MD Year 3, USM July 2008

Communication skills in HIV Counseling:

Pre and Post Test HIV Counseling

Dr WAN MOHD ZAHIRUDDIN WAN MOHAMMAD Lecturer (Epidemiology & Biostatistics) Department of Community Medicine

Objectives

At the end of the lecture/role-plays/discussion sessions, students will have adequate knowledge and basic communication skills in General HIV counseling HIV counseling and testing Aims, key points and steps in Pre-test and Post-test HIV counseling

Lecture outlines

RecallHIV/AIDS Overview on HIV counseling and testing Pre-Test and Post-Test HIV counseling Aims and key points Steps Role-plays Feedback and Discussions

What are HIV and AIDS?

HIV stands for human immunodeficiency virus. This is the virus that causes AIDS. AIDS stands for acquired immunodeficiency syndrome. AIDS is the final stage of HIV infection.

Mode of transmission of HIV

1. Sexual transmission
sexual contacts with an infected partner

2. Blood transmission

sharing needles and/or syringes with someone who is infected (e.g among injecting drug user) through transfusions of infected blood or blood clotting factors. through needle prick or when infected blood gets into an open cut or a mucous membrane.

3. Vertical transmission (mother to child)

Babies born to HIV-infected women may become infected during pregnancy, during birth or through breast-feeding.

High risk groups of HIV/AIDS

HIV/AIDS prevention and control measures must reach the people most at risk of infection, examples include: injecting drug users (IDU) men who have sex with men (MSM) commercial sex workers (prostitutes) and their clients young people women and girls migrant people, ethnic or cultural minorities and other marginalized populations. selected occupational groups that mobile (foreign workers, long distance drivers etc).

Few facts about HIV/AIDS

HIV-infected person may be symptom free for many years (median 9 years) until develop AIDS (may die within 1 2 years without treatment). Antiretroviral therapy may improve HIV/AIDS general health and quality of life, but neither cure the patients. It may prolong survival time between 4 12 years and may prevent many opportunistic infections (OIs).

First line regime of HAART (highly active antiretroviral therapy) is given free by the government to eligible and adherenceensured patients in Malaysia.

HIV Counseling and Testing

Rationales of HIV testing

Early knowledge of HIV infection is now recognized as a critical component in controlling the spread of HIV infection.

Cohort studies showed that many infected persons decrease behaviors that transmit infection to sex or needle-sharing partners once they are aware of their positive HIV status. HIV-infected persons who are unaware of their infection and those who do not return for test results do not reduce risk behaviors and might increase their risk for transmitting.

Because medical treatment that lowers HIV viral load might also reduce risk for transmission to others, early referral to medical care could prevent HIV transmission in communities while reducing a person's risk for HIV-related illness and death.
MMWR, 2001 / 50(RR19); 1-58 CDC

Benefits of knowing HIV status

AT INDIVIDUAL LEVEL

AT COMMUNITY LEVEL

Creates more realistic self-perception of clients vulnerability to HIV Promotes or maintains behaviors to prevent acquisition or further transmission of HIV Alleviates anxiety, and facilitates understanding and coping Facilitates entry to interventions to prevent mother to child transmission Helps client to plan and make informed choices for the future Leads to early referral to HIV specific clinical care, treatment, and support

Creates peer educators, and mobilizes support for appropriate responses Reduces denial, stigma and discrimination; and normalizes HIV/AIDS.

HIV testing in Malaysia

Universal testing (opt-out screening) program targeted at low and high risk group. Must have pre dan post test counseling. Routinely screened people for HIV

antenatal mothers attending government heath clinics inmates in drug rehabilitation centers (pusat serenti) and prisons (done on admission, 6-months and pre-release) TB and STD patients patients with regular blood transfusion (e.g thalassemic or hemophiliacs) sex workers (female and males).

Mandatory HIV testing Blood donor (government policy since 1986) Migrant worker (10% blue collar workers)

HIV Counseling and Testing

The World Health Organization (WHO) and major international public health organizations have drawn urgent attention to the need to rapidly increase access to knowing ones HIV status. Voluntary Counseling and Testing (VCT)

an innovative strategy for an efficacious entry point for HIV/AIDS care and support.

VCT approach follows a regimen of pre-test counseling, testing and post-test counseling.

VCT as an entry point for HIV/AIDS

care and support

What is Counseling?

Defined as an interaction in which the counselor (helper) offers another person(s) the time or attention or respect necessary to explore, discover, and clarify ways of living more resourcefully.

Counseling provides options for decision-making and behavior change.

Good counseling helps another person to be autonomous (i.e., able to choose, make decisions, and be responsible for his or her own actions).

What is HIV Counseling?

Confidential dialogue between a client and a counselor aimed at enabling the client to cope with stress and make personal decisions related to HIV/AIDS (WHO, 1994). The counseling process includes evaluating the personal risk of HIV transmission and discussing how to prevent infection.

Roles of HIV Counseling

HIV counseling plays two important roles

preventing HIV infection by promoting behavior change providing psychosocial support to people infected and affected by HIV.

These roles are fulfilled by:

Giving information about HIV/AIDS to clients and their partners; Encouraging preventive behaviors; Helping HIV-positive clients and those close to them cope with the diagnosis; Discussing decisions that need to be made, according to the clients life circumstances; Referring clients to appropriate treatment and care services.

Core Principles for HIV counseling and testing

HIV testing should be voluntary (mandatory testing is neither effective nor ethical)
Informed consent should be obtained, include following elements: Providing pre-test information on purpose of testing Offering information on treatment and support available once results are known (post-test) Ensuring understanding; and respecting individual autonomy

Confidentiality must be protected

Post-test support and service are crucial

Who should be counseled and tested?

VOLUNTARILY (potential for behavior change). Target group include Young people and High risk groups People with risk behaviors that increase chances of getting HIV

Injected drugs or shared equipment (such as needles, syringes, works) with others? Unprotected vaginal, anal, or oral sex Men who have sex with men, multiple partners, or anonymous partners? Unprotected sex with someone who could answer yes to any of the above questions? People who seeking help because of past or current risky behavior

Who should be counseled and tested?...

MEDICALLY INDICATED in clinical care settings: Patients with signs and symptoms of HIV infection or AIDS To support clinical diagnosis and treatment For TB patients regardless of sero-prevalence rates In sexual and reproductive health care settings For PREVENTING HIV IN MOTHERS and THEIR INFANTS Should be offered to all pregnant women as part of standard care and the approach could be opt in or opt out. (esp. in high prevalence areas).

Who should provide HIV counseling?

Not every person who practices counseling skills can be considered a counselor. People who may play a role in providing HIV counseling services includes:

Nurses, doctors, social workers, and other healthcare providers who have been specially trained in HIV counseling; Full-time counselors (including psychiatrists, psychologists, and family therapists) who have been trained in HIV counseling; Community-based workers whose work consistently entails appropriate handling of confidential information and emotional issues; People living with HIV AIDS (PLWHA) individual or groups

Good HIV counselors

Counselors may not actually be involved in treating illnesses related to HIV/AIDS. A good HIV counselor: Understands all aspects of HIV/AIDS (medical, behavioral, sociocultural); Should be aware to whom to refer patients for appropriate medical care Possesses good communication skills and is familiar with counseling techniques; Accessible and available to clients; Able to empathize; Able to express himself/herself coherently and precisely; Able to recognize his/her limitations; Possesses a high level of self-awareness; Is authentic, sincere, and honest; sense of humor

Place for HIV counseling

Can take place in any setting where a quiet, distraction-free, private and confidential discussion can be held. Settings can be as varied as hospital wards, antenatal clinics, community health centers, churches, or schools.

Should minimizes the difference between counselor and client. E.g, counselors should not wear a uniform or sit in a tall chair or behind a large desk.. Counseling services should always be available at sites where HIV services are being provided (where results can be linked to the individual).

Basic HIV counseling skills

1. Interpersonal Skills

Establishing rapport Ensuring confidentiality Showing respect and empathy

2. Communication skills and techniques

using an appropriate language level using impersonal statements (third-person). E.g:

People can feel a lot of confusion and guilt when they hear information about HIV. Some of my clients want to know how they can stay in good health and where they can find help.

Basic HIV counseling skills

Asking open-ended questions ( not yes or no answer).

Useful in starting a dialogue, finding a direction, and/or exploring a clients concerns. How do you think the virus is passed from one person to another? How much do you know about the risk factors or lifestyles of the people you are having sex with? What do you understand by the word confidentiality? What do you know about HIV infection? What do you know about how HIV is transmitted? What do you think about using condoms? Whom have you spoken to about taking an HIV test? Why do you think you were able to use a condom that one time?

Examples:

Basic HIV counseling skills

Clarifying

on unclear points, e.g facts about HIV transmission.

Paraphrasing on clients words in counselors own words Reframing on clients comments Repeating information Summarizing Probing Confronting differences in client's risk perception, e.g:

Based on what you told me, in that you have multiple partners and you do not use condoms with all of them, I am really concerned that you could get HIV. If this is the case, are you aware that you are putting yourself at risk of acquiring the HIV infection?

Self-awareness for HIV counselors

Counselors are not isolated from the fears and emotions that all people deal with when facing HIV/AIDS. Counselor self-reflection and self-awareness are integral to counseling interaction. To be effective, counselors need to know how they themselves function emotionally. Counselors must face their own inner feelings about HIV/AIDS. If counselors are not in touch with themselves, they cannot help others effectively.

Questions that will aid counselors in increasing self-awareness

Do I feel uncomfortable with a client or with a particular subject area? Am I aware of my own avoidance strategies? Can I be completely honest with the client? Do I always need to be in control of the situation?

Types of HIV Counseling

General HIV counseling Pre-test counseling Post-test counseling Support counseling

During symptoms and signs Medical care and follow-up Terminally ill Family and other support

Pre Test HIV Counseling

What is Pre-test HIV counseling?

A counseling which occurs before a clients blood is tested for status of HIV infection.

Aims

General: To provide information and support for behavior change and risk reduction in HIV Specific: Review and clarify a clients concern and risk of infection Check their understanding of how HIV is transmitted Explain the test and clarify its meaning Help client make informed decisions by weighing up the benefits, disadvantages and limitations of having the test Help the client think about possible reactions to the test results (either positive and negative) and whom to inform; Help the client prepare for future difficulty and to provide support for them and their contacts

Key Points

Confidentiality Risk assessment including sexual and drug history Understanding HIV infection Reducing risk of HIV infection and transmission HIV testing types, advantages, procedures Preparation for the test results Consent Informing sexual partner or drug-using partner Waiting for the result

Confidentiality

Stress to client that all information is limited to only the counselor/attending doctor/nurse and the client only. Permission from the client to document the information given should be obtained. Information maybe given to other counselor/attending medical personnel on a need-to-know basis.

Risk assessment

Clarify the clients knowledge and concern on HIV transmission

Can you tell me all the ways that you know how HIV is transmitted? How do you think you might have been infected with HIV? What do you mean by having sex? Could you please elaborate, so that I can assess your risk

Establish also the time of the first and the last perceived risk or exposure (in relation to Window Period)

Reducing risk of transmission

Take the opportunity to ask and clarify about reducing risk of HIV transmission Do you know how to protect yourself/others from HIV infection? Are you in a mutually faithful relationship with your sexual partner? Risk reduction methods may include

Abstinence Sex sexual practices being faithful, avoid penetrative intercourse, use condoms or other barriers Do not share needles or syringes (if you still taking drugs) Do not donate blood if you are at risk of having HIV infection

Roles of HIV test

Advantages

Diagnosis of present sero-status Behaviour modifications to reduce risk of infection and transmission Reduce anxiety of worried-well Enable client to seek early medical treatment Enable client to address future needs and life decision e.g marriage, children, will etc

Disadvantages

Discrimination e.g difficulty in purchasing life insurance, loss of employment, educational opportunities etc Stigma and isolation

How do HIV test works?

Once HIV enters the body, the immune system starts to produce antibodies. The presence of antibodies is used to tell whether a person has HIV in his or her body. The most common HIV tests use blood to detect HIV infection but tests using saliva or urine are also available. Some tests take a few days for results, but rapid HIV tests can give results in about 10 15 minutes. All positive HIV tests must be followed up by another test to confirm the positive result. Results of this confirmatory test can take a few days to a few weeks.

Types of HIV test

Two main types of HIV tests

antibody tests (e.g. ELISA, simple/rapid, saliva and urine, and Western blot) virologic tests (e.g., HIV antigen test, polymerase chair reaction test, and viral culture).

Antibody tests

ELISA (enzyme-linked immunoassay)

use blood drawn from a vein (the most common methods used) use oral fluid (not saliva) that is collected from the mouth using a special collection device. use urine instead of blood. The sensitivity and specificity are somewhat less than that of the blood and oral fluid tests.

Rapid HIV test

A screening test that produces very quick results, ~ 10 15 minutes. Uni-Gold Recombigen test (FDA and MOH-approved) has almost 100% Sensitivity and 99.7% Specificity. Rapid tests use blood from a vein or from a finger stick, or oral fluid to look for the presence of antibodies to HIV. These tests have similar accuracy rates as traditional EIA screening tests, but follow-up confirmatory test must be done before a final diagnosis of infection can be made.

Window period

Means the time between initial HIV infection and when the body builds a measurable antibody response to it. It can last from as little as 2 8 weeks to as long as 6 months. But 97% will develop antibodies in the first 3 months following the time of infection. Thus, if a person tests negative to antibody test (especially within 3-months following exposure), they maybe are still in the window period, and need to re-test after 3 months. However, HIV is replicating in the blood/lymph nodes and it can be detected during this phase only by lab. tests used to identify the virus itself (e.g by a virologic test as within 9-11 days)

Immunology of HIV infection

Window period

Nature Reviews Immunology 4, 630-640 (August 2004)

Consent

Prior to the HIV test, the client must have undergone pre-test counseling Informed consent must be obtained

Prepare for HIV test results

During pre-test counseling, counselor must prepare the client mentally for the subsequent negative or positive results. Assess clients past and present coping skills Useful questions: If your result is positive, how do think you would feel? When you were in trouble in the past, how do you cope? Who would you go to when youre in trouble? The client must understand the meaning and implications of the window period. And the need for re-testing if the result is negative (only applies if less than 3 months since last exposure)

Waiting for the result

In the summary of pre-test counseling session, several issues must be highlighted

Check the understanding on window period Prevention of infection and transmission Clients support system Waiting period for results and follow up appointment (avoid giving results during weekends and public holidays) What do you think you would like be doing while waiting for the results?

Useful question

Steps in Pre-Test HIV Counseling

1. Establish a relationship with the client. 2. Obtain background on reasons the client is seeking testing, his/her behaviors and perceived risk.

3. Ascertain the clients level of HIV/AIDS knowledge and the test.

4. Provide information about safer-sex practices, injecting drug use and healthy lifestyle practices. 5. To determine whether the client wants or agree to test for HIV.

Steps 1
Establish a relationship with the client.

During this phase, the counselor identifies himself/herself and clarifies his/her role.

It is critical that confidentiality is emphasized at this time.

The counselor obtains the clients basic biographical information, including his/her name or code name (if a code name is used, no address is recorded) or other required information.

Steps 2
Obtain background on reasons the client is seeking testing, his/her behaviors and perceived risk.

Obtain reasons for seeking testing. Additional information:

Clients personal habits (smoking, drinking, drug use, etc.), his/her sexual history (about steady partner, husband/wife, boyfriend/ girlfriend, or other partners, condom use, etc.) any other risky behaviors e.g sharing needles etc

Obtain relevant medical history (past and present), including serious illnesses, blood transfusions, cough, diarrhea, STIs etc. If female, determine how many pregnancies she has had.

Steps 3
Ascertain the level of HIV/AIDS knowledge and the test.

Identify misconceptions so they can be corrected. Assess understanding of what the test entails. Explain positive and negative results, window period, how the test is administered and how long the results to be available. Explore the personal implications of taking the test, including what a result will mean to the client, the family or others. Psychosocial reactions and support mechanisms should be discussed, including plans regarding whom to tell about the test result and contact for support while awaiting the result. They should recognize the benefits of knowing their HIV status.

Steps 4
Provide information about safer-sex practices, injecting drug use and healthy lifestyle practices.

If the client is practicing risky behavior, it is important to discuss what may be required of the client in terms of behavior change. A condom demonstration can be given while discussing safer-sex strategies. It is critical that the client have an opportunity to ask questions.

Steps 5
To determine whether the client wants or agree to test for HIV

At this point, the client should have a good understanding of the test, the implications of taking the test, and his/her personal reasons for doing so. If the client decides to take the test, obtain informed consent. Explain the consent form and, when feasible, allow the client time to read a leaflet on the testing procedure. After the client has taken the HIV test, he/she will need to obtain the results and post-test counseling. Where same-day results are not provided, the counselor should arrange a date and time for a follow-up interview or post-test counseling.

Checklist
At the end of pre-test counseling session, the client should understand:
1. 2.

3.
4. 5. 6. 7. 8.

HIV test information and the procedures Information about HIV/AIDS Reasons for considering testing Clients informed consent to be tested and obtained. The limits of confidentiality Psychosocial implications of testing positive HIV/AIDS preventions and risk reduction Strategies for coping including support systems.

Role plays

In role plays, people pretend they are in a certain situation or scenario and act how they think persons in that situation should behave. Participants may also have mixed feeling about the prospect of becomingly intimately involve in some role play situations. So, know your roles, pretend it and think that you are watched using a CCTV! Dont forget to de-role play and let the feelings go.

Good luck!

Objective: To practice using the counseling principles and steps in Pre-Test HIV Counseling

Time allocated: 30 minutes Case Scenario

Case A: Mr X, single, a 30 year old salesman requesting HIV test. He frequently visit sex workers during his business travels, and sometimes take drugs. Case`B: Miss R, married, a 28 year old secretary has come in asking for HIV test. She has past history of pre-marital sex with her boyfriend.

STEPS:

Divide participants into a small group of four. Each participant to write 3- 5 main learning points from the session Each group appoints: A counselor, a client and two observers

Choose on case scenario above and role play for 15 minutes. The observer should watch and NOTE: o What the counselor does o How the client reacts o What is being done to achieve the aim of pre-test counseling

At the ends of 15 minutes, discussion feedback on the role play with the facilitator (lecturer and other students)

References

Trainers Guide on HIV Counseling, 2nd ed. (2001). Institute of Public Health, Ministry of Health Malaysia. HIV Counseling and Testing. Family Health International. http://www.fhi.org/ Revised Guidelines for HIV Counseling, Testing, and Referral. MMWR, CDC, November 9, 2001 / 50(RR19);1-58.

Next..Post Test HIV Counseling