Document 0041 DOCN CDC94041 TI HIV Counseling, Testing, and Referral: Standards and Guidelines DT 9408 SO CDC National AIDS Clearinghouse - August 1994 TX TABLE OF CONTENTS HIV Counseling--Program Standards and Guidelines Client Eligibility References Risk Assessment Development Referral Service Development Quality Assurance Publicly Funded Programs - Data Collection CLIENT ELIGIBILITY CRITERIA Public health agencies that receive federal funds from the National Center for Prevention Services (NCPS) are required to routinely offer, on a voluntary basis with informed consent, HIV prevention counseling and HIV laboratory testing services to persons who are potentially HIV infected, their partners and others who have high risk behaviors (1). Grantees are encouraged to offer services to clients at designated counseling and testing sites, sexually transmitted disease (STD) clinics, drug treatment centers, tuberculosis clinics, criminal justice and correctional systems, women's health clinics, youth and adolescent programs, and other sites which serve persons with risk behaviors for acquiring HIV. To use resources as efficiently as possible, grantees are encouraged to integrate HIV counseling and testing into ongoing operations, especially in STD and substance abuse treatment clinics. HIV Prevention Community Planning provides one forum for priority setting, accomplished through a participatory process, which may guide the targeting of HIV counseling services. 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. Grantees who elect to charge for services are strongly encouraged to use a sliding scale, and to provide services regardless of ability to pay. That services will not be denied because of the client's inability to pay should be clearly communicated by the facility by posting signs or providing written materials. Program staff who register clients or collect fees should be familiar with this policy. When a client is identified to be at risk for HIV infection, the health care facility is responsible for providing services or ensuring effective referral for services. Counseling programs should develop a triage assessment procedure to identify persons at risk for HIV infection. This procedure should consider local circumstances that influence the risk of HIV infection for persons who might not be perceived as being at risk. Health care providers should take advantage of every encounter with a client to reinforce HIV prevention messages (2). STANDARDS HIV prevention program managers must accomplish the following: * Establish systems to ensure that strict confidentiality is maintained for all persons who are assessed for HIV counseling and testing services. * Seek to ensure that all persons who seek HIV testing are offered counseling relevant to their needs. * Seek to ensure that persons who are determined to be at risk for HIV infection as a result of sexual or drug using behaviors are routinely counseled. * Establish that no facility that receives federal funds for HIV counseling and testing services may deny a client services because of that client's inability to pay (3). SPECIAL CONSIDERATIONS * Clients who request repeat testing should be managed as indicated in the "Counseling and Repeat Testing Section." REFERENCES (1) CDC. 1992 HIV Prevention Program Guidance. (2) CDC. Technical Guidance on HIV Counseling, January 1993. (3) CDC. 1992 HIV Prevention Program Guidance. RISK ASSESSMENT DEVELOPMENT Program managers, from sites that provide HIV counseling services should review available data to identify site-specific HIV prevention needs. This review and evaluation should include AIDS case surveillance data, HIV seroprevalence data, STD morbidity, prevention counseling data, and demographic and risk behavior profiles of the population and the catchment community served by each site. Based on analysis of this data, the program should develop policies for each site that address the appropriate provision of primary and secondary HIV prevention services including triage assessment, targeted or universal risk assessment procedures. For example, if the voluntary HIV testing seropositivity at a site is higher than the blinded seroprevalence, this site is successfully targeting prevention efforts. However, if the voluntary HIV testing seropositivity is lower than the blinded seroprevalence, this site may not be appropriately targeting assessments, outreach efforts, prevention counseling, and/or provision of voluntary testing services. This information should be used to plan activities and services, redirect efforts and resources to meet current needs, use resources more efficiently, and identify unmet service needs. Each site that offers HIV testing must provide prevention counseling tailored to individual client needs and should develop an effective method to involve clients in identifying their risk behaviors. This approach should also address local and specific circumstances which might influence the client's perception of risk. Where available, sites should use triage assessment as one of the first efforts to direct persons at risk of HIV infection into prevention counseling. Clinic environment should support the risk assessment process, another essential method to involve clients in identifying their risk behaviors. Strategies to achieve this include group discussions, audiovisual materials, pamphlets, and/or posters. Community based organizations are excellent collaborators in the development and provision of client support services. Educating clients through multiple methods increases the chance that clients will recognize behaviors which place them at risk. STANDARDS HIV prevention program managers must make certain that the following are achieved: * Provision of training and quality assurance to staff to ensure identification of risk behaviors of all clients counseled or tested for HIV. * Establishment of site-specific demographic and risk profiles, based on analysis of HIV test data. * Ongoing collection and review of available site-specific data, including AIDS case surveillance data, HIV seroprevalence data, STD morbidity, prevention counseling data, demographic, and risk behavior profiles for targeting of resources and quality assurance of service delivery. * Determination of appropriate site-specific strategies for risk assessment of clients, based on demographic and risk profiles. * Procedures to maximize targeting of clients for prevention counseling based on risk profiles. GUIDELINES HIV prevention program managers should do the following: * Ongoing review and analysis of relevant seroprevalence data, including site specific blinded seroprevalence if available, and * Analyze by site the extent of HIV prevention counseling coverage (number of clients seen, blinded seroprevalence, and number of HIV infected persons identified through prevention counseling). REFERRAL SERVICE DEVELOPMENT A thorough client assessment often indicates a need for services that cannot be provided by the counselor (e.g. drug treatment, peer support groups, etc.). To ensure that clients receive appropriate care, the program must establish a procedure for referring persons to sites that provide services in a timely, efficient, and professional manner. A collaborative relationship should have already been established with the appropriate representative of the referral site. STANDARDS HIV prevention program managers must develop a process for routine referral which include the following: * A written referral process for identifying, evaluating, and updating referral sources in the site's operations manual. * A mechanism to provide clients with immediate access to emergency psychological or medical service. * Appropriate referral resources for - Any client at-risk for HIV infection who may be in need of support to maintain safer behaviors, - HIV negative clients who continue to test but are without risk, - HIV negative clients who continue to engage in risk behavior, - HIV positive clients who continue to engage in risk behavior, - HIV positive or high risk HIV negative clients who need STD diagnosis and/or treatment, and - HIV positive persons who need a medical assessment. * Written standards for the follow-up of confidentially tested HIV positive clients who don't return for results and counseling. GUIDELINES HIV prevention program managers should develop a process for routine referral which would accomplish the following: * Maintains a current list of community and institutional referral resources such as infectious disease specialists and clinics, free clinics, social service agencies, emergency medical services, hospitals, prenatal care clinics, family planning clinics, mental health centers, AIDS service organizations, HIV/AIDS community-based organizations (CBOs), substance abuse treatment facilities, and religious institutions; * Establishes a liaison at each of these resources; and * Provides periodic inservices from referral agencies. QUALITY ASSURANCE The objective of quality assurance is to ensure that appropriate, competent, and sensitive, methods are used for risk assessments, counseling, and referral of clients. Management staff, contractors, or collaborative agency staff should be trained and should be able to perform routine objective quality assurance site visits. A minimal level of performance should be determined and agreed upon by the funding agency and the service provider. Less than minimal performance must be remedied, or the site should suspend counseling and testing activities until an acceptable minimal standard of performance can be assured. Counseling programs should develop written quality assurance policies and procedures consistent with these standards and guidelines; these documents should be available to all staff. Client feedback should be routinely used as a factor in assessing quality assurance. STANDARDS I. Facility * The site must be geographically accessible to the population it serves. * The site must operate during appropriate hours and minimize any delay in providing services. * Counseling rooms must be private to ensure confidentiality of the counseling session. II. Staff * Management staff must ensure that necessary resources and systems are available to ensure acceptable job performance. * The program director must ensure adequate on-site supervision for staff. * Counselors must meet locally established qualification standards. * Counselors and other relevant staff must be provided updates at least annually on the scientific/public health aspects of HIV. III. Educational and Risk Reduction Materials * Culturally competent, linguistically specific, and developmentally appropriate written HIV information must be available to clients. The National HIV Clearinghouse is a useful resource to obtain and review a range of HIV education and risk reduction materials. IV. Records/Forms * Client records (confidential and anonymous) must contain a copy of the informed consent document, laboratory slip with test results, documentation of prevention counseling, result notification, and formulation of risk- reduction plans. * Records with patient identifiers must be secured. * All personal identifying information in connection with the delivery of services provided to any person must not be disclosed unless required by law or unless the person provides written, voluntary informed consent. * Routine audits of risk assessment questionnaires, counseling and interview forms, and client risk reduction plans must be conducted. GUIDELINES I. Facility * The physical facility should display a level of professionalism and client orientation relevant to the population served. II. Staff * A written job description should be provided for all counselors. * Performance tasks and standards should be established and reviewed with the employee. * All counselor and supervisory staff should be familiar with all services connected with the counseling program. * New counselors should be observed (with client consent) daily until proficiency is assured and periodically thereafter to ensure that proficiency is maintained. * The supervisor should routinely provide constructive feedback to the employee, based on the observations. * Case presentations should be conducted routinely, using techniques such as team problem solving sessions with medical, supervisory, and counseling staffs. * Each counselor and supervisor should be provided additional information through training and/or inservices about HIV, STD, TB, immunization, family planning, substance abuse, and early interventions such as antiviral treatments, etc. III. Educational and Risk Reduction Materials * Condoms should be available to the client--directly from providers and easily accessible without the client having to ask. * Current written materials should be prominently displayed in public areas and made available to clients. * Current written and audiovisual materials should be culturally and linguistically appropriate for the client population. Materials should be sensitive to the reading levels, gender, and ethnicity of the client population. PUBLICLY FUNDED PROGRAMS DATA COLLECTION AND ANALYSIS Accurate and consistent data collection from HIV prevention counseling, test results, notification of results, referrals, and partner notification activities are critical to the implementation, maintenance, and evaluation of a quality HIV prevention program. Data collection and quality assurance of referrals and partner notification are addressed in the respective guidelines. Analysis of HIV counseling and testing data in combination with seroprevalence and local demographic and STD morbidity data are essential components of prevention program operations. Required by the program, the data should: * Identify barriers and gaps in service delivery, * Plan, refine and target program intervention strategies, * Analyze resource allocation, * Provide site specific feedback to clinic staff, and * Provide specific feedback to counselors. STANDARDS Publicly funded programs must * Utilize a standard data collection tool throughout the project area. * Collect minimum required variables: - Unique record/client identifier; - Unique site identifier; - Prevention counselor identifier; - Date of prevention session; - Client demographics (age, sex, race/ethnicity, state, county, and zip code), - Client risk behavior (identified through client self-assessment and/or counselor discussion with client during prevention counseling); - Final laboratory result/report; and - Date of notification of results and prevention counseling. * Adhere to the NCPS site numbering system criteria: - Site number is determined by where the client is tested; - Each clinic within a facility has a unique site number; - Satellite clinics require a unique site number; - Site numbers are not duplicated across counties, districts, or parishes; and - Site location, not counselor identification number, determines the site number. * Counselor/DIS field services and outreach teams require a unique group site number for field work. * Conduct routine and systematic review of data for errors and inconsistencies and establish formal mechanisms for corrections. * Report client record data (with client identifiers removed) to NCPS on a quarterly basis. * Use the following program indicators to evaluate HIV counseling at individual sites: - Number of clinic visits, - Number of clients eligible for prevention counseling, - Number of clients who received prevention counseling, - Number of clients tested for HIV, - Number of clients testing positive, - Number of positive clients notified of results and provided prevention counseling, - Number of clients testing negative, and - Number of negative clients notified of results and provided prevention counseling. - Other relevant program indicators identified through ongoing quality assurance and data analysis. Note: The first three indicators provide important denominator data for sites that provide a range of health care services. GUIDELINES Publicly funded programs should * Review site-specific data analysis with appropriate staff at least quarterly. * Conduct counselor-specific data analysis and provide feedback to the counselor at least twice a year. * Conduct personnel resource analysis to establish minimum workload guidelines. * Establish a computerized data system to facilitate data analysis for quality assurance. DISTRIBUTED BY GENA/aegis (714.248.2836 * 8N1/Full Duplex) SOURCE: National AIDS Clearinghouse.