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. DISTRIBUTED BY GENA/aegis (714.248.2836 * 8N1/Full Duplex) SOURCE: National AIDS Clearinghouse.