Taking the HIV test is a very traumatic event. Furthermore, this trauma reaches an extreme condition when the test result (positive or negative) is disclosed. It is therefore essential that the process of HIV testing be accompanied by counselling.

The following is an outline of the requirements, techniques, procedure for pre-test and post-test counselling for people who come to take the HIV test. This program has been developed by Dr. Bitra George at Safdarjung Hospital, New Delhi. As this is a successful pilot project funded by NACO and there are plans to duplicate it in other hospitals, the following information may be useful to health care providers (doctors, nursing homes, hospitals) who are already dealing with patients with HIV/AIDS in their work but have not yet been exposed to the extra sensitivity and understanding required when dealing with HIV infections.

If you are living with a person who is susceptible to risky behavior, the following material can help you understand the situation. In most cases, however, you are not equipped to be an effective counsellor as there is a pre-established relationship between you that prevents the other person from accepting your advise. Our best recommendation to you both is to go together to seek the advise of a professional.

For further information, please contact Dr. Bitra George at New OPD Block, Safdarjang Hospital, New Delhi. Telephone: 6198438


# Should have patience
# Should be a good listener, sympathetic and attentive
# Should aim to help and not preach
# The attitude should be unbiased and non-judgemental
# Should be a good communicator. Here the body language, verbal skills, choice of examples, and expression all play an important role
# Ability to reach out to the patient and show empathy
# Ability to draw the patient to you and develop trust
# Willing to admit mistakes
# Willing to learn and search for right answers
# Drawing boundries of limitation both for you and the patient
# Provide accurate information. If you are caught making up "facts" or guessing, you will lose trust and your role as a counsellor to that patient is compromised. (Patients in such situations will often test you, hoping you fail since that makes them feel less low.)


# Building a rapport
# Confidentiality of the interactions and establishment of trust
# Privacy during the meetings (one on one only)
# Sustainability of the effort


# It is a one to many communication It is a one on one interaction involving confidentiality, anonymity, privacy
# One deals with issues is general One has to deal with personal issues of the individual
# One shares statistical information, data and analyses to show trends and dangers of (i) epidemics (ii) risky behavior. Have to understand the individual to make an impact on specific attitude and behavior
# The interaction is impersonal The interaction can be very emotional


Establishing a rapport from the outset is very important.

# INTELLIGENT PERSONS (graduates): They have partial knowledge and often have an attitude of superiority. You have to fill in the gaps in their knowledge before they will look up to you for counselling
# WOMEN: may prefer to work with a female counsellor. The issue of gender matching is important for both sexes
# WOMEN: If the male partner is responsible for risky behavior, it is important to encourage her to bring along the partner. Gender bias or inequality in such situations is an important issue.
# STUDENT/ADOLESCENT: explore the reason for their trauma or fear
# ILLITERATE: Need explicit visual material as talking about it and non-personal/abstract examples are not easily assimilated


# Understand why the person has come to you -- what is troubling him/her.
# Identify the problem.
# Identify the behavior/attitude that has contributed to the problem.
# Make them aware of the consequences of their behavior/attitude.
# Provide them with different options, along with an assessment of the risk for each, from which they need to select one.
# Help evaluate the efficacy of the chosen option for that individual.


Risky sexual behavior is an additive habit just like alcohol or drugs. It is very important to understand that to change this behavior requires time, patience and expertise on the part of the counsellor.

# Overview of the reproductive organs in the human body.
# Provide an Overview of Sexually Transmitted Diseases (STD) in humans
# Make the person aware of consequences of risky behavior -- Sexually Transmitted Diseases and HIV/AIDS.
# Emphasize that there is no second chance with HIV/AIDS. Devastation for self and family
# Explain OPTIONS for risk reduction: (i) Abstinence from sex, (ii) sex with only one partner, (iii) Learning to have orgasms without penetration (iv) PROPER use of condom EVERY time
# Evaluate the patients choice to see if it is an attainable goal
# A good test of ability to put on the condom properly is to be able to do it blindfolded
# Make condoms available free to patient
# Re-evaluate the patient's knowledge regularly
# Continue the counselling until convinced that the patient will sustain the modified behaviory


# Review their case history of STD's with them
# Provide information on the different types of STD's -- bacterial (curable) and viral (no cure yet)
# Explain why difference in transmission rate from man to women is about three times higher than from woman to man. Women are at higher risk.
# Explain the difference in symptoms between men and women for STD's like gonorrhea, chlay, Human Pappiloma Virus (HPV). Most Women show almost no symptoms but suffer very serious consequences like Pelvic Inflammatory Disease (PID), cervical cancer, and infertility if untreated.
# Explain why it is essential for both partners to get tested
# Motivate change in sexual behavior to avoid future STI's and HIV/AIDS. Schedule next meeting in 3 months to review progress


# It is designed to help the patient cope with the information related to the disease and the test
# Provide understanding of what the test results mean
# Informed consent before the test
# If test result is positive then the patient is taught to understand his/her social responsibilities, and to develop skills to cope with the infection.
# If the test is negative, work to increase their level of information and understanding of the consequences of HIV infection. Motivate a change in behavior that reduces risk of getting infected

PRE-TEST COUNSELLING (25-30 minutes)

# Review why they have come for the test in a relaxing manner
# Review their knowledge of (i) condom use, (ii) sexually transmitted diseases, (iii) HIV/AIDS. Fill in the gaps in their knowledge
# Review and impress on them the consequences of risky behavior
# Assess the degree of risk for the client
# Slowly go over the nature of the test and the consequences of both a positive and negative result.
# In case of a positive result review the difference between HIV and AIDS. Stress the fact that the patient can still live a productive life for even as long as ten or more years and the prospects for therapy and cure are improving daily. Discuss their support system (family and friends)
# In case of a negative result discuss the window period for antibody based tests and the need for retesting after about 4 months depending on risk assessment. Impress on them that a negative result does not imply immunity from infection, and the need for a change in behavior.
# Obtain informed consent prior to the test.
# Schedule the next meeting a week after the test date


# Immediately reveal that the test was negative
# Allow time for the relief and happiness to settle.
# Reevaluate whether the person could be in the window period -- withing 3-6 months of having got the infection during which period negative results of tests based on detection of antibodies are not conclusive. If there is reason for concern that this may be the case, schedule an appointment for a retest in about 3-4 months and ask the patient to abstain from sex (or at least from unprotected sex) during this interval
# Reassess the knowledge base and awareness of the patient
# Reinforce risk reduction information
# Explore sustainable changes in behavior


# reveal test result directly but in a gentle tone and show empathy
# Allow time for ventillation of feelings. In majority of cases there is a emotional and physical breakdown. Allow the expression of grief through crying. Often there is denial -- it cannot happen to me, there must be a mistake in the test. Sometimes there is a silent acceptance but tumoil within.
# Once the patient has calmed down sufficiently to the point that you no longer fear that they may do themselves harm, reassure them of all possible help in terms of medical care, psychological support, and referrals to specialists.
# Schedule a meeting one week later to begin therapy


# Go over very carefully the difference between HIV and AIDS
# Stress the benefits of a positive outlook to life in order to make the best use of the future and to stay productive.
# Stress the need for a good, healthy, and balanced diet. (Lots of fruits and vegetables. Avoid spicy and heavy foods. Take vitamin and mineral supplements.)
# Need for regular exercise that does not cause fatigue. 15-30 minutes of brisk walking.
# Keep immune system strong. Avoid smoking, alcohol, drugs, and stress. Rest often to avoid fatigue.
# Yoga and meditation help with maintaining a positive outlook and a healthy body
# Explain the need for them to minimize risky behavior to avoid transmitting the infection to another person
# Encourage them to continue being loving and caring parents, and to make provisions for children in advance
# Review simple infection control measures in event of cuts, blood spills, hypodermic injections, etc
# Review need To treat minor infections early and properly. Provide information on how to evaluate the morbidity and seriousness of opportunistic infections
# Review the need for special attention to tuberculosis. Suggest regular screening for TB and for other opportunistic infections. Provide a referral service -- a list of sympatheic doctors with varied specialities in case of emergency.
# Review recent developments in therapy and understanding of the disease. Offer hope for the future.
# Build a support system consisting of friends and relatives. Encourage the patient to bring along one or more such persons to the counselling sessions. Develop a system of home based care for common infections and even for some of the simpler opportunistic infections.
# Advise confidentiality of status with associates at work and other casual associates. There is no need to advertise HIV status unless patient chooses to become an activist.
# Establish the need for counselling, and continue to build trust and to provide effective and regular counselling.
Rajan Gupta