J _ 2~r:2 ---------------

COUNSELLING

oplions should include abstinence, monogamy (mutual

faithfulness) and the correct use of condoms.

In the absence of a test, emergency treatment may not be

withheld. In certain well-defined high-risk or exposure-

prone procedures, the patient should be informed and

asked to consent. If the patient declines, s/he should be

managed as if positive.

Before testing, the health professional should:

• Check for legislative processes that may regulate HIV
testing, e.g. prisons, schools, work place, Insurance

policies, etc.

• Confirm Ihat there is a clinical indication.

• Ensure that pretest counselling has been done
adequately, or do so personally.

• Ensure that the client has been fully informed and
thereafter consented.

• Be in a position to ensure confidentiality.

The Health Professions Council of South Africa and the

South African Medical Association recommend that since

an HIV test interferes with a person's rights to freedom and

securiry of person and privacy, a person may only be tested

• at his/her own request
• after s/he has given informed consent, preferably

written

• he/she may otherwise be tested when authorised by
legislation or a courI order.

Probably the most common reason for health professionals

to counsel South Africans today is in the context of HIV

testing.

A general poster in Ihe ward or clinic room that 'all patients

will be tested for HIV' does NOT constitute informed

consent Nor should a patiem JUSt be presenred with a

leafcr or referred to another organisalion for informarion.

Testing as part of research is permitted only with tile

candidate's free and informed consent. Testing an existing

blood sample can only be done if the patiem consents.

Unlinked and anonymous resting is permitted by the

Department of Health if done by a national or local health

authority. Proper ethical guidelines should be adhered to

and there should be security safeguards for confidentiality.

The HIV epidemic more than any other has brought with it

the need for health care workers to have counselling skills.

The life-changing nature of an HIV diagnosis requires that

all persons are fully informed of the consequences of a

positive result before they are tested (pretest counselling)

and thereafter be told the result and given support if it is

positive (post-test counselling). There are a number of

other situations in the context of HIV where counselling is

required, e.g. bereaved family members, loss of

reproductive capability, ete. It is therefore in the best

imerests of the health care professional not only to know

the resources to call upon for more advanced counselling

support but also to develop some personal basic

counselling skills.

Unda-Gall Bekker, .HB GliB, Fe?, PhD

InfectioUs Disease Clinical R<!search Unit, [leT Lung 11l5tiwre.. Cap!! Tcn~'11

This article has been adapted by Unda-Gail Bekker from

a chapter by Carroll Jacobs in the Handbook of HIV
Medicine (reviewed elsewhere in this issue). It is
recommended that Ihe full chapter in the handbook be

referred to.

Counselling in a health care setting consists of a supportive

relationship in a structured environment where one person

helps another person to:

• Know more about a situation/ illness/diagnosis.

• Contain his/her emotions.

• Explore and define his/her feelings, thoughts and
actions around the diagnosis.

• Find solutions to problems that he/she will encounter.

• Develop coping skills for the future.

HIV COUNSELLING

HIV counselling aims to:

• Provide a supportive environment.

• Help clients manage their problems and issues.

• Explore coping skills they have used before and develop

new ones.

• Empower clients to become self -sufficient in dealing

with emerging issues/problems.

• Counsel HIV-negative clients so that they know how to
remain negalive.

• Counsel HIV-positive cliems on how to avoid cross-
infection and how to prevem infecting others.

• Explore options with the client that will help them ID

bring about necessary changes in behaviour. These



PRETEST COUNSElliNG

Checklist for pretest counselling:

• Assure the client that both counselling and testing are

confidential procedures.

• Be sure that if more than one session is required it can

be offered.

• Provide information about HIV infection and
transmission and its links to AIDS, sexually transmitted

infections and tuberculosis.

• Provide information on the technical aspects of testing,
Ihe 'window period' and its implications and the

meaning of the terms 'posiIive' and 'negative:

• Discuss the implications of a positive or negative

diagnosis.

• Provide information about the client's legal rights in

terms of who to tell (sexual partner/si or not to tell (e.g.

the employer, third parties, etc.). Clients are not obliged

to tell anyone apart from their sexual partners.

• Evaluate risk behaviour: find out why the individual

wants to be tested, and the nature and extent of

previous and present high-risk behaviour, and discuss

the steps that they should take to prevent future

infection or transmission.

• Determine the client's coping resources and support

systems in the event of a positive result.

• Contain Ihe client's emotions as they deal with issues

about relationships.

• Determine whether the client wishes to be tested that
day or not, and whether they would like to receive the

result that day or not.

• Assure [he client that you respect their decision.

• Provide a sense of support and hope for the client.

A person who has tested HIV-positive may never have the

same quality of life again. HIV-positive people who are

properly and appropriately counselled not only feel better

following the support. but also are better able to talk about

their fears and feelings, and to plan their future. With

ongoing emotional and psychological support [he HIV-

positive person can change his or her behaviour from

destructive living to positive living.

Both pre- and post-test counselling are very important.

It is dangerous to compromise the counselling process

and take short cuts in the counselling room.

POST-TEST COUNSElliNG

Post-lest counselling helps Ihe client to work through the

crisis and other issues that may arise as a result of being

wld [heir HIV starus.

Giving the results.

• Give the results as soon as they are receivea. Do not

prolong the suspense with inane conversation.

• Give the results face to face, never telephonically and

never through third parties.

• The person who conducted the pretest counselling
should wherever possible also give the result and post-

test counselling.

• Let the client choose whether they want the result that

day or not. People may need more time to consider the

impact of a possible HIV-positive result on their lives

before they receive the result.

• If the result is positive, do not give it unless you or a
back-up support can see the client the following day.

If the HIV result is negative:

• Discuss the window period.
• Reinforce the message of prevention and safer sexual

practices.

• Pick up on any OIher issues Ihat may have been raised
in the pretest counselling session.

• Discuss referral if necessary, especially if there are

ongoing risk factors.

HIV positive result:

Initially:

• Concentrate on managing the resultant crisis and

addressing the client's immediate concerns.

• Be careful of information overload in the first

encounters.

Later [often at a follow-up appointment the next day, if

possible)

• Continue to comain the client's emotions.

• Answer any questions.
• Remind the client of the need for partner notification -

though they may still need some time and support for

this.

• Introduce concepls such as:
• the need for medical assessment and where to get

it

• safer sex
• the cost and availability of antiretroviral therapies

(ART) and drug trials

• the importance of a well-balanced diet. reSI and

exercise

• the need to eliminate alcohol, smoking or drugs.

Ongoing counselling helps the client [Q deal with issues

such as partner notification, relationship difficulties,

queries about health and treatment and disclosure to

others. With wrinen permission, the counsellor may liaise

with other caregivers. Develop a good working relationship

with them, as you may be able to share contacts and

referral sources.

JULY 2002