       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.
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