PRE-TEST AND POST-TEST COUNSELLING FOR STD's and HIV
By Dr. BITRA GEORGE, SAFDARGANJ HOSPITAL, NEW DELHI
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
QUALITIES NEEDED IN A GOOD COUNSELLOR
| # | 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.) |
PRE-REQUISITES FOR SUCCESSFUL COUNSELLING
| # | Building a rapport |
| # | Confidentiality of the interactions and
establishment of trust |
| # | Privacy during the meetings (one on one only) |
| # | Sustainability of the effort |
THERE IS A DIFFERENCE BETWEEN HEALTH EDUCATION AND COUNSELLING
| | HEALTH EDUCATION |
COUNSELLING |
|---|
| # | 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
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 |
COUNSELLING TO MODIFY BEHAVIOR -- GENERALITIES
| # | 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. |
COUNSELLING TO MODIFY RISKY SEXUAL BEHAVIOR
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 |
COUNSELLING ON STD'S
| # | 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 |
GOALS OF HIV/AIDS COUNSELLING
| # | 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 |
POST-TEST COUNSELLING (TEST NEGATIVE)
| # | 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 |
POST-TEST MEETING FOR DISCLOSING A POSITIVE RESULT
| # | 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 |
POST-TEST COUNSELLING FOR A HIV POSITIVE RESULT
| # | 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