Lay Counsellors: The Unheralded Backbone of South Africa's HCT Programme

politics hiv/aids Counselling and Testing Lay Counsellors
Wednesday, 6 April, 2011 - 10:01

Lay counsellors play a key role in the implementation of government’s HIV/AIDS programmes. Despite easing the pressure on hospitals and clinics to provide counselling and testing services, there is still no commitment on the part of government to properly recognise them

South Africa’s response to HIV and AIDS has been marred by years of HIV denialism at the highest level of government, and by fruity treatment recommendations that made our health ministry an international laughing stock. The announcement last year of revised HIV and AIDS treatment protocols and a large-scale HIV counselling and testing (HCT) campaign was therefore a welcome shift in approach.

And, if the numbers of people being tested, and as a result beginning government antiretroviral (ARV) treatment, are anything to go by, it appears to be working. According to government-issued statistics, in December 2009 there were 700 000 people on ARVs and in January 2011 the number had increased to over 1.3 million. The number of people tested for HIV since the launch of the HCT campaign is over 5.2 million.

The increasing number of people requiring testing, and the higher level of access to ARV treatment, presents new challenges for government, such as the provision of adequate testing kits, and access to ARVs and to lay counsellors.

Initially, nurses were primarily responsible for providing HIV/AIDS education, counselling, testing and support in hospitals and clinics around the country. As the incidence of the disease progressed, it became evident that nurses were being overwhelmed by the sheer number of HIV and AIDS infected patients arriving at clinics and the resulting need for the nurses to perform a role beyond simply testing. They were now informal ‘social workers’, responding to issues as diverse as food insecurity, domestic violence, rape, monetary grants, unemployment and child abuse.

The introduction of lay counsellors as a means of reducing the strain on nursing staff was a novel method of planning for and implementing HIV/AIDS initiatives, although the model has not been without its challenges.

Finding themselves in a similar position to nurses, lay counsellors struggled to deal with the complex social, gender, emotional and economic issues for which patients desperately needed support. Many counsellors are required to be versed in complex issues outside of their areas of competency. Some were stigmatised for being HIV/AIDS counsellors.

Government-sponsored communications programmes, prevention of mother to child transmission (PMTCT) programmes, provision of condoms, the gathering pace of ARV therapy roll-out and the latest HCT campaign have all contributed – to greater or lesser degrees – to a steady increase in the pressure on hospitals and clinics to provide counselling and testing services.

Up until May 2010, while the deployment of lay counsellors obviously contributed enormously to easing the burden on doctors and nurses, there were legal restrictions defining their sphere of responsibility. For example, lay counsellors were not permitted to perform ‘the prick’ and so still relied on nurses to complete the testing process. Dr Francois Venter, president of the Southern African HIV Clinicians Society and head of the HIV management cluster at Johannesburg’s Reproductive Health and HIV Research Unit, said: “It was ridiculous that one of our most important diagnostic tools be held hostage to our human resources crises.”

It was clear that the legal rules had to change in order to upscale treatment access and enable health care workers to become involved in particular stages of treatment provision where they were not previously allowed. Now, lay counsellors are permitted to carry out HIV tests, increasing human resource capacity and making the role of lay counsellors in government’s HCT campaign even more important.

Amazingly though, it is reported that lay counsellors are regularly not paid their monthly stipends by government, stipends that are, it should be noted, somewhere around just R1 000 per month. There is little or nothing in the way of formal recognition of training or skills transfer planning, career recognition or opportunities for advancement. Refresher training is at times sporadic and incomplete. There is still a lack of recognition for the role of lay counsellors in the sector.

In my work in the HIV/AIDS sector, I am often told that lay counsellors are among the most passionate and dedicated in the sector. Usually women, they display a genuine compassion for the members of their communities that are infected and affected by HIV/AIDS, attempting to provide this essential service in a manner that makes each person seated in front of them feel like they are receiving focused, individual attention and comfort during what is for far too many a desperately frightening moment in their lives. They do so day after day, month after month, in spite of delays in the payments that they require to sustain their families.

We cannot possibly expect government’s HCT programme to succeed while relying on lay counsellors’ passion alone. It is time that there is a sustained commitment, not only to conceptualising adequate policies and protocols in this area, but also to properly recognising the people that are required to implement them.

- Rachel Dlamini is programme specialist in HIV/AIDS at Tshikululu Social Investments (TSI). This article first appeared on the TSI website. It is republished here with the permission of TSI (

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