HIV/AIDS Counselling: Disclosure Counselling

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DISCLOSURE COUNSELLING

This type of counselling assists clients to understand the need to share their HIV status with trusted loved ones for the purpose of support and care. In addition, it assists clients understand the importance of disclosure to reduce risks of re-infection by partner(s).

PLWHA may need support to disclose their status to loved ones and their loved ones may need support to cope with their feelings about the information. This is what makes Disclosure counselling a complicated process because the counsellor has to give support to the primary client but also to the significant others of the client and in some instances it is the counsellor that may have to disclose the HIV status of client to loved one.

Motivations for disclosure vary greatly, and debates about “degrees of disclosure” have been evoked. The “degrees of disclosure” refer to level of disclosure a client seeks, some want to disclose to loved ones while others may want to go public with their disclosure to help in reducing stigma in the community and to work as HIV/AIDS activists.

The Benefits of Disclosure Counselling

• Helps the client ensure that an HIV negative partner does not become infected
• Help ensure that positive partner can also access early care, treatment and support
• It can also reduce the risk of an unborn baby contracting HIV from its mother.

Guidelines for disclosure counselling

• Counsellor must respect a client’s decision not to disclose to partner when adamant and not put any pressure on client to disclose status out of coercion.
• Counsellor must never disclose client’s status without consent.
• The Counsellor must support client through the decision-making process with on-going counselling sessions.
• If the client refuses or is taking time to disclose status then Counsellor must work and encourage the client to identify at least actions that would be adopted to reduce risk of infecting partner during this period.
• The Counsellor must be ready to have series of counselling sessions with client before arriving at a final decision.

PARTNER NOTIFICATION IN DISCLOSURE

There are three ways in which partner notification can be carried out. They are:

• Client Referral: This is a situation where the PLWHA chooses to inform the partner himself or herself. The advantage of this sort of disclosure is that Client is familiar with the partner and knows the best way to approach difficult issues with the partner and also knows what to do to calm or appease partner during such emotional crisis. The disadvantage is that the client lacks the counselling skills and experience which may help to alleviate the situation.
• Counsellor referral: This is a situation whereby the Counsellor provides disclosure of client’s status to client’s partner with client’s consent.
• Dual referral: In this situation the partner is informed by both client and counsellor after rehearsal has been done to see how best the disclosure can be carried out. The advantage of this sort of partner notification is that both client and counsellor can promptly react to any situation that arises from partner, the counsellor handling the situation with a professional touch while the client gives it a personal colouring.

Disclosure counselling, especially partner notification, is a controversial subject still highly debated in many countries and society, so it is wise to consider every aspect including the legal provision of the country.

REFERENCES

1. World Health Organization (1994); Source Book for HIV/AIDS Counselling Training,
2. Thomas, Prof. Gracious (2010), HIV/AIDS: Stigma, Discrimination and Prevention, IGNOU, New Delhi
3. World Health Organization (2004): Voluntary HIV Counselling and Testing, Manual for Training of Trainers, New Delhi, India
4. NACO (2011): Annual Report 2010 – 2011, National AIDS Control Organisation, Ministry of Health & Family Welfare, GOI
5. UNAIDS (2007); Counselling and HIV/AIDS, UNAIDS Technical Update, Best practice Collection

HIV/AIDS Counselling: Bereavement & Crisis Counselling

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BEREAVEMENT/GRIEF COUNSELLING

Bereavement is a term that can be used to describe any event that includes loss, so this could mean losing a job or the death of someone you know. Bereavement can also be termed as grief.

Bereavement in relation to HIV/AIDS could be grief over the loss of a dear one or grief upon learning one or a partner or a friend is HIV positive. Grief is multidimensional it can be experienced on all levels of the person, in the heart (feelings and emotions), the mind (thoughts), the spirit (meaning of life), the body (physical manifestations). It is a time of transition, beginning with period of diagnosis to death, shock of an anticipated loss, of trying to prepare for the inevitable.

When death follows a terminal illness (like AIDS) even though the family and friends know that the death is inevitable and have watched the person slip away during the illness, they are still left with a sense of loss. People grieve not only for the deceased, but also for the unfulfilled dreams and plans for the future that they hoped to share with them.

There is no right way of coping with a death; people respond to a loss in their own individual way. The way a person responds is partly dependent on their relationship with the deceased, but it also depends on their own personality and upbringing.

Goals of Bereavement Counselling

The main goal of bereavement counselling is to increase the reality of the loss to the mourners and help provide psychosocial and emotional support to them. Bereavement counselling also helps:

• To help the person deal with spoken and unspoken feelings which he/she is experiencing about the loss of loved one or the HIV diagnosis
• To help the person overcome difficulties of readjustment to everyday life after the loss or diagnosis
• To encourage the person to say an appropriate goodbye and to feel comfortable reinvesting in life after the loss of the loved one without feelings of guilt
• To help the person to be able to adjust to life after an HIV diagnosis.

CRISIS COUNSELLING

Crisis counselling is a short term intervention which focuses on dealing with the immediate situation. It involves helping clients to understand the crisis situation, express their feelings about it, and outlines an action plan and getting referrals. Crisis counselling in relation to HIV/AIDS is defined as a confidential dialogue between a PLWHA and a counsellor aimed at enabling the client to cope with the crisis which is being experienced. The crisis could be:

• · Diagnosis of HIV infection
• · Unexpected death in family
• · Breakup of a relationship
• · Death of another PLWHA
• · Emergence of new symptom
• · Treatment failure or anything that an individual perceives as a severe life event

The role of the counsellor in crisis counselling

One of the counsellors’ major roles during crisis counselling is to help the client define the problem and help restore a sense of control. Sometimes the crisis is so overwhelming for the client that he/she is unable to identify what the major problem of the crisis is, is it the HIV diagnosis itself or is it the need to disclose HIV status to a spouse that is causing the crisis and if both are regarded as a problem, which is the more serious of the two to the client. The counsellor must “Begin where the client is” and be reassuring and supportive as the client discusses the crisis. The counsellor must listen carefully and patiently because the client may sound incoherent initially but with adequate support will calm down and start communicating in a more coherent manner.

Counsellors should never offer false assurances to clients such as statements like “all will be well” because the counsellor really does not know if all will be well and cannot guarantee the client that his HIV diagnosis status will decline rapidly to AIDS or that if client was raped that the rapist is probably not HIV positive. This sort of false reassurance may temporarily help in calming the patient but on the long term I f the client does test HIV positive or declines rapidly from HIV to AIDS, the client will lose trust in the counsellor and feel that the counsellor lied to him/her.

The counsellor should help break the problem into smaller parts and help client prioritize different aspects of the problem. The counsellor should repeat certain information repeatedly to ensure that the client understands the situation and is not in denial. But the counsellor should not overstate the issue and annoy the client who is already emotionally overwrought. The counsellor should also help client set realistic goals for problems and identify which ones he can do something about and which one the client will just have to accept as a part of life.

HIV/AIDS Counselling: Preventing Mother-to-Child Transmission

 
PREVENTING MOTHER-TO-CHILD TRANSMISSION (PMTCT)

This is another form of pre-test counselling. This is because for the pregnant woman who is getting tested she will be given pre-test counselling but because she is pregnant she will also be informed about the different options available for pregnant women who are HIV positive to avoid infecting their child with HIV.

Counsellor in antenatal clinics should provide information on Mother to Child Transmission (MTCT) to pregnant women. Counsellors must explain that HIV can be transmitted from mother to child during pregnancy, delivery, or breastfeeding. The benefits of early testing during pregnancy so as to enable better care for mother and child should also be emphasized.

Most HIV-positive children get the virus from their mothers. This type of transmission is called “vertical transmission”. There are three major ways for a pregnant positive woman to pass the virus to her child they are

• During pregnancy: About 25 % of infections occur during this stage. During pregnancy, the virus can be passed to the child through the placenta, especially if it is damaged in any way.
• During childbirth: About 60% of infections occur during this stage. During childbirth, the virus can be passed to the child through contact with the mother’s vaginal secretions and blood.
• Through breastfeeding: About 15% of infections occur during this stage because of the presence of the virus in breast milk. The chances of a mother passing HIV to her baby are higher if she becomes pregnant at a time when there is a high level of HIV virus in her blood. This happens when she is in the window period or she is ill with AIDS.

Advantages of Testing during pregnancy

• Knowledge of HIV status facilitates early referral for care.
• Knowledge of HIV status allows appropriate treatment and follow-up of the child.
• Knowledge of HIV status provides an opportunity to implement strategies to prevent transmission to the child.
• Knowledge of HIV status enables women to take precautions to help prevent transmission to sexual partners.
• For HIV-negative women, knowledge of HIV status can lead to appropriate HIV prevention measures and risk-reduction behaviour.

HIV/AIDS Counselling: Preventive Counselling

This post is part of a larger write-up on HIV/AIDS Counselling & Support - A Social Works Perspective. You may download it in one single pdf: HERE

 

 
PREVENTION COUNSELLING

Prevention counselling is similar to pre-test counselling as it provides an opportunity for the counsellor/client to negotiate and reinforce a plan to reduce or eliminate the risk of HIV transmission. Prevention counselling can also be given to relatives and significant others of an infected person so as to protect them from contacting the infection in the process of caring for the PLWHA. As seen above prevention counselling can be categorized into two:

• Primary Preventive Counselling: This is the counselling given to an individual to avoid contracting an infection.
• Secondary Preventive Counselling: This is the counselling given to an individual who is positive to help reduce the risk of re-infection. It is also given to the family, significant others and care givers of any infected person to enable them to be able to give proper care to the PLWHA as well as to protect themselves. It covers such issues as Universal Basic Precaution as well as Home Based Care.

Goals of Prevention Counselling

Preventive counselling facilitates an accurate perception of HIV risk for those who are unaware, uninformed or in denial. It should also:

• Translate the client’s risk perception into a risk reduction plan that may be enhanced by knowledge of HIV infection status.
• Helps clients initiate and sustain behaviour changes that reduce their risk of acquiring or transmitting HIV
• Assess the clients readiness to adopt safer behaviours by identifying behaviour changes the client has already implemented and negotiate a realistic and incremental plan for reducing risk
• Determine the client’s understanding of HIV transmission and the meaning of HIV antibody test results
• Safe sex options can be discussed. A condom demonstration can be carried if client is willing to use condoms and is interested in knowing how to make proper and consistent use of a condom

HIV/AIDS Counselling: Post-Test Counselling

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POST TEST COUNSELLING

Post-test counselling helps the client understand and cope with the HIV test result. Here, the counsellor prepares the client for the result, gives the result and then provides the client with any further information required, if necessary referring the person to other services. The two usually discuss ways to reduce the risk of infection or transmission. HIV test results should always be given with counselling. The form of post-test counselling will depend on what the test result is.

The main goal is to help the client to understand and come to terms with his/her test results and to initiate adaptation to their sero-positive or sero-negative status. Post-test counselling helps the client to understand and cope with the HIV test result. Counselling for people who have recently received their results is similar to pre-test counselling, because both of them involve HIV risk assessment and the promotion of safer behaviours. The main difference is that in post-test counselling clients need to deal with the reality of their situation and not imagining it in the future. Clients also need to have a clear understanding of what their results mean and what options are available to them.

Giving results (positive) can be difficult and uncomfortable for the counsellor. Sometimes the counsellor fears they may not know what to say or do to an emotional client and fear that clients may harm themselves or others. Because of this counsellors may be tempted to make inaccurate suggestions and give inappropriate assurance so as to make the client feel better but this would be doing the client a disservice because the counsellor would be lying to the client and it is also unethical and unprofessional.

IMPORTANCE OF POST TEST COUNSELLING

Counselling after an HIV test is important for the following reasons:

For Positive test results: Post test counselling is given to convince the client about the reality and seriousness of the situation – it is often difficult for people to accept and believe that they are HIV positive based only on the results of a blood test, especially if they are feeling healthy and strong:

• To ensure understanding of the test result.
• To help client cope with the positive result, especially in the days and weeks to follow.
• To make a plan for ongoing medical care and necessary referrals
• To provide information about the dangers infecting others and getting re-infected with different strain of the virus.
• To understand the need for careful planning and importance of medical attention for client who want to have children
• To help the client with the issue of disclosure.

For negative test results

• First, because of the “window period”, a negative result may not mean absence of infection, and the client might wish to consider returning for a repeat test after 3-6 months.
• Second, counsellors need to discuss HIV prevention, providing support to help the client adopt and sustain any new safer practices.

For indeterminate test results

• To explain the need for re-testing and the reasons that the result could have been indeterminate
• To help the client develop a plan for protecting him/herself from HIV

Clients may experience a range of emotions upon learning their test results. Many of these emotions will be very strong and should be acknowledged by the counsellor. A client who is very emotional, either in a positive or negative way may be too distracted to hear information that is given to them. Therefore, it is important to help the client to explore his/her emotions and “vent” them. Once a client has released his/her feelings, s/he will be more receptive to receiving other information regarding prevention, treatment and referrals.

Reactions to results from clients can vary from happiness (negative result) to anger despair, depression, grief, anxiety, suicidal ideations, shock and denial (positive or indeterminate result). What determines people’s reactions to their result varies. One of the most important is how well-prepared the person was for the news during the pre test counselling at which the counsellor should have properly prepared the client for the result and also have studied the client and be able to determine the pre-test psychological condition of the client which would help in anticipating how the client would react to the result.

IMPORTANT POINTS FOR POST TEST COUNSELLING

Post test counselling must begin the session by asking how the client has been feeling since having the test and what has been going through his/her mind since taking the test. They should also give the test result in a neutral tone of voice which shows no emotions to reflect what the result is. State the result clearly and simply.

• It is important to begin the post-test session by asking how the client has been feeling since having the test and what has been going through his/her mind since taking the test.
• Ask the client if they have any questions but by this time most clients are anxious to receive their result and might not be ready to ask any questions.
• Give the test result in a neutral tone of voice which shows no emotions to reflect what the result is. State the result clearly and simply.
• Make sure that the client has understood the test result and that the client is emotionally and psychologically ready for more information to be provided
• Assess the clients understanding of the test result. Ask the client to explain what the test result means to him/her and check for any misperceptions or misinformation.
• Assess emotional understanding by asking the client how he or she is feeling at that moment, and allow the client to express the emotions

Once the client is emotionally able to cope start to help the client to plan what the next steps will be. This is called behavioural integration. Behavioural integration requires that the client make an immediate plan (ask ‘what are you planning to do when you leave here today?’) as well as plans for partner notification (disclosing HIV status to partner), modifying the risk-reduction plan or other behavioural changes depending on their test result and the clients Situation.

HIV/AIDS Counselling: Pre-Test Counselling

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1. PRE-TEST COUNSELLING

HIV counselling is often given in connection with a voluntary HIV test. Such counselling helps to prepare the client for the HIV test, explains the implications of knowing that one is or is not infected with HIV, and facilitates discussion about ways to cope with knowing one’s HIV status. It also involves a discussion of sexuality, relationships, possible sex- and drug-related risk behaviours, and how to prevent infection. It helps correct myths and misinformation around the subject of AIDS. Whenever resources permit, pre-test counselling should be made available to those who desire it.

People who do not want or do not have access to pre-test counselling should not be prevented from taking a voluntary HIV test, however. In contrast, informed consent is always required before an HIV test where the individual’s name will be linked to the result. To allay anxieties while awaiting the test result, some individuals may seek support not only from their own families or a knowledgeable community worker.

Pre-test counselling simply refers to counselling given to an individual prior to taking an HIV test. It is given to prepare the person for the HIV test and the implications of taking the test. Pre test counselling has certain core objectives which are:

• To explain the test and clarify its meaning;
• To also explain the limitations of test results and to caution the client about potential misuse of results.
• To help the client to think about possible reactions to the test result and who should be told. If the test result is positive, who could be informed and who could provide emotional support
• To help the client understand why the test is required and to make a decision about the test.
• To review the client’s risk of infection which is also called risk assessment. HIV/AIDS risk assessment requires discussion of personal sexual lifestyle of the client, with far-reaching implications.
• Correct myths and misinformation about HIV
• Review the test procedure, including issues related to false positive and false negative and also “window period”
• Explain and obtain informed consent Discuss potential implications (personal, medical, social, psychological and legal) of a negative or positive result; discuss and demonstrate condom use

1.1 IMPORTANT POINTS FOR PRE TEST COUNSELLING

Pre-test Counselling is usually the first point of contact of the client with counsellor/health facility that is providing the testing service so it is important to establish a good rapport. If you prepare your client well during the pre-test session, you may encounter fewer difficulties during the post test.

• Identify yourself and clarify your role as a counsellor.
• Emphasize confidentiality of everything that will be discussed.
• Ask if relevant why he/her opted to come for counselling and/or testing or clarify why he was referred for counselling.
• Obtain relevant medical history (past and present) e.g. serious illness in the past, blood transfusion; cough and diarrhoea, STD's etc;
• Ask about personal habits such as smoking, drinking, drugs etc. This helps with assessing risk behaviour
• Ask about sexual history. Does the individual have a steady partner, wife/husband, boy/girlfriend, other partners outside relationship, etc;
• Assess client's knowledge on HIV/AIDS. This enables the counsellor the opportunity to correct misconceptions /misunderstandings; Also to cover such issues as modes of transmission, prevention etc.
• Assess the client’s understanding of getting tested for HIV and what the test entails
• Explain what the result will mean if positive or negative including the window period and explore the personal implications of having the test, and what a positive or negative result will mean to him/her and their family and/or significant others;
• Educate the individual on safer sex practices and healthy lifestyle practices.
• Discuss with the client what will be required in the area of behaviour change to reduce the risk of contracting HIV irrespective of whether the result will be positive or negative;
• Help identify how the client will protect their sexual partner/s
• Explore clients support mechanisms. Who they will tell or talk to about their results? Where they will get support? Explore areas of strength e.g. faith and/or other support systems (supportive husband/wife, relatives, or work-mates);
• Explain the procedure for the HIV test and what it entails
• Provide an opportunity for the client to ask questions
• If the client decides to test, obtain informed consent. Explain the informed consent form and allow the client time to read a leaflet on HIV testing where feasible

1.2 RISK ASSESSMENT

Risk assessment refers to conducting a review of clients’ risk of HIV infection. It is important to remember that this is a very sensitive subject and the client is expected to share information that he/she may never have shared with any other person. To assess the client’s personal risk, the counsellor should continue to explore with him/her the following areas:

• Current and past client’s sexual behaviour
• Current and past sexual behaviour of the client’s sexual partner(s)
• Current and past drug usage pattern of both the client and clients partner
• Has client’s ever had a blood transfusion done?
• Client’s exposure to non-sterile invasive procedures

Based on the information gathered from the risk assessment, the counsellor can help the client identify any behaviour that leaves the client open to risk of acquiring or transmitting HIV. The essence of exploring risk with the client is not only to show the client that he/she is open to risk of infection but also to help the person examine ways in which he/she can reduce the chances of getting infected. This means helping the client to develop a risk reduction plan.

1.3 EXPLAINING HIV TESTING AND THE MEANING OF TEST RESULTS

Clients considering testing for HIV must be provided with appropriate information they need to make an informed decision and this should include the method for testing used in the organization. This is very important because some people have a fear of needles and need a lot of psychological preparation before taking an injection so the counsellor may have to prepare the individual as well answer questions the client will have about the testing procedure.

It is important that the counsellors be sufficiently knowledgeable about HIV testing procedures as clients will often have concerns about the accuracy of the test and have specific questions about the laboratory procedures used and the counsellor has to be able to show familiarity with the testing procedure so as to convince the client. The client should also be assured of the confidentiality of the whole testing procedure.

The counsellor should also take time and ensure that the client understands the meaning of a negative or positive HIV result. The counsellor should never assume that the client understands the meaning of the negative/positive test result because the meaning of negative/positive in the English language may confuse some clients.

1.4 CONSENT FOR HIV TESTING

Counsellors should always ensure that a client’s consent is given and depending on the organization maybe in written format. It is the client’s right to have or refuses to have an HIV test carried out and they should not be coerced.

It is the counsellors duty is to ensure that client understands the meaning and possible implications of HIV testing and to ensure that the client does not feel pressured to make a decision but rather that the client makes the decision to test at their own pace.

Finally it is important to reassure the client that the test result will be held in the confidence, to reinforce reasons why the client may benefit from knowing his/her HIV sero-status, and provide an appointment to return for test results.

HIV/AIDS Counselling: Definition, Goals & Types

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HIV/AIDS COUNSELLING: DEFINITIONS

Counselling has been defined as a process of helping a person/people learn how to solve certain interpersonal, emotional and decisional problems. Counselling, in relation to HIV and AIDS is a confidential dialogue between a person and a care provider aimed at enabling the person cope with stress and make informed personal decisions relating to HIV and AIDS (World Health Organisation-WHO 1994).

Counselling poses an essential part of HIV antibody testing. HIV/AIDS Counselling is universally performed in two distinct phases - before (pre-test) and after testing (post-test) - regardless of the client’s HIV status. Counselling prior to the test, known as Pre-test Counselling, will help the client understand the test results and its implications. Post-test Counselling is undertaken irrespective of the test result to help the client to integrate and understand the meaning of the test result at all levels - rationally, emotionally, behaviourally, and medically (Jose & Jyothiram, 2008).

MAJOR GOALS OF HIV/AIDS COUNSELLING
The major goals of HIV/AIDS counselling are as follow:

a) Preventive: Providing counselling service and information to help prevent and mitigate the continued spread of HIV by providing information about risk behaviours that leave people vulnerable to contracting HIV infection as well as helping individuals to develop the required skills for behaviour change.

b) Supportive: Providing counselling services to help support people that are infected or affected by HIV. The support includes emotional, social and psychological help given to people who are infected by HIV and those that are affected by the virus.

c) Rehabilitative: Ensuring that clients have access to all the health services available by providing adequate referrals for treatment, care and support services.

TYPES OF HIV COUNSELLING

There are several types of counselling in relation to HIV Counselling. The essence of the different types is to provide for the different stages of the HIV infection that the infected person and the relations will go through. The types include:

a) Pre-test counselling
b) Post-test counselling
c) Prevention counselling
d) Bereavement counselling
e) Crisis counselling
f) Disclosure Counselling
 
The Various type of HIV/AIDS Counselling are explained in the next posts….