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       Document 0041
 DOCN  CDC94041
 TI    HIV Counseling, Testing, and Referral: Standards and Guidelines
 DT    9408
 SO    CDC National AIDS Clearinghouse - August 1994
 TX    TABLE OF CONTENTS

       HIV Counseling--Program Standards and Guidelines
         Client Eligibility
           References
         Risk Assessment Development
         Referral Service Development
         Quality Assurance
         Publicly Funded Programs - Data Collection

       CLIENT ELIGIBILITY CRITERIA

       Public health agencies that receive federal funds from the
       National Center for Prevention Services (NCPS) are required to
       routinely offer, on a voluntary basis with informed consent, HIV
       prevention counseling and HIV laboratory testing services to
       persons who are potentially HIV infected, their partners and
       others who have high risk behaviors (1).  Grantees are encouraged
       to offer services to clients at designated counseling and testing
       sites, sexually transmitted disease (STD) clinics, drug treatment
       centers, tuberculosis clinics, criminal justice and correctional
       systems, women's health clinics, youth and adolescent programs,
       and other sites which serve persons with risk behaviors for
       acquiring HIV.  To use resources as efficiently as possible,
       grantees are encouraged to integrate HIV counseling and testing
       into ongoing operations, especially in STD and substance abuse
       treatment clinics.  HIV Prevention Community Planning provides
       one forum for priority setting, accomplished through a
       participatory process, which may guide the targeting of HIV
       counseling services.

       Unless it is prohibited by state law or regulation, clients
       should be offered reasonable opportunities to receive HIV-
       antibody counseling and testing services anonymously.  The
       availability of anonymous services may encourage some persons at
       risk to seek services who would otherwise be reluctant to do so.
       Grantees who elect to charge for services are strongly encouraged
       to use a sliding scale, and to provide services regardless of
       ability to pay.  That services will not be denied because of the
       client's inability to pay should be clearly communicated by the
       facility by posting signs or providing written materials.
       Program staff who register clients or collect fees should be
       familiar with this policy.  When a client is identified to be at
       risk for HIV infection, the health care facility is responsible
       for providing services or ensuring effective referral for
       services.

       Counseling programs should develop a triage assessment procedure
       to identify persons at risk for HIV infection.  This procedure
       should consider local circumstances that influence the risk of
       HIV infection for persons who might not be perceived as being at
       risk.  Health care providers should take advantage of every
       encounter with a client to reinforce HIV prevention messages (2).

       STANDARDS

       HIV prevention program managers must accomplish the following:

       *  Establish systems to ensure that strict confidentiality is
          maintained for all persons who are assessed for HIV counseling
          and testing services.

       *  Seek to ensure that all persons who seek HIV testing are
          offered counseling relevant to their needs.

       *  Seek to ensure that persons who are determined to be at
          risk for HIV infection as a result of sexual or drug
          using behaviors are routinely counseled.

       *  Establish that no facility that receives federal funds
          for HIV counseling and testing services may deny a client
          services because of that client's inability to pay (3).

       SPECIAL CONSIDERATIONS

       *  Clients who request repeat testing should be managed as
          indicated in the "Counseling and Repeat Testing Section."

       REFERENCES

         (1) CDC. 1992 HIV Prevention Program Guidance.

         (2) CDC. Technical Guidance on HIV Counseling, January 1993.

         (3) CDC. 1992 HIV Prevention Program Guidance.

       RISK ASSESSMENT DEVELOPMENT

       Program managers, from sites that provide HIV counseling services
       should review available data to identify site-specific HIV
       prevention needs.  This review and evaluation should include AIDS
       case surveillance data, HIV seroprevalence data, STD morbidity,
       prevention counseling data, and demographic and risk behavior
       profiles of the population and the catchment community served by
       each site.  Based on analysis of this data, the program should
       develop policies for each site that address the appropriate
       provision of primary and secondary HIV prevention services
       including triage assessment, targeted or universal risk
       assessment procedures.  For example, if the voluntary HIV testing
       seropositivity at a site is higher than the blinded
       seroprevalence, this site is successfully targeting prevention
       efforts.  However, if the voluntary HIV testing seropositivity is
       lower than the blinded seroprevalence, this site may not be
       appropriately targeting assessments, outreach efforts, prevention
       counseling, and/or provision of voluntary testing services.  This
       information should be used to plan activities and services,
       redirect efforts and resources to meet current needs, use
       resources more efficiently, and identify unmet service needs.

       Each site that offers HIV testing must provide prevention
       counseling tailored to individual client needs and should develop
       an effective method to involve clients in identifying their risk
       behaviors.  This approach should also address local and specific
       circumstances which might influence the client's perception of
       risk.  Where available, sites should use triage assessment as one
       of the first efforts to direct persons at risk of HIV infection
       into prevention counseling.  Clinic environment should support
       the risk assessment process, another essential method to involve
       clients in identifying their risk behaviors.  Strategies to
       achieve this include group discussions, audiovisual materials,
       pamphlets, and/or posters.  Community based organizations are
       excellent collaborators in the development and provision of
       client support services.  Educating clients through multiple
       methods increases the chance that clients will recognize
       behaviors which place them at risk.

       STANDARDS

       HIV prevention program managers must make certain that the
       following are achieved:

       *  Provision of training and quality assurance to
          staff to ensure identification of risk behaviors
          of all clients counseled or tested for HIV.

       *  Establishment of site-specific demographic and
          risk profiles, based on analysis of HIV test
          data.

       *  Ongoing collection and review of available site-specific
          data, including AIDS case surveillance data, HIV
          seroprevalence data, STD morbidity, prevention counseling
          data, demographic, and risk behavior profiles for
          targeting of resources and quality assurance of service
          delivery.

       *  Determination of appropriate site-specific
          strategies for risk assessment of clients, based
          on demographic and risk profiles.

       *  Procedures to maximize targeting of clients for
          prevention counseling based on risk profiles.

       GUIDELINES

       HIV prevention program managers should do the following:

       *  Ongoing review and analysis of relevant seroprevalence data,
          including site specific blinded seroprevalence if available, and

       *  Analyze by site the extent of HIV prevention counseling coverage
          (number of clients seen, blinded seroprevalence, and number of
          HIV infected persons identified through prevention counseling).

       REFERRAL SERVICE DEVELOPMENT

       A thorough client assessment often indicates a need for services
       that cannot be provided by the counselor (e.g. drug treatment,
       peer support groups, etc.).  To ensure that clients receive
       appropriate care, the program must establish a procedure for
       referring persons to sites that provide services in a timely,
       efficient, and professional manner.  A collaborative relationship
       should have already been established with the appropriate
       representative of the referral site.

       STANDARDS

       HIV prevention program managers must develop a process for
       routine referral which include the following:

       *  A written referral process for identifying, evaluating,
          and updating referral sources in the site's operations
          manual.

       *  A mechanism to provide clients with immediate access to
          emergency psychological or medical service.
       *  Appropriate referral resources for

          -  Any client at-risk for HIV infection who may be in
             need of support to maintain safer behaviors,
          -  HIV negative clients who continue to test but are
             without risk,
          -  HIV negative clients who continue to engage in risk
             behavior,
          -  HIV positive clients who continue to engage in risk
             behavior,
          -  HIV positive or high risk HIV negative clients who
             need STD diagnosis and/or treatment, and
          -  HIV positive persons who need a medical assessment.

       *  Written standards for the follow-up of confidentially
          tested HIV positive clients who don't return for results
          and counseling.

       GUIDELINES

       HIV prevention program managers should develop a process for
       routine referral which would accomplish the following:

       *  Maintains a current list of community and institutional
          referral resources such as infectious disease specialists
          and clinics, free clinics, social service agencies,
          emergency medical services, hospitals, prenatal care
          clinics, family planning clinics, mental health centers,
          AIDS service organizations, HIV/AIDS community-based
          organizations (CBOs), substance abuse treatment
          facilities, and religious institutions;

       *  Establishes a liaison at each of these resources; and

       *  Provides periodic inservices from referral agencies.

       QUALITY ASSURANCE

       The objective of quality assurance is to ensure that appropriate,
       competent, and sensitive, methods are used for risk assessments,
       counseling, and referral of clients.  Management staff,
       contractors, or collaborative agency staff should be trained and
       should be able to perform routine objective quality assurance
       site visits.  A minimal level of performance should be determined
       and agreed upon by the funding agency and the service provider.
       Less than minimal performance must be remedied, or the site
       should suspend counseling and testing activities until an
       acceptable minimal standard of performance can be assured.
       Counseling programs should develop written quality assurance
       policies and procedures consistent with these standards and
       guidelines; these documents should be available to all staff.
       Client feedback should be routinely used as a factor in assessing
       quality assurance.

       STANDARDS

       I.  Facility

       *  The site must be geographically accessible to the
          population it serves.

       *  The site must operate during appropriate hours and
          minimize any delay in providing services.

       *  Counseling rooms must be private to ensure
          confidentiality of the counseling session.

       II. Staff

       *  Management staff must ensure that necessary resources and
          systems are available to ensure acceptable job performance.

       *  The program director must ensure adequate on-site supervision
          for staff.

       *  Counselors must meet locally established qualification
          standards.

       *  Counselors and other relevant staff must be provided
          updates at least annually on the scientific/public health
          aspects of HIV.

       III.  Educational and Risk Reduction Materials

       *  Culturally competent, linguistically specific, and
          developmentally appropriate written HIV information must
          be available to clients.  The National HIV Clearinghouse
          is a useful resource to obtain and review a range of HIV
          education and risk reduction materials.

       IV.  Records/Forms

       *  Client records (confidential and anonymous) must contain
          a copy of the informed consent document, laboratory slip
          with test results, documentation of prevention
          counseling, result notification, and formulation of risk-
          reduction plans.

       *  Records with patient identifiers must be secured.

       *  All personal identifying information in connection with
          the delivery of services provided to any person must not
          be disclosed unless required by law or unless the person
          provides written, voluntary informed consent.
       *  Routine audits of risk assessment questionnaires,
          counseling and interview forms, and client risk reduction
          plans must be conducted.

       GUIDELINES

       I.  Facility

       *  The physical facility should display a level of
          professionalism and client orientation relevant to the
          population served.

       II.  Staff

       *  A written job description should be provided for all
          counselors.

       *  Performance tasks and standards should be established and
          reviewed with the employee.

       *  All counselor and supervisory staff should be familiar
          with all services connected with the counseling program.

       *  New counselors should be observed (with client consent)
          daily until proficiency is assured and periodically
          thereafter to ensure that proficiency is maintained.

       *  The supervisor should routinely provide constructive
          feedback to the employee, based on the observations.

       *  Case presentations should be conducted routinely, using
          techniques such as team problem solving sessions with
          medical, supervisory, and counseling staffs.

       *  Each counselor and supervisor should be provided
          additional information through training and/or inservices
          about HIV, STD, TB, immunization, family planning,
          substance abuse, and early interventions such as
          antiviral treatments, etc.

       III. Educational and Risk Reduction Materials

       *  Condoms should be available to the client--directly from
          providers and easily accessible without the client having
          to ask.

       *  Current written materials should be prominently displayed
          in public areas and made available to clients.

       *  Current written and audiovisual materials should be
          culturally and linguistically appropriate for the client
          population.  Materials should be sensitive to the reading
          levels, gender, and ethnicity of the client population.

       PUBLICLY FUNDED PROGRAMS
       DATA COLLECTION AND ANALYSIS

       Accurate and consistent data collection from HIV prevention
       counseling, test results, notification of results, referrals, and
       partner notification activities are critical to the
       implementation, maintenance, and evaluation of a quality HIV
       prevention program.  Data collection and quality assurance of
       referrals and partner notification are addressed in the
       respective guidelines.  Analysis of HIV counseling and testing
       data in combination with seroprevalence and local demographic and
       STD morbidity data are essential components of prevention program
       operations.  Required by the program, the data should:

       *  Identify barriers and gaps in service delivery,

       *  Plan, refine and target program intervention strategies,

       *  Analyze resource allocation,

       *  Provide site specific feedback to clinic staff, and

       *  Provide specific feedback to counselors.

       STANDARDS

       Publicly funded programs must

       *  Utilize a standard data collection tool throughout the project
          area.

       *  Collect minimum required variables:

          -   Unique record/client identifier;
          -   Unique site identifier;
          -   Prevention counselor identifier;
          -   Date of prevention session;
          -   Client demographics (age, sex, race/ethnicity, state,
              county, and zip code),
          -   Client risk behavior (identified through client self-assessment

              and/or counselor discussion with client during prevention
              counseling);
          -   Final laboratory result/report; and
          -   Date of notification of results and prevention counseling.

       *   Adhere to the NCPS site numbering system criteria:

           -  Site number is determined by where the client is tested;
           -  Each clinic within a facility has a unique site number;
           -  Satellite clinics require a unique site number;
           -  Site numbers are not duplicated across counties, districts,
              or parishes; and
           -  Site location, not counselor identification number, determines
              the site number.

       *  Counselor/DIS field services and outreach teams require a
          unique group site number for field work.

       *  Conduct routine and systematic review of data for errors and
          inconsistencies and establish formal mechanisms for corrections.

       *  Report client record data (with client identifiers removed) to
          NCPS on a quarterly basis.

       *  Use the following program indicators to evaluate HIV counseling
          at individual sites:

          -  Number of clinic visits,
          -  Number of clients eligible for prevention counseling,
          -  Number of clients who received prevention counseling,
          -  Number of clients tested for HIV,
          -  Number of clients testing positive,
          -  Number of positive clients notified of results and provided
             prevention counseling,
          -  Number of clients testing negative, and
          -  Number of negative clients notified of results and provided
             prevention counseling.
          -  Other relevant program indicators identified through ongoing
             quality assurance and data analysis.

       Note:  The first three indicators provide important denominator
       data for sites that provide a range of health care services.

       GUIDELINES

       Publicly funded programs should

       *  Review site-specific data analysis with appropriate staff at
          least quarterly.
       *  Conduct counselor-specific data analysis and provide feedback
          to the counselor at least twice a year.
       *  Conduct personnel resource analysis to establish minimum
          workload guidelines.
       *  Establish a computerized data system to facilitate data
          analysis for quality assurance.

       DISTRIBUTED BY GENA/aegis (714.248.2836 * 8N1/Full Duplex)  SOURCE:
       National AIDS Clearinghouse.