home
***
CD-ROM
|
disk
|
FTP
|
other
***
search
/
Shareware Overload Trio 2
/
Shareware Overload Trio Volume 2 (Chestnut CD-ROM).ISO
/
dir26
/
cdcguide.zip
/
CDC94042.TXT
< prev
next >
Wrap
Text File
|
1994-08-05
|
29KB
|
638 lines
Document 0042
DOCN CDC94042
TI HIV Counseling, Testing, and Referral: Counselor and Provider
Standards and Guidelines
DT 9408
SO CDC National AIDS Clearinghouse - August 1994
TX TABLE OF CONTENTS
Risk Assessment
HIV Prevention Counseling
Notification of HIV Results and Prevention Counseling
Counseling and Repeat Testing
References
Referral Process
RISK ASSESSMENT
Risk assessment--an integral component of HIV prevention
counseling--is based on the premise that certain behaviors
increase risk for infection with HIV. The counselor should
engage the client in a discussion which enables the client to
recognize and accept personal risk for HIV. Because the risk-
assessment process serves as the basis for assisting the client
in formulating a plan to reduce risk, it is an essential
component of all pretest counseling.
When the counselor assesses a client's risk or reviews risk
information previously recorded by the client or a clinician, the
approach should be thorough and individualized for each client.
The counselor should accept that the client's disclosures
concerning risk behaviors correspond to his or her readiness to
initiate behavior change. Each counselor should develop
effective interactive methods to involve the client in
identifying risk behaviors.
STANDARDS
* Assure the client that test results and other information
he or she provides will remain confidential.
* Determine client's prevention and clinical needs by engaging
him/her in a discussion that addresses: client's reason for
visit and other relevant concerns, other personal circumstances,
client's resources and support systems, behavioral and other
sources of risk, demographic and epidemiologic factors
that influence risk; client awareness of risk; readiness
to change behavior; and receptiveness to available
services and referrals.
* Counselors should listen for and address as appropriate
information such as the following:
- Number of sex partners (casual and steady) and sexual
activities including vaginal, anal, and oral sex, both
receptive and insertive activities;
- Sex with a person known to be HIV-positive;
- Sharing needles or having sex with persons who share needles;
- History of STDs and having sex with persons who have STDs,
especially genital lesions;
- Assessment of current STD symptom status;
- Sex in exchange for drugs, money, or other inducements;
- Use of substances such as alcohol, cocaine, etc., in connection
with sexual activity;
- History of HIV antibody testing and results;
- Condom use; and
- Birth control--pregnancy prevention methods.
* Document acknowledged risk behavior, decisions about testing,
and negotiated risk reduction plans in the client's record.
SPECIAL CONSIDERATIONS
* Risk assessment information may also be obtained by
- The clinician during the sexual/drug/medical history
prior to or as a component of the counseling session.
- A risk assessment tool completed by the client while
in a confidential environment, e.g., waiting room, to
be reviewed during the counseling session.
HIV-PREVENTION COUNSELING
Counseling provides a critical opportunity to assist the client
in identifying his or her risk of acquiring or transmitting HIV.
Counseling also provides an opportunity to negotiate and
reinforce a plan to reduce or eliminate the risk. Counseling
prior to HIV testing, prevention counseling (pretest counseling),
should prepare the client to receive and manage his or her test
result. Prevention counseling should also 1) facilitate an
accurate perception of HIV risk for those who are unaware,
uninformed, misinformed, or in denial; 2) translate the client's
risk perception into a risk reduction plan that may be enhanced
by knowledge of HIV infection status; 3) help clients initiate
and sustain behavior changes that reduce their risk of acquiring
or transmitting HIV. 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.
STANDARDS
* Assure the client that test results and other information he or she
provides will remain confidential.
* Discuss anonymous testing options.
* Provide client-centered counseling to:
- Establish and/or improve the client's understanding of his/her
HIV risk,
- Assess the client's readiness to adopt safer behaviors by
identifying behavior changes the client has already implemented,
and
- Negotiate a realistic and incremental plan for reducing risk.
* Discuss history of HIV testing and results.
* Involve the client in an assessment to determine his or her
behaviors which result in a risk of acquiring HIV infection.
- Tailor the counseling session to the behaviors, circumstances,
and special needs of the client.
- Assist the client in recognizing those behaviors which
put him or her at risk for HIV.
- Identify steps already taken by the client to reduce risk
and provide positive reinforcement.
* Identify barriers/obstacles to the client's previous efforts to
reduce risk.
- Determine one or two behavioral changes the client may be
willing to make to reduce risk.
- Discuss the steps necessary to implement these changes.
- Address any difficulties the client anticipates in taking
these steps.
- Respond to the client's concerns.
- Provide the client with necessary referrals and a written
copy of the risk reduction plan (this plan should not include any
personal identifiers). For clients who cannot read, a verbal
summary should be provided.
* Assist the client to arrive at an appropriate decision concerning
HIV testing.
- Obtain informed consent from the client prior to testing.
- Establish a plan with the client to receive test results.
GUIDELINES
* Document the risk assessment in the client's record for use during
subsequent care.
- Document the risk reduction plan in the client's record.
- Ensure that the client understands the risks and benefits of
knowing his or her HIV infection status.
* Discuss the client's expectations of test results.
- Discuss the client's plan to cope while waiting for test
results.
* Explore with the client any support systems that may be available.
* Ensure that the client understands what will happen during his or
her visit to receive test results.
- Discuss the client's responsibility to disclose HIV infection
status to sex/needle sharing partners.
SPECIAL CONSIDERATIONS
As part of the assessment, the counselor should ascertain the client's
understanding of HIV transmission and the meaning of HIV antibody test
results. When appropriate and relevant to the client, the counselor
may:
* Discuss what the virus is and how it is transmitted. Assist the
client to comprehend transmission of HIV and the delay between
infection and development of a positive test.
* Discuss what the test results mean and how they are used in medical
management.
- Negative Result - A negative test means that the person is either
(1) not infected, or (2) so recently infected that the test could
not detect the infection.
- Positive Result - A positive test means that the person is
infected with HIV and can transmit it to others.
* Discuss need for retest.
Clients engaging in continued high-risk behavior should be retested
6 months after the last possible exposure to any HIV risk. (See
"Counseling and Repeat Testing" Section.)
* Review risk reduction options with the client, for example:
- Abstain from sex and injecting street drugs; enroll in a drug
treatment program.
- Practice mutual monogamy between two HIV negative persons.
- Use condoms to prevent STDs and HIV transmission.
- Modify sexual practices to low or no risk behaviors.
- Limit the number of sex partners.
- Disinfect drug injecting equipment and avoid sharing
paraphernalia.
* Advise persons with behavioral risk for HIV not to donate blood and
not to use the blood bank as a means of periodic HIV testing.
* Discuss related healthy behaviors, for example:
- Limit the use of alcohol and other drugs.
- Obtain family planning assistance, when appropriate.
- Obtain early diagnosis and treatment for STDs, when appropriate.
* Explain authorized disclosures and antidiscrimination protection.
* Discuss bringing a support person of the client's choice, at the
time of receiving test results.
NOTIFICATION OF HIV RESULTS and PREVENTION COUNSELING
Providing HIV antibody test results to a client involves
interpretation that is based on the test result and the person's
specific risk for HIV infection and dealing with the client's reaction
to his/her test result. The client will most often focus on the
result itself. Client-centered counseling is required to reassess
behavioral risk that may influence the interpretation. When the
client receives HIV test results, the primary public health purposes
of counseling are (1) to reinforce perception of risk for those who
are unaware or uninformed; (2) to help uninfected persons initiate and
sustain behavior changes that reduce their risk of becoming infected;
(3) to arrange access to necessary medical, prevention, and case
management services for persons with a positive test result; (4) to
assist those who may be infected to avoid infecting others and remain
healthy; and (5) to support and/or assist infected clients to ensure
the referral of as many sex or needle sharing partners as possible.
Knowledge of HIV status is an important piece of information a client
can use in planning the scope of behavioral changes. Persons who
abstain or have sexual relations with others who are known to be free
of HIV infection and who do not use injecting drugs can essentially
eliminate their risk of acquiring HIV. However, the consistent and
correct use of condoms or the adoption of certain non-insertive sexual
activities can greatly reduce the risk of acquiring or transmitting
HIV. Although methods may be employed to reduce the risk of HIV from
injecting drug use (such as the use of new needles), injecting drug
use constitutes a health risk even in the absence of HIV and must be
avoided.
The risk assessment and risk reduction plan developed during
counseling prior to HIV testing provide a framework for strengthening
efforts the client has already taken toward healthier behaviors and
for recommending modifications based upon the HIV test result.
STANDARDS
* Review available documentation including the risk assessment, prior
to meeting with the client.
* Assure the client that test results and other information he or she
provides will remain confidential.
* Provide HIV positive test results only by personal contact,
assuring a confidential environment.
* Provide counseling at the time results are given to
- Assess the client's readiness to receive HIV test results;
- Interpret the result for the client, based on his or her risk for
HIV infection;
- Ensure that the client understands what the result means and
address immediate emotional concerns; and
- Renegotiate or reinforce the existing plan for reducing risk
considering the client's HIV status.
* Discuss with the client the need to appropriately disclose HIV
status.
* Assess the client's need for subsequent counseling or medical
services.
* Develop a plan to access necessary resources and appropriate
referrals.
* For use during subsequent clinical care, document test results,
risk reduction plan, and identified need for any resources and
referrals in the client's chart.
* Ensure that confidentially tested HIV infected clients who do not
return for results and counseling are provided appropriate
follow-up. Document all follow-up. Exhaustive efforts should be
made to ensure that confidentially tested HIV infected clients are
offered their HIV test results and counseling.
Interpretation of HIV antibody test results depends upon the client's
risk behaviors. Some recently infected clients may have negative
antibody tests. Indeterminate results may represent a recent HIV
infection or a biologic false positive. Eliciting specific information
about recent risk behavior is essential to accurate interpretation and
counseling.
The client will likely encounter circumstances where it is appropriate
to reveal their HIV infection status (e.g., to health care or dental
providers; past, present, or potential sex and needle sharing
partners). It is important to discuss such situations with the client
and assist in developing a plan and skills for appropriate disclosure
of HIV infection status.
GUIDELINES
I. Negative HIV Test Result
* Ensure that the client understands what the test result means
including
- Limitations of test (i.e., time lag between infection and
development of antibodies); and
- Need for periodic retesting if the client participates in risk
behaviors.
* Identify any steps already taken by the client to reduce risk and
provide positive reinforcement.
* Encourage the client to continue avoiding risk behaviors.
* Determine one or two behavioral changes the client may be willing
to make to reduce risk and discuss steps to implement these
changes.
* Assist the client in building skills to negotiate risk reduction
activities with current or potential partners through discussion
and role plays.
* Offer referral for further assistance in avoiding risk behaviors
and maintaining low-risk behaviors.
I. Negative HIV Test Result
* Discuss his/her need and ability to help partners realize they are
also at risk for HIV infection.
* Reinforce the importance of discussing risk reduction measures with
potential partners; identify any difficulties the client perceives.
* Advise client about importance of early STD detection and treatment
to reduce HIV risk.
* Advise client to refrain from donating blood, plasma, and organs.
* Advise client on access to other prevention and treatment services
(i.e., drug treatment, psychosocial support, etc.)
II. Positive HIV Test Result
Some HIV positive clients may be better prepared to receive positive
test results than others. Counseling of patients with positive results
must be directed to the client's specific circumstances and may
require more than one session. Counselors should recognize that the
emotional impact of learning about an HIV positive test result often
prevents clients from absorbing other information during this
encounter. Counselors may need to arrange additional sessions or
provide appropriate referrals to meet the client's needs and
accomplish the goals of counseling persons who are HIV positive.
* Allow time for the client's emotional response after learning his
or her positive HIV result. A subsequent counseling session or
follow-up telephone call may be required.
* Ensure that the client understands what the test result means.
* Assess the client's immediate needs for medical, preventive and
psychosocial support. (e.g., financial, personal, and other)
* Make the client aware of the need for additional medical evaluation
and the availability of treatment.
* Establish a plan for continuing medical care and psychological
support, including a subsequent prevention counseling session if
necessary. As part of the plan, the counselor should
- Identify necessary referrals and assist the client with
contacting them, and,
- Provide the client with written referral information.
* Reassess the client's risk for transmitting HIV infection.
* Help facilitate behavior change and/or reinforce behaviors that
minimize or eliminate risk of transmission.
* Discuss with the client access and availability to ongoing
prevention services including psychosocial and support services.
* Discuss with the client the responsibility to assure that sex
and/or needle-sharing partners are counseled about their exposure
to HIV and the need for them to seek medical evaluation.
* Assist the client in developing a plan which ensures that all
partners are counseled about their exposure to HIV.
* Discuss how the client will notify other persons of his or her HIV
status including future sex and needle-sharing partners, health
care providers, and dental providers.
* Discuss with the client his or her specific plans for the next few
days and ensure that the client has access to support systems
during this time.
* Advise client to refrain from donating blood, plasma and organs.
The current testing strategy of two EIA determinations followed by a
supplemental test for confirmation, such as the Western blot, makes
false positive test results extremely unlikely; however, the
possibility of a mislabeled sample or laboratory error must be
considered, and for a client with no identifiable risk for HIV
infection, a repeat test may be appropriate.
SPECIAL CONSIDERATIONS
II. Positive HIV Test Result
* Clients whose results are HIV infected may have specific
medical questions. Considering the complexity of medical
questions, responses should be left to clinicians to whom
the client is referred, or to counselors or case managers
with specific expertise in this area.
* Some clients may be at very high risk of transmitting the virus to
others. Sites are encouraged to provide, either on-site or through
referral, additional prevention counseling (individual, couple,
group, or peer), as appropriate to the needs of these clients.
GUIDELINES
III. Indeterminate Test Result
* Explain that the test result is inconclusive and may represent
either
- a biologic false positive test, or
- a truly positive test from a recent infection in which
antibodies have not yet fully developed.
* Schedule a repeat test approximately 6 weeks after the date of this
inconclusive test.
* Emphasize that the client must take the same risk reduction
precautions as persons testing HIV positive until the indeterminate
finding is resolved.
* Assess the client's concerns and anxieties during the waiting
period. If necessary,
- Arrange psychological referral to assist the client with coping
while resolving the indeterminate test result,
- Provide a hotline telephone number(s) as a referral option, and
- Provide a subsequent counseling session or follow-up telephone
call.
COUNSELING AND REPEAT TESTING
Situations where clients need repeat HIV counseling or request repeat
HIV testing challenge and pose difficult issues for counselors. These
situations include previously counseled persons who continue to place
themselves or others at risk for infection, persons with indeterminate
test results, seronegative persons with no risk who continue to
request testing, and persons doubting or disbelieving their
seropositive test results. Repeat testing is not advised as a
substitute for initiating and maintaining safer behaviors.
STANDARDS
* Assess the reasons the client requests repeat testing or continues
risk behaviors.
* Emphasize that repeated testing for HIV will not prevent infection
if the client continues to engage in risk behaviors.
* Arrange the specific services to meet the client's needs.
* Document all counseling activities, negotiated plans, and referrals
in the client's record.
GUIDELINES
I. Persons with Continued Risk--Previous HIV Test Negative
The counselor should
* Review previous risk assessment and risk reduction plan with
client.
* Proceed with HIV counseling as outlined in the Section, "HIV
Prevention Counseling."
* Provide alternative counseling options (e.g. referral to community
based group or individual counseling) to the client to further help
him or her understand his or her recidivist risk behavior(s) and
modify the behaviors accordingly.
* Acknowledge incremental behavior changes, reinforce those which
have reduced risk, and document in the client's chart.
* Assess the client's attitudes and feelings about testing HIV
positive.
* Identify obstacles which the client encountered in adopting safe
behaviors.
* Explain potentially negative impact of HIV reinfection or exposure
to other STDs.
II. Persons with Continued Risk--Previous HIV Test Positive
* Explain the continued risk of infecting sex and needle sharing
partners.
* Negotiate a plan with the client to prevent HIV transmission.
GUIDELINES
* Identify resources and alternative counseling options to ensure
that the client implements this plan and to reinforce the
importance of practicing safer behaviors to protect himself or
herself and others.
* Reinforce the importance of informing partners and making
risk-reduction decisions with partners.
* Ensure that the client understands the adverse impact of STDs and
drug use upon immune function.
III. Persons with Indeterminate Test Results
The counselor should
* Arrange a repeat test approximately 6 weeks from the date of this
current test.
* Assess the client's concerns and level of anxiety during the
waiting period. If necessary, arrange psychological referral to
assist the client in coping.
* Consider persons to be negative for antibodies to HIV if their
Western Blot test results continue to be consistently indeterminate
for at least 6 months in the absence of any known risk behaviors,
clinical symptoms, or other findings (1).
* Encourage the client to follow guidelines outlined in the
"Notification of HIV Results and Prevention Counseling Section."
IV. Persons with No Risk--Negative Test Results
The counselor should
* Counsel the client on modes of HIV transmission and behaviors that
place persons at risk for HIV.
* Counsel the client on unwarranted fears.
* Arrange referral for additional counseling for clients who continue
to exhibit unfounded anxiety about HIV.
V. Persons Who Doubt Previous Seropositive Test Results
The counselor should
* Assess why the client doubts the accuracy of the test results.
* Explain the process of multiple tests to confirm a positive result.
* Assist the client in recognizing the behaviors that lead to HIV
infection.
- For clients with no acknowledged risk for HIV, repeat
the test.
- For clients with behavioral risk for HIV, arrange for
medical referral and repeat test, if necessary.
REFERENCES
1. CDC. Interpretation and use of the Western Blot Assay for
Serodiagnosis of Human Immunodeficiency Virus Type 1 Infections. MMWR,
1989;38(pl 7):1-7.
REFERRAL PROCESS
A thorough client assessment often indicates a need for services that
cannot be provided by the counselor. The counselor has two
opportunities to make referrals: (1) the HIV prevention counseling
session and (2) the test notification/prevention counseling session.
STANDARDS
* Provide appropriate referral resources for:
- Any client who may be in need of support to maintain safer
behaviors,
- HIV negative clients who continue to engage in risk behavior,
- HIV negative clients who continue to test but are without risk,
- HIV positive clients who continue to engage in risk behaviors,
and
- HIV positive clients with additional medical, social, or
psychological needs.
* Provide the client with a written list of referrals including
telephone numbers, addresses, hours of operation, and services
provided.
* Document referrals in the client's record. Referrals made during
the initial HIV prevention counseling session should be followed-up
during the test notification/prevention counseling session.
GUIDELINES
The counselor should
* Offer referral to case management provider, if one is available.
* Seek feedback from the client about preferences for referrals, the
accessibility of the referral, and the client's intention to follow
through with the referral.
* Provide the client with relevant details about referral sites,
e.g., the name of a specific contact person.
SPECIAL NOTE
Any HIV positive or negative client who continues to engage in risk
behaviors should know where and how to access STD detection and
treatment services.
DISTRIBUTED BY GENA/aegis (714.248.2836 * 8N1/Full Duplex) SOURCE:
National AIDS Clearinghouse.