In this writing the writer is going to discuss the stages of HIV and AIDS Counseling and these are pre-test counseling, post test counseling and on- going counseling, which is normal done for HIV positive clients. However before these stages are discussed further, the writer is going to give a brief background of HIV and AIDS Counseling. This will include the definition of HIV and AIDS Counseling. Various definitions by different scholars are going to be reviewed.
HIV has emerged as the greatest challenge faced by communities in the past 20 years. This impact has been particularly devastating for the individual who is infected and for the family of such an individual.HIV has cut through the very fabric of human existence and brought with it untold suffering for the infected and the affected. The suffering is as a result of inter alia that HIV has no cure and is life limiting, that progression of infection may and often brings about gradual and painful deterioration of the being of the infected individual that HIV brings to a premature end and individuals aspirations and dreams for the future.HIV brings with it a host of emotional or psychological, economic, spiritual, medical or physical problems. Coupled with this are problems that may be to do with unavailability of needed drugs, the unaffordability of anti-HIV drugs and for some lack of access to health institutions. People who are infected with HIV have to make such adjustment in their lives that will enable them to cope with new demands placed on them. These adjustments are aimed at enhancing chances of enjoying a reasonably good quality of life and chances of long-term survival and thus counseling comes in to do exactly this.
Counseling is an intervention strategy that seeks to help individuals make adjustments and to support in their efforts to live positively with HIV. It is therefore incumbent upon every health practitioner to be familiar with and competent in counseling and to make counseling an integral part of the service they provide to their clients. To best understand (and practice) HIV Counseling, one has to gain an appreciation of basic counseling concepts. There are many definitions of counseling. Counseling has been defined in many different ways. One definition which l find apt is by Albers, which states: ’’It is a process of helping people learns how to solve certain interpersonal, emotional and decisional problems. The goal is to help each individual take charge of his or her own life by developing the ability to make decisions wisely and to alter one’s behavior to produce desirable consequences.” While Gillis defined counseling as a ‘facilitative process in which the counselor, working within the framework of a special helping relationship, uses specific skills to assist clients to develop self knowledge, emotional acceptance, emotional growth, and personal resources.” Both definitions talks about giving the client the opportunity to explore and discover ways of living more fully, satisfying and resourcefully as well as addressing and resolving specific problems, making decisions, coping with crisis, working through feelings and inner conflict, or improving relations with other.
According to Egan,’’ counseling has a dual purpose, that is to help clients manage their problems more effectively and develop unused or underused opportunities to cope more fully and to help and empower clients so that they become more effective self-helpers in their everyday lives”.
The framework of counseling outlined above can be adapted to most forms of counseling (child abuse, violence or HIV).The pertinent question is to determine which issues to discuss for each type of counseling. The purposes of HIV Counseling as has been mentioned above is to enable the client to talk about their problems, concerns and fears in an atmosphere of acceptance and trust and to help the client to develop strategies for living with HIV, to provide psychosocial support to enable the infected and affected to resolve the wider range of problems that they may and do encounter and to enable the prevention of the spread of HIV infection by helping individuals reflect on the extent to which they have been at risk of acquiring HIV and by helping the individuals introduce and sustain positive behavior change. Below are the stages of HIV and AIDS Counseling (pretest counseling, post test counseling and follow –up or on- going counseling). What are outlined below are the highlights of what should form part of HIV Counseling at each stage. The first stage to be discussed is pretest counseling.
Pretest counseling, before a person decide to take the HIV test they need to understand what the test will and will not tell them. The principal focus of this stage is to establish what the clients knows about HIV testing, the client’s knowledge of HIV and to help the client with relevant knowledge about HIV including how it is spread and prevention strategies because having an HIV test is a very serious decision to make, a positive or negative result may affect a person’s life in many ways. According to Egan,” the purpose of Pre test counseling is to raise important issues and considerations about the HIV test and individual concerned. The important issues and considerations raised during counseling may even influence the individual to go or not to go for test.” This view is supported by Alta van Dyk, who states that the purpose of pre test counseling is to give someone who is considering being tested for HIV all the necessary information and support to make an informed decision. She further states that information on the technical aspects of testing and the possible personal, medical, social, psychological, legal and ethical implications of being diagnosed as either HIV positive or HIV negative should be provided . In this regard there is also need to find out the reasons why individuals want to be tested; the nature and extent of their previous and present risk behavior; and the actions required preventing them from becoming infected or from transmitting HIV infection. The following are the steps that should be followed in conducting a pretest counseling session; relationship building, confidentiality, reasons for testing, assessment of risk, belief and knowledge about HIV infection and safer sex, information about the test, the implication of an HIV test result, anticipate the results, information about giving the results and on- going support, informed consent and conclusion. Each of these steps will be discussed more in detail below;
Relationship building as the first step used in pre-test interview involves creating an atmosphere of safety and trust and to help the client tell his or her story. The Counselor should assure privacy and welcome the client. The counselor should introduce herself or himself and explain his or her role for example is he or she doing only counseling or will also carry-out the testing? The counselor should also explain the reasons for pre test counseling; that it is a legal and ethical requirement; that the test may have vast implications; that the clients need to be sure about having the test; and that it remains the client’s choice to be tested or note. The client will also need to be assured of confidentiality as will be explained more in the next step. The counselor also need to find out more about the client, for example age, occupation, relationship status and family background before moving to the next step, that is confidentiality.
Confidentiality as the second step in pre test interview, assures clients that their right to confidentiality will be respected at all times. If individuals choose not to disclose their status, they must be reassured that no information will be communicated to anyone without their prior permission so as to open up during the interview. According to Bloom, The counselor should also discuss the concept of group confidentiality when necessary. Group confidentiality applies where the counselor is not qualified to do the HIV test and a third party, usually a nurse will be required to administer and interpret it . For example Health care professionals are ethical and legally required to keep client information confidential. Giving out information on a patient’s illness or treatment requires the patient’s consent. If clients do not have the assurance that health care professional will keep their diagnosis confidential, they might be afraid to go for treatment. If the client is satisfied with the confidentiality arrangements, then the counselor should move further to ask the client the reasons for testing, which is the next step in the pre test interview.
Reasons for testing as the third step in pre test interview involve exploring why clients want to be tested. It is for insurance purpose, because of anxiety about high –risk sexual behavior, worry after being raped or because the person has been forced by somebody else to take the test? Any issues that make the client feel that he or she might be infected must be explored. The counselor should also observe any particular behaviour or symptoms causing concern to the client. For example the counselor should check whether the client has sought testing before and, if so, when? From whom? For what reason? And with what result? These questions give the counselor insight in to individual’s perceptions of their own high risk behavior, the urgency of having the test, their knowledge of HIV, and their emotional state. If the client is tested because you as a counselor you had suggested it, explain why you think it is advisable. For example for treatment purposes only. Also the counselor should explain to the client that the test is voluntary and he or she may refuse to be tested. However knowing the client’s reasons for testing is important for the counselor because it sets the scene for the rest of the pre test counseling sessions, for example it will helps in carrying out the client’s risk assessment which is next step or session in pre test counseling.
Assessment of risk as another step in pre test counseling involve the assessment of the likelihood of whether the client has been exposed to HIV considering if and how frequently he or she has been exposed to the risk factors and lifestyle indicators. This involves checking the client’s sexual risk history in terms of frequency and type of sexual behavior. For example has the client been involved in high-risk sexual behaviours such as virginal or anal intercourse with more than one sex partner without the use of a condom? In case of anal sex was it anal-receptive or anal-insertive sex? Is the client’s partner HIV positive? This assessment exercise can go on and on until all risk areas or situations have been explored. If explanations reveal that the client has been at risk of HIV infection, the counselor should share this with the client. For example if the client is positive discuss the possibilities of HIV transmission to her baby during pregnancy, during birth or during breast feeding as well as ways to prevent mother to child transmission of HIV. Once the assessment has been done the counselor should further determine what the client believes and know about HIV. This will take us to the next step for pre test interview, which looks at beliefs and knowledge about HIV infection and safer sex.
Beliefs and knowledge about HIV infection and safer sex are also checked as part of the important step in pre test counseling after the assessment of risk. Here the counselor is expected to determine exactly what the client believes and knows about HIV infection and AIDS, and to correct errors and myths by providing accurate information about what HIV infection and AIDS entails the modes of transmission, prevention, symptoms, and the progression from HIV to AIDS. The amount of information given will depend on the clients’ needs and their knowledge and level of comprehension. The counselor should also ask the client about their past and present sexual behavior and also provide information about safer sex practices and health lifestyle. For example you can find out whether the client knows a condom and how to use it correctly. If possible you can demonstrate how to use them or even give them condoms if necessary. Once the beliefs and knowledge about HIV infection and safer sex have been established, the next step will be to establish whether the client knows what the HIV test entails. This will then take us to the next step of pre test interview, which looks at information about the test.
Information about the test is one of the steps in pre test interview that helps to ensure that your clients know what the HIV test entails and the test procedure as well as the meaning of the results. The following are some of the HIV testing procedures which according to Blom, clients may need to know. First the testing procedure, that is if the rapid HIV antibody test is done, the counselor should explain to the client that his or her finger will be pricked to collect a drop of blood for the test. It is also important to explain the period that it will take for the results to be available depending on the type of test. Some results may take 10- 15 minutes (anti body test), while some may take 2 to 14 days(ELISA test).Further more it is important to explain to the client the role of confirmatory test, the difference between being seropositive and having HIV, the meaning of positive test and a negative test result. It also important to ensure the client that the results are very reliable with rare occurrences of false positive or false negative results. Once information about the test is given, the next step will be to look at the implications of an HIV test result as the next step in pre test interview.
The implication of an HIV test result is one of the important steps in pre test interview, which explore with clients all the possible advantages and disadvantages of testing, and explore the implications of each result (positive, negative and inconclusive) for the individual, for the partner/s and for the family. For example one advantage of taking the test is that knowing the results may reduce the stress associated with uncertainty while one disadvantage of testing may be problems in maintaining relationships and in making new friends. It is important to ensure clients who test positive that medical treatments are available that can help them stay healthier for longer. It is therefore important at this stage of pre test interview for the counselor to anticipate a negative or positive result and start talking about it with the client. This will be dealt with in the next paragraph.
It is important for the counselor to anticipate a negative as well as a positive HIV antibody test result and to talk about how the client will deal with the test outcome. The counselor should ask the client how she or he would feel about a negative test result and the importance of staying negative. Anticipating a positive result also helps the counselor ascertain the client’s ability to deal with and adjust to a positive result Preparing a client for a positive result paves the way for more effective post-test counseling.Albers suggest that in order to prepare the client for the test result, the following questions should be asked, that is, for example how would you feel if you tested negative or positive? .However the choice to be tested remains with the client despite any reaction to the said questions. It also important at this stage for the counselor to the client information about giving the results and ongoing support, as will be highlighted below.
Information about giving the result and ongoing support should be explained to the client and be assured of personal attention, privacy, confidentiality and ongoing support and advice if needed. Clients should be told that they are free to bring along a friend or family member when they come for the results and the counselor should accommodate such request from client, however issues of confidentiality and disclosure should be discussed with the client. This stage now brings us to another important step of pre test interview which talks about support networks and the waiting period which will be talked about in the next session.
The counselor should identify the client’s support networks, by asking the client whether is there anyone who knows that they are inquiring about HIV testing and what they will do if the HIV test result is positive. This can go further to enquire about how the client has been associating with other people and whether those people are still available. This is important because waiting for results can be very stressful. If the client has to wait for the results the counselor should anticipate the difficulties of this period. It is therefore important to encourage client to do something enjoyable to keep occupied while waiting for the results. At this point the counselor can seek for informed consent from the client about whether to be tested or not and this will discussed in the paragraph below.
The decision to be tested can be made by the client only and the counselor must obtain informed consent prior to testing. Consenting to medical testing or treatment has two elements; information and permission. This means that before testing the client must understand and the nature of testing and must not be deceived into consenting to an HIV test. Pre test HIV counseling is extremely important as it gives an opportunity to educate people about HIV /AIDS and safer sex. It also forms the basis of post test HIV counseling which will be discussed as the second stage of HIV and AIDS Counseling.
The principal focus of post-test counseling is to give the client the results and to support the client through whatever emotional reactions become manifest. Although the post-test counseling interview is separate from the pre test counseling interview, it is inextricably linked to it. The pre test counseling should have given the client an idea of what to expect in post test counseling. Pre test and Post test counseling should preferable be done by the same person because the established relationship between the client and counselor provides a sense of continuity for the client. The counselor will have a better idea of how to approach the post test counseling.
Counseling after testing will depend on the outcome of the test, which may either be a negative result, a positive result or an indeterminate or inconclusive test result. For both the counselor and the client, a negative HIV result is a tremendous relief. However a negative test result could give someone who is frequently involved in high risk behavior a false sense of security. It is therefore extremely important for the counselor to counsel HIV negative clients in order to reduce the chances of future infection. Risk reduction and safer sex practices must be emphasized. For example people who practice high risk behavior and test negative may believe that they are immune to HIV and that precautions are therefore unnecessary. This is dangerous assumption and must be rectified. The counselor must explain to the client that no one is immune to HIV and that there is also the possibility that the client is in the window period, or that the negative test result may be false negative. However if there is concern about the HIV status of a person, he or she should return for a repeat test 3-6 months later and during this period the client should take appropriate precautions to protect him or herself and sex partners. If the result is HIV positive, the counselor should take the following steps.
Counseling after a positive HIV test result needs a health care person who is tremendously responsible in how to communicate positive test result to clients. People’s reactions to test result depend largely on how thoroughly their counselors have educated and prepared them before and after testing. Although it is good to ask questions, one should not bombard a client with information that he or she is unable to absorb at that moment. Although there is no recipe or plan for telling a person that he or she is HIV positive. The best the counselor can do is to be there for the client and let the client lead in your response and care. According to Albers and Blom, the following guidelines may prove useful.
The first guideline is that the counselor should prepare him or herself before giving a client the result (positive or negative) of an HIV test, by making sure that he or she have the right results by checking the name of the client against the formal results, make sure that he or she understands what the results mean, make sure that he or she have time to spend with the client and finally must make sure that he or she is emotionally ready to give results to the client. The second guideline of telling the client result involves sharing the results with the client and is outlined below.
Positive or negative test results should be given to the client personally and feedback should take place in a quiet, private environment, and enough time should be allowed for discussion. During this process the counselor should greet and welcome the client and ascertain that the client is ready for the results. A positive result ought to be communicated calmly, professionally and empathically. Simply and straight forward language should be used. The counselor should not give the client a false hope. For example when conveying positive result, the counselor should not attach value to the results by saying ‘l have bad news for you’. Such an attitude reflects hopelessness in the mind of the counselor. Rather the counselor should say:’ Mr. Moyo, the results of your HIV test came back, and you are HIV positive’ and go on to tell the client that nowadays HIV infection is a chronic, manageable infection and the counselor’s task is to convey realistic optimism and hope. However they are a few don’ts that we need to observe when sharing a positive HIV test results with a client and these include; don’t lie or dodge the issue, don’t beat about the bush or use delaying tactics, don’t break the news in a corridor or any other public place, don’t give results over phone, don’t interrupt or argue and don’t be afraid to admit ignorance if you don’t know something. The third step in HIV post test counseling or interview involves handling client’s reaction to a positive HIV test result.
It is never easy to tell people that they are HIV positive. Counselor should therefore work through their own feelings about the results before they counsel and clients’ responses to the results usually vary from one client to another, and may include shock, disbelief, numbness, crying, agitation, stress, guilt, withdrawal, anger and outrage, while some may respond with denial, indifference or even relief. The counselor should not take any reactions personally, and he or she should show empathy, warmth and caring and allow client to deal with the results in their own way and give them the opportunity to express their own feelings. The counselor should accept and normalize any responses and feelings that have been evoked, by reflecting the feelings that are demonstrated and talk about the expressed feelings, concerns and reactions. In doing so the counselor should maintain neutrality and respond professionally to outburst and keep in mind that the client is facing multiple losses. The counselor should respect the personal nature of an individual’s feelings as this may affect the way he or she responds to the client’s needs, which is the next step that follow after handling the client’s reaction to a positive HIV test result.
People’s needs after receiving HIV positive test results will vary, and the counselor has to determine what those needs are and deal with them accordingly. It is important to note that these needs may necessarily need to be discussed in the first session, but some time later during the second visit or follow up counseling sessions. The counselor should allow the client to lead the session and to introduce his or her needs, while he or she provides a safe and caring environment for the client to explore his or her needs. The following are some of the issues that can be discussed at the client’s pace; the issue of antiretroviral medication. In this case the counselor has to be sure that he or she is familiar with the latest research on antiretroviral and functions of ART should be explained in full to the client. The other issue could be the availability of support groups to the client. Clients should be referred to support groups where people meet regularly to talk about their difficulties or simply to relax and enjoy each other’s company. According to Brouard, the counselor should work with hope and empowerment when responding to a client’s needs by supporting the client’s realistic hopefulness and being encouraging without discounting the client’s concerns or avoiding talking about death and dying and stressing that people with HIV are living productive lives. The counselor should help the client to plan clearly and concretely how he or she will manage his or her life and arrange follow-up counseling appointments if possible . Follow up counseling or visits will be discussed more in detail below.
Follow up counseling or visits brings us to the third stage of HIV and AIDS counseling and these are important for HIV positive clients because when people hear that they are HIV positive, they usually experience so much stress that they absorb very little information. Follow up visits are therefore necessary to give the clients the opportunity to ask questions and talk about their fears and the various problems they encounter. It is important to include other members of the family in the session if possible to get their support. However if the health care professionals are not in a position to do follow up counseling, they should give the client information are relevant health services. If there is concern that that the person might not return to follow up counseling, information about available medical treatments such as antiretroviral therapy, treatment of opportunistic infections, social services for financial and ongoing emotional support should be given. Clients should also be given a handout with whatever relevant information he or she may need such as telephone numbers and address of AIDS centres and other social services.
Follow-up counseling is also necessary in crises intervention. This is often necessary if the client shows tendencies to or talks about suicide. The possibilities of suicide can be identified in the pre test counseling session. The counselor should take a more active role in crises intervention to help the client contain his or anxiety or despair, to identify and evaluate any immediate threat to safety and to take active steps to increase the safety of the client. The counselor should focus on options to access immediate informal support, professional help or emergency services. This may also involve contacting friends or family members, but if they cannot be with the client then hospitalization will be option. Follow up counseling is also necessary after an inclusive HIV test result and this will be discussed in detail below. Follow up counseling is necessary after inconclusive HIV test result because waiting for further test to be done after inconclusive results can induce acute and severe psychological effects in people. Follow up counseling enables the counselor to explain to the client what the result means as well as to advise the client about other methods that can be used to try to achieve a reliable result he test can be repeated after two weeks. If it is still inconclusive, it should be repeated at three, six or twelve months. If still inconclusive after a year, it should be accepted that the person is not infected with HIV. Clients should be supported while waiting for their results by encouraging them to use safer sex practices while waiting.
In conclusion, HIV and AIDS counseling is very crucial for both HIV negative and positive test results clients as was discussed in all the stages of HIV and AIDS counseling. The stages included pre test counseling, post test counseling and follow up or ongoing counseling. Pre HIV test counseling is extremely important and should not be seen only as a preparation for HIV test but also an opportunity to educate people about HIV and AIDS and safer sex, while post test for HIV positive test result makes a tremendous and irreversible impact on people’s life. Post test HIV test counseling also help people to make important decisions about their lives and to live within the constraints imposed by the virus. The counselor must therefore undertake the very important task of helping the client make the decision to live a healthy and happy life after diagnosis through regular follow up or ongoing counseling.
End Notes
G.R,Albers,Counseling AIDS,Dallas;World Publishing; 1990 H.Gillis,Counseling young people 2nd edn;Pretoria;Kayiso;1994 G,Egan,The skilled helper, a problem management approach to helping 6th edn;Pacific Groove;Brooks/Cole;1998 Ibid Van Dyk, Alta,HIV and AIDS Counseling; Pearson Ed.SA Pvt Ltd;Capetown;1999 S,Blom, Pre and Post test counseling and testing; Cape Consulting; Capetown;2001 G.R,Albers,Counseling AIDS,Dallas;World Publishing; 1990 Ibid P,Bouard, et al, HIV and AIDS in South Africa; University of Pretoria Centre for the study of AIDS; 2004
Alta Van Dyke,HIV and AIDS Counseling; Pearson Ed.SA Pvt Ltd;Capetown;1999
Blom. S, Pre and Post test counseling and testing; Cape Consulting; Capetown;2001
Bouard P, et al, HIV and AIDS in South Africa; University of Pretoria Centre for the study of AIDS; 2004
Egan. G,The skilled helper, a problem management approach to helping 6th edn;Pacific Groove; Brooks/Cole;1998
Gillis. H,Counseling young people 2nd edn;Pretoria;Kayiso;1994
