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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.