Carol Apiyo* is struggling to cope with bitterness and anger towards her husband, whom she blames for infecting her with HIV; a few months ago, she tried to kill him by poisoning his food.
Fortunately her husband recovered after treatment at Gulu Hospital in northern Uganda. "I can't forgive him for what he has done to me – he is the only man I have known in my life," she told IRIN/PlusNews. "I [still] feel like killing him."
Her husband, Richard Okello*, told IRIN/PlusNews he had no idea he was HIV positive. "I [only] knew the result when my wife told me that I was required to undergo HIV testing with her at the antenatal clinic," he said. "The result was shocking because I have been using condoms with my other partners.
"I apologized to her but all she says is I betrayed her; I didn't know it would end like this," he added.
According to health workers in Gulu district, the counselling given to people such as Okello and Apiyo is insufficient to deal with the complicated feelings and issues they face following a positive diagnosis.
"Counselling lasts less than 15 minutes when patients are given their results; they are later left on their own without follow-up counselling," said William Odur, senior psychiatrist at Gulu Hospital. "After they are given their HIV status, a number develop mental disorders, are depressed, commit suicide or kill their partners."
The country has had several cases of murder following HIV-positive diagnoses, including a man in the southwestern district of Rukungiri murdering his wife in 2008, the lynching of a woman in Gulu suspected of infecting a man and, in September, a 20-year-old woman in the eastern district of Soroti being sentenced to death for killing her soldier husband after she tested positive and he was negative.
|I apologized to her but all she says is I betrayed her; I didn't know it would end like this|
"One session is rarely sufficient, especially with discordant couples," said Goretti Nakabugo from Strengthening HIV/AIDS Counsellor Training in Uganda (SCOT), part of the national NGO, The AIDS Support Organization (TASO). "Counsellors need to put couples in touch with peer support networks or arrange for follow-up home visits."
She noted that over and above dealing with the fear, suspicion and anxiety when one partner is found to be HIV-positive, counselling was needed to support both the negative partner - now at high risk of contracting HIV - and the positive partner, who needed to know how to live a healthy life.
Under Ministry of Health guidelines on HIV counselling and testing, only trained counsellors should provide HIV pre- and post-test information or counselling; training for counsellors is at least one-month long and must be conducted by a government-approved institution.
Need for more counsellors
However, Zainab Akol, head of the HIV programme in the Ministry of Health, told IRIN/PlusNews the government had no register of all the HIV counsellors operating in the country; she added that many professionally trained counsellors worked in fields other than HIV.
A counsellor at Gulu Hospital told IRIN/PlusNews that counsellors often conducted their work hurriedly due to the high volume of people turning up for VCT after public campaigns encouraging widespread testing.
Paul Olobo said he was counselled for just 10 minutes at Gulu Hospital.
"Your test result shows that you are HIV positive, it's not the end of the world and you should accept it - that is what I was told at the hospital and the health worker sat quietly waiting to see the next patient in the line as I walked out of the counselling room," he said. "It's up to the patient to decide what next; it's not easy."
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Uganda is also in the process of rolling out provider-initiated counselling and testing - where health workers routinely offer HIV counselling and testing to all patients visiting health facilities - and couples counselling and testing, which will require even more health workers.
Quality over quantity
"Counsellors need to look beyond targets and numbers and try to provide a quality service to their clients," SCOT's Nakabugo said. "The 45 minutes or one hour allocated for each client is often not enough to ease their anxiety; shock is a natural reaction so both pre-test and post-test counselling must be provided.
"Counsellors should also make use of the wealth of the communities they work in - use their referral networks to put people in touch with people who can support them," she added. "Guidance on disclosure is also important - for example, if telling your family that your partner is HIV-positive and you are not will cause trouble, perhaps it's better not to do so."
* Not their real names