       Document 0040
 DOCN  CDC94040
 TI    HIV Counseling, Testing, and Referral: Historical Perspective
 DT    9408
 SO    CDC National AIDS Clearinghouse - August 1994
 TX    TABLE OF CONTENTS
       HIV Counseling and Testing Overview
         Historical Perspective                                      
         Goals                                                          
         Objectives                                                     
         Elements                                                       
         Definitions                                                    
         References                                                     

       HIV COUNSELING AND TESTING - OVERVIEW
       HISTORICAL PERSPECTIVE

       Publicly funded HIV antibody counseling and testing services were
       initiated in March 1985 to provide an alternative to the donation of
       blood as a means for high-risk persons to determine their HIV status.
       At that time little was known about the prevalence and natural history
       of HIV infection.  Counseling was considered an essential adjunct to
       HIV testing.  The counseling addressed the accuracy and consequences
       of the test and was designed to help persons interpret the meaning of
       positive or negative antibody results.  HIV counseling was based on
       the recognition that learning HIV status may be difficult for some
       clients.

       In 1987, with increased understanding about the scope and severity
       of the HIV epidemic and the predictive value of a positive test, HIV
       counseling and testing were expanded.  Persons seeking care for
       sexually transmitted infections, family planning, childbirth, or
       substance abuse were counseled and tested in an attempt to reduce
       their risk for HIV transmission.  "The primary public health purposes
       of counseling and testing are to help uninfected individuals
       initiate and sustain behavioral changes that reduce their risk of
       becoming infected and to assist infected individuals in avoiding
       infecting others." (1)

       Since that time, public awareness about HIV infection has increased,
       and the reliability and predictive value of the HIV test have been
       proven.  Investigations have demonstrated the benefit of early
       antiviral and prophylactic treatment for HIV infected persons. These
       HIV counseling standards and guidelines are the result of increased
       knowledge about HIV prevention and experience with HIV counseling.
       Counseling is a direct, personalized, and client-centered intervention
       designed to help initiate behavior change to avoid infection or, if
       already infected, to prevent transmission to others, and to obtain
       referral to additional medical care, preventive, psychosocial and
       other needed services in order to remain healthy.

       GOALS OF HIV COUNSELING, TESTING, AND REFERRAL SERVICES

       The current goals of HIV counseling are as follows:

       *  provide a convenient opportunity for persons to learn their
          current serostatus;
       *  allow such persons to receive prevention counseling to help
          initiate behavior change to prevent the transmission or
          acquisition of HIV;
       *  help persons obtain referrals to receive additional medical-
          care, preventive, psychosocial and other needed services;
       *  provide prevention services and referrals for sex and
          needle sharing partners of HIV-infected persons.

       OBJECTIVES OF HIV COUNSELING, TESTING, AND REFERRAL SERVICES

       1.  Identify persons who are unaware, uninformed, misinformed, or
           in denial of their risk for HIV infection and facilitate an
           accurate self-perception of risk.

       2.  Prepare clients for and provide them with knowledge of
           their HIV infection status.

       3.  Negotiate a relevant risk reduction plan and obtain a
           commitment from clients to reduce their HIV risk.

       4.  Refer clients to resources that will provide psychosocial
           support and facilitate desired behavior change.

       5.  Provide referral to appropriate drug treatment
           services for clients whose substance abuse problems
           enhance their HIV risk.

       6.  Provide information on the increased risk of HIV transmission
           associated with other sexually transmitted diseases (STDs) and
           give referrals for STD detection and treatment.

       7.  Provide family planning information and referrals for women of
           child bearing age who are infected or at high risk for HIV.

       8.  Provide referrals to HIV positive and high risk HIV negative
           persons for necessary medical, preventive, and psychosocial
           services.

       9.  Communicate to the client the responsibility for appropriate
           disclosure including the notification of sex and needle-
           sharing partners.

       NECESSARY ELEMENTS OF HIV COUNSELING, TESTING, AND REFERRAL
       SERVICES

       *  Maintenance of Confidentiality

          Strict protection of client confidentiality must be
          maintained for all persons offered and receiving HIV
          counseling services.

       *  Risk Assessment

          Risk assessment is the portion of a client-centered discussion
          that encourages the client to identify, understand, and
          acknowledge his or her personal risk for acquiring HIV.

       *  Prevention Counseling

          Counseling provides a critical opportunity to assist the
          client in identifying his or her risk of acquiring or
          transmitting HIV.  It also provides an opportunity to
          negotiate and reinforce a plan to reduce or eliminate
          behavioral risk.  Counseling prior to HIV testing (pretest)
          should prepare the client for receiving, understanding and
          managing his or her test result.

       *  Providing Test Results

          Providing HIV antibody test results to a client involves
          interpretation that is based upon the test result and the
          client's specific risk for HIV infection.  Knowledge of HIV
          status is important information that a client can use to plan
          behavior change.  Skillful, client-centered counseling is
          required to reassess behavioral risks which may influence the
          interpretation of test results.  The client will most often
          focus on the actual result itself rather than behavioral and
          prevention messages.

       *  Provision of Referrals

          Clients may require referral for physical and
          psychological evaluations, appropriate therapies (i.e.,
          drug treatment), and support services to enhance or
          sustain risk reduction behaviors.  Each program should
          maintain complete knowledge of referral resources,
          including the availability, accessibility, and eligibility
          criteria for services.

       DEFINITIONS

       These standards and guidelines on HIV counseling were established
       after consultation between outside experts and Centers for Disease
       Control and Prevention (CDC) staff.  The document is divided into two
       sections.  The first section addresses program level guidance in
       establishing policies and procedures which are critical to the
       development and maintenance of an HIV prevention counseling program.
       The second section describes guidance for counselors and other
       providers in the approach to and delivery of HIV prevention counseling
       services.    
       
       This document will provide two levels of guidance (2):

       *  Standards in this document are intended to be consistently applied 
          to the delivery of HIV counseling services.  They must be followed 
          in virtually all cases.

       *  Guidelines are intended to be more flexible.

          They should be followed in most cases.  However, they recognize
          that, depending on the client, setting and other factors,
          guidelines can and should be tailored to fit individual needs.

       These standards and guidelines are intended for persons who
       provide counseling in connection with HIV testing (3) and
       encompass the following concepts and terminology:

       *  Triage assessment is the process that determines whether
          someone should be referred to counseling.  Triage
          assessment facilitates access to prevention counseling
          services for those persons at increased risk for HIV.
       
       *  Risk assessment is the process of assisting the client to
          identify behaviors that place him or her at risk for HIV.
          The risk assessment should include:  reason for visit and
          other relevant concerns; personal circumstances; the
          client's resources and support systems; behavioral and
          other sources of risk; demographic and epidemiologic
          factors that influence risk; client's awareness of risk,
          readiness to change behavior, and receptiveness to
          available services and referrals.  An integral component
          of HIV prevention, risk assessment is not intended solely
          as a screening tool for client eligibility for HIV
          testing.  The discussion between the client and counselor
          should result in a negotiated risk reduction plan.  The
          plan must be a realistic, attainable strategy that is
          developed with the client to achieve behavior changes to
          reduce the risk for acquiring or transmitting HIV.

       *  Client-centered counseling refers to counseling conducted
          in an interactive manner responsive to individual client
          needs.  This counseling avoids a preconceived set of
          points to be made by the counselor and encourages the
          client to do most of the talking.  The focus is on
          developing prevention goals and strategies with the
          client rather than simply providing information.  An
          understanding of the unique circumstances of the client
          is required--behaviors, sexual identity, race/ethnicity,
          culture, knowledge, and social and economic status.
          
       *  Appropriate disclosure involves all of the circumstances
          in which others should be informed of the client's HIV
          infection status.  This determination requires
          consideration of local and state laws, client
          confidentiality and the need to inform others.
          Disclosure to health care providers and current and
          subsequent sex and/or drug partners is essential.  The
          client may need guidance and assistance on the methods of
          informing persons who need to know.

       REFERENCES

          (1) CDC.  Public Health Service Guidelines for Counseling and
       Antibody Testing to Prevent HIV Infection and AIDS.  MMWR
       1987;36:509-515.

          (2) Eddy, DM.  Designing a Practice Policy, Standards,
       Guidelines, and Options.  JAMA.  1990;263:3077-3084.

          (3) CDC.  Public Health Service Guidelines for Counseling and
       Antibody Testing to Prevent HIV Infection and AIDS.  MMWR
       1987;36:509-515.

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       National AIDS Clearinghouse.
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