1. Midwest AIDS Training & Education Center Health Care Education & Training, Inc. HIV/AIDS Case-Finding In Family Planning Clinics

2. HIV/AIDS Case-Finding in Family Planning Clinics Section 3: HIV Prevention and Test Counseling in Family Planning Clinics: A Client – Centered Approach

3. HIV/AIDS Case-Finding in Family Planning Clinics Objectives for Section 3 Discuss the importance of HIV counseling for family planning clinics Discuss the process of behavior change Describe effective counseling formats and practices Identify information about sexual transmission of HIV to be conveyed in counseling

4. HIV/AIDS Case-Finding in Family Planning Clinics Benefits of HIV Counseling in a Family Planning Clinic Comfort level of staff already established in talking about sexual behavior Clients are already concerned about preventing pregnancy and/or STIs / HIV Clients will expect to disclose some sexual history to staff Opportunity to reach a population that doesn’t seek other care

5. HIV/AIDS Case-Finding in Family Planning Clinics Providing HIV Counseling in a Family Planning Clinic Establish a private area for HIV counseling Train staff members on client-centered counseling and HIV risk reduction methods If you only offer confidential testing, be sure to provide referral options to anonymous testing

6. HIV/AIDS Case-Finding in Family Planning Clinics Providing HIV Counseling in a Family Planning Clinic Whenever possible, keep the same counselor for each client’s HIV counseling sessions Establish a written policy requiring staff to offer HIV tests to ALL clients Assess your environment and materials

7. HIV/AIDS Case-Finding in Family Planning Clinics Predictors of Successful Behavior Change A Perceived A Sense of Self Social Having a – Risk of harm – Benefit of Change – Efficacy – Support – Plan

8. HIV/AIDS Case-Finding in Family Planning Clinics Client-Centered Counseling versus Directive Counseling Why use Client-Centered Counseling? It works! A client is much more likely to act on behaviors determined by them and by someone else. Directive counseling is based on the beliefs, skills, perceived risks & benefits, and self- efficacy of the counselor, not the client – that’s why it doesn’t work!

9. HIV/AIDS Case-Finding in Family Planning Clinics Client-Centered Counseling Principles The Client’s Needs Come First The Client is in Charge / Control Clients are responsible for their own decisions and behavior changes Options, rather than directives, are offered Counseling is not interviewing or educating Focus on feelings as much as information Behavior change is a process

10. HIV/AIDS Case-Finding in Family Planning Clinics Client-Centered Counseling Techniques Active Listening Attending Open questions Paraphrasing Reflecting feelings Clarifying Articulating non-verbal messages

11. HIV/AIDS Case-Finding in Family Planning Clinics Client-Centered Counseling Techniques Reframing Third-Personing Weighing

12. HIV/AIDS Case-Finding in Family Planning Clinics Client-Centered Counseling Techniques Confronting Rehearsing / Role Playing Giving Information (KISS) Summarizing and Closing

13. HIV/AIDS Case-Finding in Family Planning Clinics HIV Counseling Goals Goal  to get every client tested Goal  to reduce the spread of HIV by: Improving client’s perception of risk Supporting positive behavior changes the client has made Providing the information and suppor a client needs to make decisions Negotiating a realistic, incremental plan to further reduce risk

14. HIV/AIDS Case-Finding in Family Planning Clinics HIV Counseling How do you bring up HIV? Establish RAPPORT and address the client’s presenting concern(s) first Within CONTEXT of family planning Explain REASON for raising the issue Offer as a service to EVERYONE

15. HIV/AIDS Case-Finding in Family Planning Clinics HIV Counseling Once you start, what do you talk about? Client’s perception of risk Efficacy of client’s birth control choice Prevention / risk reduction Previous experience with testing and willingness to be tested or retested Testing decision

16. HIV/AIDS Case-Finding in Family Planning Clinics HIV Prevention Counseling Assess client’s perception of risk “Has anything happened that you think might have put you at risk?” If so, “Can you tell me what happened?” “What can you tell me about how HIV is transmitted?” “Why do you think you could be at risk?” “From unprotected sex / needle sharing?”

17. HIV/AIDS Case-Finding in Family Planning Clinics Transmission of HIV Infectious Body Fluids Blood, Semen, Vaginal Fluids, Breast milk Routes of Transmission Unprotected sexual intercourse (oral, vaginal, and anal) Exchange of Blood or Blood Products (ie, sharing needles, body piercing/tattoo) Perinatal transmission during pregnancy and delivery, or after birth through breast feeding

18. HIV/AIDS Case-Finding in Family Planning Clinics Discuss prevention / risk reduction Assess client’s behavior “What are you doing to protect yourself from HIV / STI’s?” Support any positive change “Would you like to work on reducing your risk (even more)?” HIV Prevention Counseling

19. HIV/AIDS Case-Finding in Family Planning Clinics Discuss prevention / risk reduction Discuss additional options “What are some things a person can do to avoid getting HIV?” Negotiate a plan “What would work for you?” “When would you like to try that?” consider potential obstacles rehearse the steps involved HIV Prevention Counseling

20. HIV/AIDS Case-Finding in Family Planning Clinics HIV Test Decision Counseling Ask about previous experience with testing and willingness to be tested or retested “Have you been tested for HIV before?” If Yes: “When were you tested?” “Where were you tested?” “What were the results?” “Are you interested in retesting?”

21. HIV/AIDS Case-Finding in Family Planning Clinics HIV Test Decision Counseling “Have you been tested for HIV before?” If no… “How would you feel about being tested?” “Would you consider having a test?” “What would be good about testing?” "What would be difficult?”

22. HIV/AIDS Case-Finding in Family Planning Clinics Typical Services for HIV-Positive Persons Primary Care Case Management Dental Care Drug Reimbursement Legal Assistance Substance Abuse Counseling Rent & Utility Assistance

23. HIV/AIDS Case-Finding in Family Planning Clinics HIV Pre-Test Counseling Explain window period / meaning of results “Are you familiar with ‘window period’ for the test?” “It can take 2-12 weeks for the test to show if someone has been infected.” “What do you understand positive means?” “Yes, it means a person has HIV and can pass it on to others.”

24. HIV/AIDS Case-Finding in Family Planning Clinics HIV Pre-Test Counseling “What do you understand negative means?” “Yes, it could mean that a person is not infected with HIV, or...” “It could mean a person was infected recently and it’s too soon to show up on the test yet.” “If your test is negative it might be a good idea to be retested if you have had a recent risk.”

25. HIV/AIDS Case-Finding in Family Planning Clinics HIV Pre-Test Counseling Discuss reactions to Test Results “How do you think you will feel while you’re waiting for results?” “How do you think you would feel if your test came back negative?” “How do you think you would feel if your test came back positive?” “What would you do?” “Whom would you turn to for support?”

26. HIV/AIDS Case-Finding in Family Planning Clinics HIV Pre-Test Counseling Obtain written consent “In order to do the test, I need you to sign a consent form.” “Please read the consent form and let me know if you have any questions or concerns before you sign it.”

27. HIV/AIDS Case-Finding in Family Planning Clinics HIV Pre-Test Counseling Plan follow-up visit for test results Explain when and how to get results “Your test results will be ready...” “You will need to come back in person to get your test results.” “When you come back, I will give you your results and we can talk about what they mean for you.”

28. HIV/AIDS Case-Finding in Family Planning Clinics HIV Post-Test Counseling Negative test result Disclose the test result “Your HIV test was negative.” Assess the client’s reaction “How do you feel about that?” Review the meaning of the result “Can you tell me what a negative test result means?”

29. HIV/AIDS Case-Finding in Family Planning Clinics HIV Post-Test Counseling Negative test result Discuss possible need for retesting “Remember, it might be good to get retested if you’ve had a recent risk.” Review the client’s risk reduction plan “How do you plan to stay negative?” support the client’s intentions review other options as needed encourage implementation soon

30. HIV/AIDS Case-Finding in Family Planning Clinics HIV Post-Test Counseling Positive test results Disclose the test result “Your HIV test was positive.” Assess the client’s reaction “What are your thoughts / feelings?” Review the meaning of the result “Can you tell me what a positive test result means?”

31. HIV/AIDS Case-Finding in Family Planning Clinics HIV Post-Test Counseling Positive test results Validate feelings and offer hope “I can see you’re feeling...” “There’s a lot to learn about living with HIV, but there’s plenty of time and lots of people to help you.” Assess emotional stability and coping “What are your plans when you leave?” “Whom can you turn to for support?”

32. HIV/AIDS Case-Finding in Family Planning Clinics HIV Post-Test Counseling Positive test results Discuss disclosure to partner / others “Have you thought about who you might share your results with?” “We can talk about how and when you might tell them.” Discuss need for continued risk reduction “It’s important to avoid reinfection and other illnesses. Are there some things you can do to protect yourself?”

33. HIV/AIDS Case-Finding in Family Planning Clinics HIV Post-Test Counseling Positive test results Recommend follow-up medical care “The next step is to assess your health and decide how to manage your infection.” Schedule a return visit or make referral “I’d like to see you again in a few days so we can develop a plan for your care.” Offer an interim contact and written material “In the meantime, you can reach me at…”

34. HIV/AIDS Case-Finding in Family Planning Clinics HIV Post-Test Counseling Indeterminate test results Disclose and explain test result “Your HIV test was indeterminate, which means the lab couldn’t determine if you were infected with HIV.” Assess the client’s reaction “What are your thoughts / feelings?”

35. HIV/AIDS Case-Finding in Family Planning Clinics HIV Post-Test Counseling Indeterminate test results Validate feelings and offer support “I can see you’re feeling...” “This result can be very confusing and unsettling. Let’s talk about what the next step is and what kind of support you need until you get a clear result.” Determine the client’s window period “When was the last time you…”

36. HIV/AIDS Case-Finding in Family Planning Clinics HIV Post-Test Counseling Indeterminate test results Recommend retesting “At this point, we need to retest you in order to get a clear result.” p24 antigen pcr for DNA pcr for RNA (viral load) HIV antibody test Provide (or schedule visit for) retesting

37. HIV/AIDS Case-Finding in Family Planning Clinics HIV Post-Test Counseling Indeterminate test results Discuss need for continued risk reduction “What’re you doing to protect yourself?” Assess emotional stability and coping “What are your plans when you leave?” “Whom can you turn to for support?” Offer interim contact until results are back “In the meantime, you can reach me at…”