anyone has ever been to the market when someone was trying to sell them something that they weren’t interested in buying. Acknowledge responses and ask what they were thinking as this person continued to describe items they did not want to buy. Make the connection that when we don’t offer education in a client-centered way, we run the risk that our patients feel the same way the participants felt in the market.
Explain that, while we have information and expertise clients might need, our abilities to convey information are maximized if we begin by finding out our patient’s agenda. State the simplest ways to learn patient’s chief concern is to ask. Questions like: “What are you most concerned about?” or “What would you like to get out of today’s visit?” are excellent examples.
• Start education by asking what your patient already knows.
One simple strategy for assessing a patient’s information gaps as well as verbal abilities can be to ask an open question like “What do you know about the risks for HIV in this village/your community?” A patient’s response gives you valuable information about their existing knowledge, and allows providers to work more efficiently by not teaching patients what they already know.
• Use simple, non-technical language; use terms your patient uses.
Note that one ongoing challenge for health care workers is translating medical knowledge into concepts easily understood by patients. Stress that most providers do this all the time, but ask if anyone has ever realized that their patient hadn’t understood what they said. Ask how they knew their patient had not comprehended. Listen and confirm responses.
Ask what providers can do to increase the chances that the information we are trying to convey has been received. Listen and confirm strategies. Remind participants that one of the most certain ways to be sure you will be understood is to use language that is identical to the language patients use.
• You can sometimes provide health education on sensitive topics by discussing them in third-person language.
One strategy with shy patients or uncomfortable topics may be to say something like, “many of our patients find it really hard to disclose their status to their husbands/partners.” Ask participants what benefit might come from making statements in the third person terms. Listen and confirm responses like minimizing confrontation, decreasing anxiety, allowing patient to maintain confidentiality.
State that the goal of health education is for patients to use information, and presenting information in a minimally threatening way is ideal. Note also that these kinds of interventions can also be important prompts for clients to discuss barriers to behavior change or feelings and issues which are getting in their way.
• Patients can retain an average of only three take-home messages in any health education intervention.
Ask if anyone has ever needed to be taught a new skill by someone who was trying to offer them too much information and too many choices. Confirm responses. Explain that health information is as foreign to our patients as that information may have been for many of us.
The skill for providers is to prioritize which health education issues are most important at this visit and to prioritize those while allowing the opportunity to return to other topics in subsequent visits.
Share the observation that an important concept in behavior change is self-efficacy, a patient’s ability to feel ‘I can do that new behavior.’ If patients are overwhelmed or given a message that there are many things they need to work on, the provider may actually decrease self-efficacy and increase feelings of pessimism about behavior change.
2. Transition to the next section by suggesting that the course now invites participants to discuss key educational concepts for providers performing HIV testing.
KEY CONCEPTS: HIV ANTIBODIES
Time: 15 minutes
Materials: Flipchart
Steps:
1. State that, in doing pre-test education in a testing context, certain information about HIV antibody development as well as prevention issues are critical.
2. Draw a horizontal line on a piece of newsprint, and make a mark near the left side of the line and label the mark ‘HIV infection’. Suggest that, in order to be able to explain key concepts, you will be walking participants through a timeline of HIV infection with an emphasis on teaching points for clients taking HIV tests. Explain that this first mark signifies when someone is infected with HIV.
Ask what must have happened in advance of this event if we know that someone has been infected with HIV. Listen and confirm responses, focusing on two points: someone has been exposed to the infected fluids of another person and those fluids have had access to the other individual’s blood system.
Ask which fluids—outside of a medical setting—could have contributed to this individual becoming HIV infected. Listen and confirm the following fluids: blood, semen, vaginal secretions, and breast milk. Emphasize that, if someone was definitely infected with HIV, we would know they had to have been exposed to one of these fluids.
3. Next, make a mark on the flipchart slightly to the right of the previous mark, and label this point ‘Seroconversion’.
Ask participants what is meant by the term seroconversion. Listen and confirm responses, explaining that seroconversion refers to a period when enough antibodies have been produced that they can be detected by an antibody test. Make the point that an infected person can transmit the virus even before there are sufficient antibodies for a positive test.
Ask participants how long it typically takes between HIV infection and development of a sufficient amount of antibodies for an HIV test to be reactive as a positive test. As participants respond, suggest that most individuals convert between 6 and 12 weeks after infection. State that almost everyone who has been exposed converts to antibody positive by six months.
4. Draw a bracket between the existing points on the flipchart and label the space in between these points ‘Window Period’.
Ask participants what is meant by this term. Confirm that the term window period is used to describe the time in between infection and seroconversion. Follow up by asking the implications of this on client education in a pre-test information session. Confirm response, highlighting the need to assess a patient’s recent HIV risk behavior and instruct them on the need for re-testing of persons with possible recent exposure.
Remind participants that virtually everyone infected with HIV will seroconvert within six months following exposure. Advise participants that, in doing pre-test information giving, emphasis should be placed on re-testing if possible exposures occurred less than six months before the current test.
5. Invite any additional questions about the timeline and thank participants for their attention and involvement. Transition to the final activity of the module by stating that you will now cover the minimum expectations of pre-test information giving in provider-initiated testing.
PRE-TEST INFORMATION
Time: 15 minutes
Materials: Flipchart, Elements of Pre-Test Information (Slides 8-13)
Steps:
1. Begin this section by suggesting that there are several core components of HIV pre-test information giving which should be considered minimum standards in the testing intervention.
Reveal Slide 8, Elements of Pre-Test Education, review briefly. Use the subsequent slides to expand the discussion and offer an overview of HIV transmission and course of illness.
Mechanics and logistics of testing and receiving results-
Reveal Slide 9, and instruct participants that among the most basic questions to be covered during the pre-test information will be understanding how the test is performed and when results will be available. It may also be helpful to teach about how a sample will be obtained.
If doing confirmatory testing, advise clients of what they will need to do if they are returning for results. If performing rapid tests, explain availability of results using national testing algorithm and policy to guide you.
When clients will be waiting to return for results, you may also wish to note that the waiting period for results can be stressful. Suggest that clients may wish to seek out supportive family and friends during this time. If appropriate, you may wish to advise them of services available to clients of the clinic during this time.
Facts about transmission and prevention-
State that providers performing HIV test must review ways HIV can be transmitted and strategies to avoid infection [or re-infection/co-infections for PLWHA]. Remind participants of the previous discussion of health education strategies and suggest the most effective way to begin this dialogue may be to ask clients what they have heard about HIV or about how people avoid contracting HIV.
Reveal Slide 10, and point out that every HIV infection has two common elements: a person with infectious body fluid and a route of entry into the other person’s body. Remind participants that HIV is a blood-borne illness; suggest this is why only certain fluids are efficient transmitters of HIV. Other fluids—like sweat, saliva, and tears—do not contain enough blood cells and cannot transmit HIV.
Possible need for repeat testing-
Ask participants why repeat testing is necessary. Listen and confirm responses.
Reveal slide 11, and remind participants of the previous section in this module with its emphasis on antibody development. Make the connection between antibody development and the length between an accurate HIV test. Suggest that this time gap is often referred to as the window period after infection.
State that—at a minimum—providers should briefly explain that the accuracy of the current test will hinge on avoiding recent risk behavior. The most succinct way to teach about this is to emphasize the need for six months without possible exposure to be certain of the test results.
Information about availability of treatment and care services if positive-
Reveal Slide 12, and note that the rationale for scaling up HIV testing is intricately linked with the scale up of HIV treatment in the region. Ask participants to describe enhancements to the delivery of care and treatment in the last three years. Confirm all responses.
Advise participants that assuring clients of the availability of medical as well as social support services for persons living with HIV/AIDS must be done during the pre-test information giving. Stress that this implies providers will be proficient at knowing where resources are and committed to remaining knowledgeable as services are added and change in their communities.
Summarize that many treatment scenarios—monotherapy or combination therapy—are extremely effective at prolonging health. That said, all providers must be aware that HIV medications must be taken exactly as prescribed. It must be noted there are significant side effects associated with many HIV medications, and adherence to exacting regimes poses challenges for many patients. Finally, offer the caution that the most effective course of treatment begins with early intervention. The prognosis for a patient who has good immune functioning and comes to care earlier in their disease process is generally much better than for a patient who comes to care later in the illness.
Importance of disclosure –
Reveal Slide 13, and point out that it is important public health practice that the sexual and drug-sharing partners of persons testing HIV positive be advised of the possibility of their exposure to HIV, and the need for testing. Point out that, in instructing patient’s about disclosure, emphasize that this is what the clinic sees as responsible practice.
In addition, make the point that disclosing to partners will lower anxiety in the long run as worries about a partner finding out or when to tell will be eliminated.
Stress that the most helpful way to present this to a client is to emphasize that this service is always performed by professionals who assure their confidentiality. If clients are resistant, ask them to consider someone they love and the possibility their sexual partners had a communicable disease. Ask if they would want their loved one informed of the possible need to be tested.
Lastly, stress that PLWHA should notify their health workers of their HIV status when they go for care or return to care. Emphasize that health care workers must maintain confidences, and that honestly informing health workers is primarily for the client’s protection, not merely to protect the worker.
2. Invite any final suggestions about pre-test education components and thank participants for their interest. Transition to the next module by suggesting the course will now focus on a very challenging task in HIV testing: the giving of HIV test results.
END MODULE 3
MODULE 4: GIVING HIV TEST RESULTS AND EFFECTIVE REFERRALS
Total Time: 55 minutes
15 minutes Delivering HIV Test Results
20 minutes Result Giving Practicum
20 minutes Steps in Effective Referral
Module Objectives: Participants will be given a model for delivering HIV test results, and a chance to practice in simulation. Strategies for successfully referring patients into HIV testing and care as well as other services will be addressed.
Preparation: Flipchart; Delivering HIV Test Results (Slide 14) and Steps in Effective Referral (Slides 15-16).
DELIVERING TEST RESULTS
Time: 15 minutes
Materials: Flipchart, Slide 14
Steps:
1. The first task for health care workers offering HIV results is to think about the emotional responses patients may have to HIV test results.
Ask participants what emotions they have seen in patients whose test result is negative. Listen and confirm responses, adding any from your clinical practice. Expect answers like:
• Relief (at not having HIV)
• Excitement (elation at good news)
• Confusion (may have perceived themselves as positive; may have positive current or former partners)
• Optimism (may feel like a new opportunity)
Next, invite the group to consider the emotional reactions for patients whose test result is positive. Again, confirm all responses, and record them on flipchart. Highlight these possible emotional responses to bad news:
• Confusion
• Anger
• Denial
• Sadness
• Loss
• Bargaining
• Uncertainty
• Fear of death
• Shame/embarrassment
• Fear of rejection
• Disbelief
Ask participants to view the list of possible emotions and identify the ones they expect they would have if they tested HIV positive. Ask for volunteers to respond. If they need another prompt, ask “Which of these would be your reaction to hearing someone tell you that your test was HIV positive?” Invite as many participants to share their reactions as desire to do so. Thank each one without additional comment.
Once this is finished, review newsprint from earlier in the day on which participants discussed the qualities they would hope for in a health care provider labeled “Helpful Traits”. Ask participants which of these traits would be important to them as they consider their emotional reaction to HIV test results. Confirm all responses.
2. Explain that sensitivity to patient emotions coupled, accurate medical information, and helpful referrals are the cornerstones of effective HIV result giving.
Reveal Slide 14, and discuss steps for delivering HIV test results:
• Verify patient identity: Ensure that the person to whom you are giving the result is the same person who submitted for the test. Re check name, code, or identifying number or whichever was presented for testing.
• Assess patient readiness to receive results: Note that most patients are completely ready to hear the news of their results, and this should not drag out the waiting time. Rather, a short check in [i.e. ‘Are you ready for your results?’] allows the patient to control this process and offers an opportunity for any additional questions or information.
• Deliver and interpret HIV test result: Promptly deliver the result, offering explanation of the test’s meaning. One effective strategy can be, “The test result is ____ that suggests you DO/DO NOT have HIV in your blood system.” This informs patient of the results, but also doesn’t rely exclusively on use of terms reactive/non-reactive or even the terms positive and negative which may be confusing.
• Allow for emotional reaction: It can always be helpful to allow some time for silence after giving news, particularly a positive result. Offering an empathic comment [e.g. “This is really hard news to hear.”] offers your patients a chance to talk about their emotions, perhaps to have them validated. If you have time and feel comfortable, use of open-ended questions about their feelings is an excellent method for supporting patients.
• Provide follow-up teaching/medical information as appropriate: It may be important to remind patients about recent exposures and the need to be re-tested if they receive a negative result. Patients who test positive should be counseled about the need for medical follow up, availability of additional support services, and the need to notify sexual partners so they can also obtain testing.
Note: Recent reports on patient with current STI and recent HIV exposure suggest that these patients may be especially infectious because of high levels of viremia following exposure. Particular emphasis on detection of acute HIV infection and education on need for re-testing is especially important in light of these findings.
• Offer referrals and follow-up options: Knowing about community resources to address needs, especially of persons who tests positive, are critical for quality HIV testing centers. Reminding patients of additional services at your health center is important.
RESULTS GIVING PRACTICUM
Time: 45 minutes
Materials: N/A
Steps:
1. State that the course will now offer a chance for participants to practice delivering an HIV test result.
Ask participants to partner with one person in the group with whom they have not worked during the training. Once groups have formed, tell the person whose birthday is closest to January 1 that they will play patient in this simulation. Ask them if they are willing to be patients who have been tested in the health center. If so, ask them to step out of the room while you instruct the health care workers.
Participants left will be health care providers. Advise them that they get to choose which results to practice. State the suggestions of the previous section should guide this intervention. They should imagine the patient had been tested two weeks ago, and they have returned for their test results. The patient will be led back in just a moment to hear test results. Again, remind provider they should determine if they would like to give a positive or negative result in this practice session.
Bring patients back into the training room, and advise them that their test results have been read and their provider is prepared to discuss them. Instruct them that some sessions may take longer, so if they finish before 10 minutes, they should quietly discuss the session with their provider. Ask providers to begin result-giving simulation. Monitor participant’s work, and after 8-10 minutes end the simulation.
Ask patients to debrief with their provider by focusing on all the ‘successes’ they can find. Instruct them to focus on the specific details of what providers did well. Invite participants to discuss among themselves what went well initially, and advise them the group will have a discussion after they have concluded.
Allow five minutes for partners to debrief, and then ask the group what went well. Ask particular participant what felt good to them when they were given results. Invite counselors to discuss their reactions to this process, and what things they felt worked effectively.
Transition to the next activity by stressing that one of the most difficult things health care workers face in doing HIV testing is delivering a positive result. Suggest you would like to demonstrate a result-giving session which applies the steps outlined earlier to the task of giving positive results.
2. State that you would now like to demonstrate a counseling session-attempting to accomplish the steps outlined above. NOTE: You should prepare a patient scenario in advance. If possible, you should rely on having your co-trainer in role as the patient.
Invite your patient to sit down. Begin demonstrating HIV result giving, using the steps outlined as a guide. If at all possible, you should demonstrate giving a positive test result. Incorporate into your case some dynamics that relate to issues which have been discussed in the training.
Conduct a demonstration for 10-12 minutes. At a logical stopping point, call time.
Invite your patient to de-brief, focusing first on what they felt good about. Next, ask if there was anything they would have liked their counselor to provide that they didn’t. Confirm all responses.
Invite other participants to comment, addressing their positive comments first, and then invite their suggestions for improving the interaction. As before, listen and confirm all responses.
3. Summarize the discussion by making the following critical points it they have not been made by participants:
o The giving of HIV test results is a critical time for patients and providers should take great care to maximize the benefit.
o It is important to note that the most opportune time for education and information-exchange is in the pre-test information session. Once patients have heard their result, it is not likely they will attend to much educational content.
o The negative result-giving session can be an important time to motivate patients to avoid future risk (e.g. ‘Let’s think about how you can not have to worry again.’) and, where time allows, might be beneficially to provide in-person.
o The positive result-giving session is a very difficult interaction for many providers. It will be important to provide emotional support and offer resources.
o Providers should not try to ‘fix’ emotions; this is a difficult time for your patients and we cannot make that change.
o If nothing else can be accomplished, providers should strive to make a medical appointment and address patient’s immediate safety needs.
Once discussion has ended transition to the next activity by asking providers if they felt the patient they were seeing could benefit from additional community services or medical care. Next, ask how often real patients will need support or medical services from the HIV testing center. Acknowledge this common occurrence. State that the task is so important, we take some time to focus on steps for making effective referrals.
STEPS IN EFFECTIVE REFERRAL
Time: 20 minutes
Materials: Steps in Effective Referral (Slides 15-16)
Steps:
1. Begin the module by emphasizing that one of the most important components of post-test support in the provider-initiated testing session must be the process of making referrals. Emphasize this is especially important for persons who test positive.
Reveal Slide 15 (continue with Slide 16) and offer some suggestions for effective referral, emphasizing that the goal is to maximize that a patient follows through with our referral.
Referral letter- A referral letter establishes authority and assists the client to act on their own behalf. It should be noted that a referral is not a way to pass a problem along, but has a meaningful purpose for promoting the clients well being.
Observe Confidentiality- In the course of making referrals, confidentiality must be observed. Patients should know the information about themselves that is included in making the referral. The referral letter which you are giving to the patient should not contain any information that you would not want them to know or can prove harmful to them if it is lost or misplaced. Agency guidelines should direct the nature and content of information to be included on referral forms.
• Maintain and Update Directory – Formalizing the process of development of a directory and charging one individual with responsibility to maintain this resource facilitates easy access to a listing of multiple services and programmes for persons who need various forms of support and assistance. Know the resources that are available in your environment and use them.
• Refer to known and trusted resources- The most effective referrals are to specific providers with whom you have had experience and who can deliver.
• Offer referral as one option- In a client-centered approach, the client is offered the referral as a possible resource for them to take advantage of. It is contradictory in a humanistic approach to attempt to mandate clients receive any service: this is both disempowering and holds the possibility of clients reacting to our directives by rejecting them.
• Assess client’s reaction to referral- Note that clients may have a history with agencies and providers, and some referrals may have negative stigma in client’s minds. It is the client’s right to refuse a referral, it is your responsibility to offer.
• Instruct clients and prepare clients for agency services you are referring to- Suggest that specific teaching about what to bring, how to get to agencies, and what to expect at the organization will maximize the possibility that clients don’t ‘fall through the cracks’ of the service plan.
• Assess level of support for active referral- At times, client empowerment means giving client little direction and encouraging them to follow through, while other clients need to have appointments made or a plan of assistance developed. Managing the balance of providing too much support or not enough support is a critical clinical choice.
• Follow-up with client and referral source as appropriate: determine mechanism to find out from client and/or provider if client did follow through and how successful the interaction was.
• Receiving referrals- This is an equally important part of the referral process. How you receive and treat with a referred client will determine the success or failure of the intervention. It is important to acknowledge receipt, preferably through a written response. Where possible you may also wish to make a quick phone call to the referring agency just to inform that the referral has been used. All agencies should establish follow up and evaluation procedures.
• Disclosure and partner notification: Your role is to assist clients who are HIV positive to understand the importance of partner notification and the importance of their present and past sex partners being tested if this has not already been done. It is imperative that providers assist clients to develop a plan for disclosure.
It is suggested providers allow clients to discuss their fears and ask questions about any critical challenges that they may face, such as violence; this can direct where and to whom you refer.
Explore possible immediate personal sources of support such as friends or family. Referral to an identified professional, support group, or agency, can be useful for providing support and coaching in disclosure and partner notification.
2. Invite any final recommendations and suggestions for making referrals. Listen and confirm any responses.
3. Finally, acknowledge that the primary care provider may not have time to perform all the necessary functions associated with making referral. Ideally, the primary care provider would be the person who explains and emphasizes the need for and availability of treatment and care. In any event, the chief concern for the interdisciplinary team must be an assessment of appropriate referrals for clients receiving HIV test results and employing clinical skills at encouraging client follow-through on referrals made.
4. Transition to the workshop closure by explaining that the content for the workshop has been completed, and the final steps in the workshop will begin.
END OF MODULE 4
WORKSHOP CLOSURE
Time: 10 minutes
Materials: Evaluations
Steps:
Announce to participants that the training is concluding. Thank them for their hard work and willingness to participate.
Reveal newsprint labeled:
“I learned
or
One thing I’ll do differently”.
Ask if anyone wants to conclude the experience by sharing something they learned that was meaningful or something they will do differently. Invite participants who are willing to mention one thing they found valuable if they choose.
1. When participants have finished, instruct them to complete evaluation, discuss any follow-up training opportunities, and adjourn the workshop
END OF WORKSHOP
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