When is HIV counselling necessary?
Pre-test discussion
A discussion of the implications of HIV antibody testing should accompany any offer of the test itself. This is to ensure the principle of informed consent is understood and to assist patients to develop a realistic assessment of the risk of testing HIV antibody positive.
This process should include accurate and up-to-date information about transmission and prevention of HIV and other sexually transmitted infections. Patients should be made aware of the window period for the HIV test that a period of 12 weeks since the last possible exposure to HIV should have elapsed by the time of the test.Patients may present for testing for any number of reasons, ranging from a generalised anxiety about health to the presence of HIV-related physical symptoms. For patients at minimal risk of HIV infection, pre-test discussion provides a valuable opportunity for health education and for safer sex messages to be made relevant to the individual. For patients who are at risk of HIV infection, pre-test discussion is an essential part of post-test management. These patients may be particularly appropriate to refer for specialist counselling expertise. In genitourinary medicine clinics where HIV antibody testing is routinely offered as a part of sexual health screening, health advisers provide counselling to patients who have been identified as high risk for testing HIV positive.
The importance of undertaking a sensitive and accurate sexual and/or injecting drug risk history of both the patient and their sexual partners cannot be overstated. If patients feel they cannot share this information with the physician or counsellor then the risk assessment becomes meaningless; patients may be inappropriately reassured, for example, and be unable to disclose the real reason for testing. Counselling skills are clearly an essential part of establishing an early picture of the patient
Box 13.1 Counselling
Prevention
Determining whether the lifestyle of an individual places him or her at risk
Working with an individual so that he or she understands the risks
Helping to identify the meanings of high-risk behaviour
Helping to define the true potential for behaviour change
Working with the individual to achieve and sustain behaviour change
Support
Individual, relationship and family counselling to prevent and reduce psychological morbidity associated with HIV infection and disease
Box 13.2 Different HIV counselling programmes and services
Counselling before the test is done
Counselling after the test for those who are HIV positive and HIV negative
Risk-reduction assessment to help and prevent transmission
Counselling after a diagnosis of HIV disease has been made
Family and relationship counselling
Bereavement counselling
Telephone hotline counselling
Outreach counselling
Crisis intervention
Structured psychological support for those affected by HIV
Support groups
Box 13.3 Pretest discussion checklist
Indications for further counselling and referral to counsellor
People who have been sexually active in areas of high HIV prevalence
Men who have sex with men
Current or previous sexual partners HIV positive
Client presenting with clinical symptoms of HIV infection
High-risk sexual behaviour
High-risk injecting drug practices
Learning or language difficulties
Points for counsellor and/or physician to cover
What is the HIV antibody test (including seroconversion)?
The difference between HIV and AIDS
The window period for HIV testing
Medical advantages of knowing HIV status and treatment options
Transmission of HIV
Safer sex and risk reduction
Safer injecting drug use
If the client were positive how would the client cope: personal resources, support network of friends/partner/family?
Who to tell about the test and the result
Partner notification issues
HIV status of regular partner: is partner aware of patient testing?
Confidentiality
Does client need more time to consider?
Is further counselling indicated?
How the results of the test are obtained (in person from the physician or counsellor) and his/her history and of how much intervention is needed to prepare him or her for a positive result, and to further reinforce prevention messages.
It is at this stage that potential partners at risk are identified which will become an important part of the patient's management if HIV positive.Post-test counselling
Results
HIV results should be given simply, and in person. For HIV negative patients this may be a time where the information about risk reduction can be heard and further reinforced. With some patients it may be appropriate to consider referral for further work on personal strategies to reduce risks, for example one-to-one or group interventions. The window period of 12 weeks should be checked again and the decision taken about whether further tests for other sexually transmitted infections are appropriate.
HIV positive patients should be allowed time to adjust to their diagnosis. Coping procedures rehearsed at the pre-test discussion stage will need to be reviewed in the context of the here and now; what plans does the patient have for today, who can they be with this evening? Direct questions should be answered but the focus is on plans for the immediate few days, when further review by the counsellor should then take place. Practical arrangements including medical follow-up should be written down. Overloading the patient with information about HIV should be avoided at the result giving stage sometimes this may happen because of the health professional's own anxiety rather than the patient's needs.
Newly diagnosed patients
Counselling support should be available to the patient in the weeks and months following the positive test results. Immediate issues often include disclosure to others which may present a complex challenge to the patient. Current and previous sexual partners at risk will have been identified at the pre-test discussion stage and possible ways of informing these people will be explored with the counsellor. It is also important to discuss safer sex with those diagnosed with HIV. Pregnant women who test HIV positive need information and advice on the management of their pregnancy, including: options on reducing the risk of materno-fetal transmission, options for their own treatment and referral to specialist medical and counselling support.
Although testing HIV positive is not a reason per se for seeking a termination of pregnancy, all women should be given the opportunity to discuss this if appropriate. Families may be a source of support but in many instances patients need time to come to terms with their diagnosis and to fully understand its implications before they have the capacity or resources to raise it with parents, siblings and/or loved ones who will inevitably be distressed. Being identified HIV positive may facilitate constructive planning for the future, such as deciding on the future welfare and care of children, although this tends to happen later in the counselling process when the early shock has resolved.Counselling involves understanding a person in their social and familial contexts and many patients will derive crucial support and strengthening of coping mechanisms from this intervention during this vulnerable period. Counselling support can also help a patient engage in wider medical care and monitoring. If a person is inadequately prepared for the test, or a positive result is given inappropriately, he or she may reject further intervention including accessing medical care and therefore the likelihood of psychological morbidity and disease progression may be increased. It seems the getting it right for patients at early stages of diagnosis has a profound effect upon
Box 13.4 Counselling skills
Empathy
Non-judgemental approach
Active listening
Clear discussion and information giving
Ability to establish working relationship with client
Facilitating appropriate planning by the client
Motivating appropriate self-care and reflective abilities
Box 13.5 Post Test Counselling HIV Positive Result IMMEDIATE FOLLOW-UP
Time for ventilation
Awareness of shock factor keep information to a minimum
Focus on coping today, tonight, next few days
Who knows the patient is receiving the result today?
Safer sex/Partners
Arrangements for confirmatory HIV test
Follow-up medical and counselling appointment
Written information support numbers
Box 13.6 Psychological issues in HIV/AIDS counselling
Shock
of diagnosis
recognition of mortality
of loss of hope for the future
Fear and anxiety
uncertain prognosis
effects of medication and treatment/treatment failure
of isolation and abandonment and social/sexual rejection
of infecting others and being infected by them
of partners reaction
Depression
in adjustment to living with a chronic viral condition
over absence of a cure
over limits imposed by possible ill health
possible social, occupational and sexual rejection
if treatment fails
Anger and frustration
over becoming infected
over new and involuntary health/lifestyle restrictions
over incorporating demanding drug regimens, and possible side-effects, into daily life
Guilt
interpreting HIV as a punishment; for example, for being gay or using drugs
over anxiety caused to partner/family their capacity to cope in the subsequent months and years, and to access help appropriately in later stages of disease.
The importance of encouraging and working towards coping strategies involving active participation (to the extent the patient can manage) in planning of care and in seeking appropriate social support has been demonstrated clinically and empirically. Such an approach includes encouraging problem solving, participation in decisions about their treatment and care, and emphasising self-worth and the potential for personal control over manageable issues in life.