1. HIV Counseling and Testing MTN-003 Study-Specific Training

2. Overview of Presentation HIV C&T at screening (brief check-in) HIV C&T at screening (brief check-in) HIV C&T at follow-up HIV C&T at follow-up Scenarios highlighting HIV testing algorithm and associated counseling messages Scenarios highlighting HIV testing algorithm and associated counseling messages Role play Role play Review of forms Review of forms Risk reduction counseling Risk reduction counseling Documentation Documentation

3. START sample 1 2 different rapid tests Sample 1 WB Sample 2 2 different rapid tests STOP. Report to participant as HIV-uninfected STOP. Report to participant as HIV-infected Discordant/requires additional testing. Notify The MTN Network Laboratory - -/--/- + +/++/+ +/-+/- ind Repeat testing, beginning at “START” in approximately one month. HIV Testing at Screening

4. START Sample 1 rapid test Sample 1 WB Sample 2 WB STOP. Report to participant as HIV-uninfected STOP. HIV infection confirmed Report to participant as HIV-infected Requires additional testing. - or ind - + + Consult the MTN Network Laboratory for further testing and follow up + + Sample 1 HIV viral load - HIV C&T at Follow-Up: Scenario #1

5. START Sample 1 rapid test Sample 1 WB Sample 2 WB STOP. Report to participant as HIV-uninfected STOP. HIV infection confirmed Report to participant as HIV-infected Requires additional testing. - or ind - + + Consult the MTN Network Laboratory for further testing and follow up + + Sample 1 HIV viral load - HIV C&T at Follow-Up: Scenario #2

6. START Sample 1 rapid test Sample 1 WB Sample 2 WB STOP. Report to participant as HIV-uninfected STOP. HIV infection confirmed Report to participant as HIV-infected Requires additional testing. - or ind - + + Consult the MTN Network Laboratory for further testing and follow up + + Sample 1 HIV viral load - HIV C&T at Follow-Up: Scenario #3

7. START Sample 1 rapid test Sample 1 WB Sample 2 WB STOP. Report to participant as HIV-uninfected STOP. HIV infection confirmed Report to participant as HIV-infected Requires additional testing. - or ind - + + Consult the MTN Network Laboratory for further testing and follow up + + Sample 1 HIV viral load - HIV C&T at Follow-Up: Scenario #4

8. HIV Counseling By the time of the first VOICE follow-up visit, participant will have undergone HIV C&T twice and risk reduction counseling three times By the time of the first VOICE follow-up visit, participant will have undergone HIV C&T twice and risk reduction counseling three times With monthly C&T throughout follow-up, care must be taken to avoid rote repetition of the same information each month With monthly C&T throughout follow-up, care must be taken to avoid rote repetition of the same information each month What are your thoughts on discussion of “standard” HIV education and pre-test information at each visit? What are your thoughts on discussion of “standard” HIV education and pre-test information at each visit?

9. Risk Reduction Counseling A client-centered and case-management type of approach should be used to make risk reduction counseling as effective as possible A client-centered and case-management type of approach should be used to make risk reduction counseling as effective as possible Relies on four Ps Relies on four Ps Quality of participant-provider relationship Quality of participant-provider relationship Partnership in a shared goal Partnership in a shared goal Mutually respectful Mutually respectful Non judgmental Non judgmental Personalized strategies to try to address barriers to risk reduction Personalized strategies to try to address barriers to risk reduction

10. Client-Centered Approach Counselor’s role is to ask questions, actively listen to participant’s responses, and guide participant toward next steps Counselor’s role is to ask questions, actively listen to participant’s responses, and guide participant toward next steps Outcome should be participant identifying Outcome should be participant identifying Her barriers to risk reduction Her barriers to risk reduction Her strategies and action plans to try to address the barriers Her strategies and action plans to try to address the barriers Supported and facilitated by the counselor Supported and facilitated by the counselor

11. Client-Centered Approach Greet client and establish rapport Greet client and establish rapport Describe purpose of the session Describe purpose of the session Emphasize confidentiality of the session Emphasize confidentiality of the session Listen effectively, allow client to speak, avoid interruptions Listen effectively, allow client to speak, avoid interruptions Communicate effectively, verbally and non-verbally Communicate effectively, verbally and non-verbally Communicate at client’s level of understanding Communicate at client’s level of understanding Use open-ended questions Use open-ended questions Clarify misconceptions Clarify misconceptions Provide positive reinforcement Provide positive reinforcement

12. Closed-Ended vs Open-Ended Do you know how HIV is passed from one person to another? Do you know how HIV is passed from one person to another? Do you understand what your test results mean? Do you understand what your test results mean? Do any of these risk factors apply to you? Do any of these risk factors apply to you?

13. Client-Centered Approach Strategies and action plans should: Strategies and action plans should: Reflect the participant’s current risk assessment Reflect the participant’s current risk assessment Be realistic and practical, yet challenging toward risk reduction Be realistic and practical, yet challenging toward risk reduction Be agreed upon by the participant Be agreed upon by the participant Be documented, with copy available to participant if desired Be documented, with copy available to participant if desired

14. Client-Centered Approach Participant’s risk reduction issues/barriers may be significant Participant’s risk reduction issues/barriers may be significant Strategies may need to be incremental Strategies may need to be incremental Participant’s risk reduction issues/barriers may change over time Participant’s risk reduction issues/barriers may change over time Strategies may need to evolve over time Strategies may need to evolve over time

15. Client-Centered Approach Counselor should also Counselor should also Offer skills building Offer skills building How to use male and female condoms (hands-on demonstrations) How to use male and female condoms (hands-on demonstrations) How to talk to partners (role play) How to talk to partners (role play) Offer couples counseling and/or other counseling with influential persons Offer couples counseling and/or other counseling with influential persons

16. Risk Reduction Counseling Each month, risks/issues/barriers and action plans identified at the previous counseling session should be reviewed and discussed with the participant Each month, risks/issues/barriers and action plans identified at the previous counseling session should be reviewed and discussed with the participant What was her experience over the past month? What was her experience over the past month? Was she able to carry out her plan? Was she able to carry out her plan? What was the outcome? What was the outcome?

17. Risk Reduction Counseling Action plans for the coming month should build on the past month’s experience Action plans for the coming month should build on the past month’s experience Successful strategies should be continued Successful strategies should be continued Additional strategies may be identified to achieve further risk reduction Additional strategies may be identified to achieve further risk reduction Alternative strategies may be identified if strategies tried over the past month were not successful Alternative strategies may be identified if strategies tried over the past month were not successful All as identified and agreed upon by the participant with the counselor’s guidance and support All as identified and agreed upon by the participant with the counselor’s guidance and support

18. Risk Reduction Counseling For this type of approach to be successful For this type of approach to be successful Issues/barriers/strategies/action plans discussed at each session must be documented Issues/barriers/strategies/action plans discussed at each session must be documented Documentation must be accessible for review at the next session Documentation must be accessible for review at the next session

19. General General HIV education and pre-test counseling HIV education and pre-test counseling HIV post-test counseling HIV post-test counseling Risk assessment Risk assessment Risk factors and barriers to risk reduction Risk factors and barriers to risk reduction Risk reduction plan – experience and outcomes since last visit Risk reduction plan – experience and outcomes since last visit Risk reduction plan – strategies for the coming month Risk reduction plan – strategies for the coming month Additional notes page Additional notes page HIV Counseling Worksheet

20. Referrals Referrals are expected components of risk reduction plans (when indicated) Referrals are expected components of risk reduction plans (when indicated) Referrals should be actively followed up at subsequent visits to determine Referrals should be actively followed up at subsequent visits to determine If participant sought the services to which she was referred If participant sought the services to which she was referred The outcome of the referral The outcome of the referral If additional referrals are needed If additional referrals are needed Document all referrals, outcomes, and follow-up plans and actions Document all referrals, outcomes, and follow-up plans and actions

21. What Are Your Questions Thoughts and Reactions?