1. HIV Counseling and Testing (HCT)
Unit 2
HIV Care and ART: A Course for Healthcare Providers
Unit 2 should take approximately 2 hours to complete
Step 1: Unit Learning Objectives (Slide 1-2) – 5 minutes
Step 2: Values Clarification (Slide 3) – 15 minutes
Step 3: Overview of HCT (Slides 4–19) – 30 minutes
Step 4: Counseling Skills and HCT (Slides 20–36) – 25 minutes
Step 5: Pre/Post-Test Counseling (Slides 37– 43) – 40 minutes
Step 6: Key Points (Slides 44–46) – 5 minutes

2. Learning Objectives Define HCT, VCT, and PIHCT
Explain the purpose and benefits of HCT as the entry point to HIV prevention, care, and treatment
List the basic components of a HCT program and pre- and post-test counseling
Identify the skills and characteristics of an effective HCT counselor
Step 1: Unit Learning Objectives (Slide 1-2) – 5 minutes
Begin by reviewing the Unit aim and objectives.
The aim of this unit is to better understand the skills needed to provide counseling within the context of VCT for HIV. These skills will act as a foundation for adherence counseling, discussed in detail later in the training course.
Ask the participants if they have any questions before continuing.

3. Values Clarification Exercise
Step 2: Values Clarification (Slide 3) – 15 minutes
Refer to Handout 2.1 for statements for this exercise.
Before beginning the unit, post signs reading “STRONGLY AGREE”, “AGREE”, “DISAGREE”, and “STRONGLY DISAGREE” on the four walls of the room.
Explain to participants that the values clarification exercise “Where do you stand?” is a good tool for enabling individuals to reflect on their thoughts and feelings about HIV.
Read each statement aloud (see Handout 2.1) and have participants respond by moving to the sign that most closely echoes their feelings. Emphasize that there are no right or wrong answers. Invite participants to briefly share the reasons for choosing their response. If participants are hesitant to speak, call on a group standing under one of the signs and specifically ask why they chose this sign.
At the end of this activity, lead a brief discussion.
What did you learn from this activity?
How might your own beliefs and biases related to VCT affect the advice or counseling that you give to your patients?
What can you do about this?
Summarize the activity by explaining that HIV/AIDS arouses many strong emotions and often touches some of our deepest beliefs. Because of this, and our role as health care providers, it is important to know ourselves, and particularly our attitudes and feelings about HIV/AIDS, treatment, and HIV-affected persons.

4. HIV Counseling and Testing
HIV Counseling and Testing (HCT) is composed of two types of testing:
VCT – Voluntary Counseling and Testing
PIHCT – Provider Initiated HIV Counseling and Testing
Step 3: Overview of HCT (Slides 4–19) – 30 minutes

5. Providing HCT In High & Low Prevalence Areas
High HIV prevalence in general population, >8%
Universal access for HCT services recommended
Low HIV prevalence in general population, <1%
HCT should target high-risk groups

6. HIV Testing Algorithm Neg Pos Sample Screening Test (Determine®)
Confirmatory Test (Capillus™)
Tie Breaker (Uni-Gold™or SeroCard™ )
Source: WHO Rapid HIV Tests: guidelines for use in HIV testing and counselling services in resource-constrained settings
Source: WHO 2004

7. (Uni-Gold™ or SeroCard™)
Parallel Test
Sample
Test 1
(Determine®)
Test 2
(Capillus™)
Neg
Neg
Pos
Pos
Source: WHO Rapid HIV Tests: guidelines for use in HIV testing and counselling services in resource-constrained settings.
Tie Breaker
(Uni-Gold™ or SeroCard™)
Source: WHO 2004
Neg
Pos

8. Knowing your HIV Status
HCT is a cornerstone for early access to prevention, as well as care and support
Why?
“Think About It” exercise
Refer participants to Handout 2.2, “Knowing Your HIV Status - Think About it”. Ask for a volunteer to read Scenario 1. Ask for a different volunteer to read Scenario 2.
Ask participants to imagine that the young man in Scenario 1 is tested and learns that he is not infected with HIV, and that the woman in Scenario 2 gets tested and discovers that she is infected with HIV.
Discuss:
How might the young man feel and act differently? For example, what has changed for him?
What are the benefits of the woman knowing her status?

9. Objectives of HCT HCT assists individuals and couples to:
Assess their HIV risk behaviors
Develop a risk reduction plan
Discuss testing of children
Access HIV testing
Adopt risk reduction behavior
Access medical and psychosocial referral services

10. HCT: Foundation of HIV Prevention and Care
ACCEPTING AND
COPING
WITH HIV STATUS
SUPPORT
FAMILY
FELLOWSHIP
HIV POSITIVE PEERS
LIVING POSITIVELY
NUTRITION
CLEAN WATER
REDUCED STRESS
WELLBEING
MEDICAL CARE
STI & TB TREATMENT
TB & OI PROPHYLAXSIS
PEDIATRICS HIV
DIAGNOSIS, CARE AND
TREATMENT
RISK REDUCTION
BEHAVIOR CHANGE
DISCLOSURE OF STATUS
PARTNER REFERRAL TO VCT
CONDOM ACCESS
HCT
Link the previous “Think About It” exercise to this diagram. Point out how knowing one’s HIV status is the foundation for all of the components in this slide.
PLANNING FOR FUTURE
FAMILY PLANNING
ORPHAN CARE
FINANCIAL PLANNING
COMMUNITY INTERVENTIONS  
SENSITIZATION
MOBILIZATION
DESTIGMATIZATION
PREVENTION OF
MOTHER TO CHILD
TRANSMISSION

11. VCT Overview
Voluntary Counseling & Testing (VCT) is an HIV-prevention intervention initiated by the client at his or her free will
VCT provides the opportunity for the client to confidentially explore and understand his/her HIV risks and to learn his/her HIV infection status with the support of a counselor
VCT is composed of:
Counseling
Testing
Referral

12. VCT Models
Integrated within existing health services, i.e., general clinical care settings and specialized clinics, such as ANC, TB, STI
Free-standing VCT sites
Mobile (outreach) VCT services
Private VCT services
Youth-friendly VCT services
Workplaces
Ask participants to share their experiences with VCT models at their sites.

13. Seeking VCT: Logic Model
Community Education
Individuals/Couples/Family
Want to Have HIV Test
Decision to Seek Testing
VCT/Pre- and Post-Test
Counseling Risk Reduction
Ongoing Counseling
(Preventive & Supportive)

14. VCT Program Components
Type of counseling session
Individual
Couple
Family
Pre-test counseling
Introduction and orientation
Risk assessment
Discussion of testing children, if applicable
Options for risk reduction
Preparation for the test result

15. VCT Program Components (2)
HIV Test
Post-test counseling
HIV negative test result
Negotiate risk reduction plan
Support for risk reduction plan
Negotiate disclosure & partner referral
HIV positive test result
Identify source of support
Negotiate disclosure and partner referral
Risk reduction issues
Referral
Clients receiving an HIV negative test result should be encouraged to return in three months (or less, depending on how recently they report exposure).
Encourage abstinence or safer sex during this window period.

16. What are the Concerns and Benefits of VCT?
To the individual
To the couple, children, and family
To the community
Ask participants to brainstorm what the benefits and concerns may be to the individual, in relation to VCT. Record their responses on flipchart paper. Next, ask them to brainstorm benefits and concerns in relation to VCT to the couple and family. Record responses on flipchart paper. Finally, ask the group to brainstorm benefits and concerns related to VCT for the community.
Encourage active participation by using questions or phrases such as “what else?” “Who else wants to add something?” “Anything more?” “How about the back of the room, we haven’t heard from you yet!” “How about this side?” Remind participants to remember the “Think About It” discussion to help them come up with responses.
Following are some possible answers:
Individual benefits: empowers uninfected person to protect himself or herself from becoming infected; assists infected persons to protect others and live positively; offers the opportunity for treatment of HIV and HIV-related conditions.
Individual concerns: financial difficulties; fear of stigma; depression about test results.
Couple and family benefits: supports safer relationships–enhances faithfulness; encourages family planning and PMTCT treatment; allows planning for the future.
Couple and family concerns: break-up of relationship; anger towards HIV-positive spouse.
Community benefits: generates optimism because large numbers of people test HIV-negative; changes community norms around testing, risk reduction, disclosure of status, and condom use; reduces stigma as more people disclose HIV status.
Community concerns: fear about local culture changing; worries about how to care for HIV-positive persons.

17. Provider Initiated HIV Counseling and Testing
PIHCT is routine, confidential, HIV testing offered to patients visiting health institutions
Routine HIV testing (opt-out) at health institutions increases access to HIV testing
Many people prefer to be tested by a medical provider within the context of a regular health care visit
PIHCT takes less time as the focus is more on post-test counseling and referral
During this discussion, issues concerning opt-out and opt-in should be raised.

18. Indications for Offering PIHCT
Patient reporting high risk behavior
Patient with tuberculosis
Patient presenting with STI
Symptom complex suggestive of HIV/AIDS
Pregnant women attending antenatal clinic
Patients receiving in-patient care

19. Difference between VCT and PIHCT
VCT
PIHCT
Clients/Patients
Come to receive HIV testing
Come with a medical problem
Expect to be tested
Are not expecting testing
Mostly asymptomatic
Providers
Trained counselor may not be health personnel
Health care provider trained to provide counseling
Purpose of HCT
Primary purpose is prevention
Primary focus on Dx, Mx of OI and HIV, and referral
Pre/Post-test Encounter
Client centered counseling
Provider recommends testing
Result discussed with neg & pos
Little time for negative results
Primary focus on pos result
Follow-up
HIV positive referred to medical care
Care of HIV positive patient coordinated with Tuberculosis clinic

20. Counseling Skills for HCT
Step 4: Counseling Skills and HCT (Slides 20–36) – 25 minutes

21. Counseling is a Relationship
Client and counselor both bring:
Hope
Knowledge
Questions and answers
Personal experiences

22. Seven Qualities of a Good Counselor
Self-confidence
Empathy
Acceptance
Genuineness
Trustworthiness
Confidentiality
Competence
Refer participants to Handout 2.3 for further explanation of each of these qualities and for counseling tips.

23. Skills and Characteristics of Effective HCT Counselors
Believes that HIV prevention counseling can make a difference in preventing and controlling HIV for the individual, the family, and the community
Balances well-selected, open-ended questions with statements, summaries, and reflections that guide the session and maintain the focus on risk issues

24. Skills and Characteristics of Effective HCT Counselors (2)
Uses active listening skills
Feels and behaves comfortably when discussing specific HIV risk activities
Able to help a client develop a realistic and relevant risk reduction plan

25. Counseling Essentials
Remember to always:
Demonstrate professionalism and maintain rapport throughout the session
Convey to the client that his or her confidentiality will be strictly protected
Speak with the client at his or her level of understanding
Conduct an interactive session focused on risk reduction

26. Counseling Essentials (2)
Clarify important misconceptions, but avoid extended talk on issues not related to risk
Stay organized, and avoid counseling outside the protocol’s structure
Know that it is all right to tell the client that you will be covering something later
Avoid collecting data about the client during the counseling session

27. Questioning Skills
Acknowledge that you have heard and understood the client
Blend reflective, guiding, and directive statements with well chosen open-ended questions
Ask questions that guide the client to consider their HIV risk, risk reduction, coping, and support
Ask appropriate follow-up questions
Ask client to elaborate on unclear issues
Ask client to clarify confusing or contradictory information
Ask for a participant to explain what is meant by open-ended questions (versus close-ended or closed questions).
Answer: A close-ended question is a question that can be answered with a single word response, such as “yes” or “no”. Such questions often do not provide much information to the counselor.
Direct participants’ attention to Handout 2.4, Questioning Skills, and ask for volunteers to read several of the examples of open-ended and closed-ended questions.

28. Closing a Counseling Session
Remind client of pre-test information
Assess client’s emotional state
Give client space to ask questions
Schedule client for further sessions
Refer to appropriate services

29. Referrals Developing linkages with other services
Referral directory of services
Referring clients
Developing a system for tracking referrals

30. Pre and Post Test Counseling ART administration and follow up
VCT Client Referral
VCT Client
Pre and Post Test Counseling
Referral NO
Medical Examination
(Clinical and Lab)
YES
ART counseling
ART administration and follow up

31. Working With Couples
Make sure both partners have an understanding of HIV/AIDS
Review willingness to have HIV test
Explain the process of testing and receiving results
Discuss advantages and disadvantages of knowing results as a couple
Partner notification should be encouraged if a person is tested alone.
Counselors may wish to encourage a person receiving HIV+ test results alone to repeat the test with their partner as a way of notifying the partner.
The counselor should privately ask each partner if they want counseling and testing together or individually.
For couples choosing to get results separately, explore ways before testing for disclosing results.
During the session, the counselor should ensure that both partners have their questions answered and that one partner does not dominate the conversation. The counselor may want to leave time for individual discussion.

32. Working With Couples: Making a Plan
Review options for positive, negative, and discordant results
Explore the possibility of discordant results
Identify others who may be affected by the outcome
Discuss testing their children
Discordant results are when one partner is positive and one is negative. Ask the couple what they understand about discordant results and how they think they would deal with it.

33. Ethical Principles
Counselors must be respectful toward the patient’s/client’s dignity and rights
Dignity
Acceptance
Non-judgment
Rights
Confidentiality
Privacy
Autonomy
Self-determination

34. Ethical and Legal Issues: Disclosure
Counselors cannot force disclosure of HIV status
To whom and when is always the choice of the patient
Can encourage the partner to have an HIV test
Can prevent the spread of HIV to the partner
Stigma is being recognized as the single greatest challenge to slowing the spread of HIV. It is not new. Stigma associated with TB, leprosy, and epilepsy have challenged care providers in the past. It is crucial that health-care providers be aware of their role in “breaking the silence”.
Like ARVs, which can change the course of HIV disease, a strong community of HIV activists can change the burden of isolation.

35. Ethical and Legal Issues: Children
Persons 15 years-old and above can give informed consent for testing
Children under 15 years-old may only be tested with consent of their parents or guardians
“Mature minors” between years of age are allowed to consent for HIV testing
Mature minors = married, pregnant, commercial sex workers, street teenager, family head and with a history of sexual intercourse

36. Ethical and Legal Issues: Children (2)
Mature minors should be informed of their results like adults
Children 12 years-old and above should be informed after appropriate counseling, and with the involvement of their parents or guardians
Children under 12 should not be informed of results until they reach an age when they can understand and parents/guardians give consent
Counselors should carefully consider to whom they disclose results, with the child’s best interests in mind
In post-test counseling of minors, counselors should be careful in making a decision as to whom to give results. It may not be to the one who gave consent for the testing. Children should not be tested simply for the parents or guardians to know their own status.
The result of HIV testing is the property of the child tested and shall not be disclosed to third parties unless to the benefit of the child.

37. Pre/Post-Test Counseling
Trainer Role Plays
Step 5: Pre/Post-Test Counseling (Slides 37– 43) – 40 minutes
The next part of the unit is three role plays presented by the trainers to demonstrate pre-test and post-test counseling with both HIV-negative and HIV-positive results. Instruct participants to observe carefully, jotting down notes regarding things the counselor does well and any suggestions they might have for improving the counseling session.

38. Pre-Test Counseling What does the client understand about HIV?
What does the client understand about HIV testing?
How does this information apply to the client?
Remind participants of the components of pre-test counseling mentioned earlier:
Risk assessment
Options for risk reduction
Preparation for the test result

39. Pre-Test Counseling in the PIHCT Setting
Trainer Role Play
Present the first role-play, a demonstration of pre-test counseling in the PIHCT setting. Follow the script in Handout 2.5, Pre-Test Counseling.
Two role-players will be required, one to play the role of the counselor, one the role of the patient. If a second trainer is not available, a participant volunteer can play the role of the patient while the trainer plays the counselor.
Two suggested patient profiles are provided in Handout 2.5. The profiles provide some basic information about the patient’s situation, but the role player will need to fill in details during the role play. The person playing the role of the patient can choose to use one of these profiles, or develop his or her own scenario.
Briefly discuss the role play with participants:
What did you learn about pre-test counseling from the role play?
What did the counselor do well? What would you advise him/her to do differently next time?
What were some of the challenges or difficulties in the counseling process?

40. HIV-Negative Results
Give time and space for the client to express emotions
Explore the client’s reaction
Review the meaning of the
test result (revisit the window period)
Discuss prevention/risk reduction
Refer for ongoing support/counseling at appropriate site
Take a look at these pictures. Most of us assume that a negative test result is “good news”.
However, some people may experience survivor guilt. Others may know that the rest of their family is HIV infected, and worry that they will be left behind should the family members die. Be sure to explore the patient’s feelings about the results and not make assumptions.

41. Giving HIV-Negative Results
Trainer Role Play
Present the second role-play, Providing HIV-Negative Test Results, following the script in Handout 2.5.The same two role-players should continue, with the patient playing the same role as in the pre-test role play.
Briefly discuss the role play with participants:
What did you learn about providing HIV-negative test results from the role play?
What did the counselor do well? What would you advise him/her to do differently next time?
What were some of the challenges or difficulties in the counseling process?

42. Giving HIV-Positive Results
Allow some time
Discuss what this means
Identify a coping strategy
Emphasize risk reduction
Link with support services
Ask participants to close their eyes and imagine themselves in a testing situation. In a compassionate voice, say “your test result is positive”. Allow the group to sit in silence and think about this for a moment.
Discussion points:
When giving a patient positive results, it is important to allow some time for the patient to absorb the information. You should discuss what the results mean, and begin to help them to identify a coping strategy. One approach that may be useful is to help the patient recall how they may have coped with difficult issues in the past.
Initially, people may not “hear” much beyond the test result.

43. Giving HIV-Positive Results
Trainer Role Play
Present the third role-play, Providing HIV-Positive Test Results, following the script in Handout 2.5. The same two role-players should continue, with the patient playing the same role as in the pre-test role play.
Briefly discuss the role play:
What did you learn from the role play about providing HIV-positive test results?
What did the counselor do well? What would you advise him/her to do differently next time?
What were some of the challenges or difficulties in the counseling process?

44. Key Points
HCT is a cornerstone of early access to prevention, care and support
HCT is composed of Voluntary Counseling and Testing (VCT) and Provider Initiated Counseling and Testing (PIHCT)
Step 6: Key Points (Slides 44–46) – 5 minutes
Summarize the presentation, review the Key Points presented in this Unit and answer final questions.

45. Key Points (2)
VCT is a HIV-prevention intervention initiated by the client at his or her free will.
VCT provides an opportunity to individuals and couples to work confidentially with a counselor to:
Assess their HIV risk behaviors
Develop a risk reduction plan
Adopt risk reduction behavior
Access medical and psychosocial referral services

46. Key Points (3)
PIHCT is routine confidential testing of HIV offered to patients visiting health institutions by their providers
Effective counseling requires a number of qualities, characteristics and skills that can be developed and improved with practice.