1. HIV Screening and Women’s Health Health Care Education & Training, Inc. Originally developed by: HIV Prevention and Test Counseling: A Client-Centered Approach Section 2:

2. 2 2007 Contributors from AETC Women’s Health and Wellness Workgroup:  Laura Armas, MD; Texas/Oklahoma AETC  Monique M. Clesi; Planned Parenthood of Indiana  Andrea Norberg, MS, RN; AETC National Resource Center  Tonia Poteat, MPH, MMSc, PA-C; Southeast ATEC (SEATEC)  Barbara Schechtman, MPH; Midwest ATEC (MATEC)  Karen Sherman, MA; Health Care Education and Training, Inc.  Jamie Steiger, MPH; AETC National Resource Center The original curriculum was developed in 2002 by MATEC and Health Care Education & Training, Inc. HIV Screening and Women’s Health

3. 3 Objectives for Section 2: 1.Identify the benefits of HIV counseling for family planning clinics 2.Describe effective client-centered counseling techniques 3.Discuss the stages of behavior change 4.Describe the steps in performing an HIV client- centered counseling session 5.Provide examples of open-ended questions for each step HIV Screening and Women’s Health

4. 4 Benefits of HIV Counseling in a Family Planning Clinic  Staff are comfortable talking about sexual behavior  Clients are already concerned about preventing pregnancy and/or STIs/HIV  Clients expect to disclose some sexual history to staff  Opportunity to reach a population that doesn't seek other care HIV Screening and Women’s Health

5. 5 Providing HIV Counseling in a Family Planning Clinic Environment  Assess your environment and materials Policies and Procedures  Establish a written policy requiring staff to offer HIV tests to ALL clients  If you only offer confidential testing, be sure to provide referral options to anonymous testing  Follow your state requirements for reporting positives  Whenever possible, the same counselor should do the counseling and give results HIV Screening and Women’s Health

6. 6 Providing HIV Counseling in a Family Planning Clinic Provider Needs  Training on how women acquire HIV  Training on client-centered counseling  Training on HIV, women, and risk factors Clients Needs  Information on how HIV is transmitted  Information on the risk factors for HIV HIV Screening and Women’s Health

7. 7 Client-Centered Counseling vs. Directive Counseling Client-Centered Counseling:  Interactive  Uses open-ended questions and active listening  Develop objectives and strategies with the client Directive Counseling:  Counselor gives information  Counselor provides advice HIV Screening and Women’s Health

8. 8 Client-Centered Counseling vs. Directive Counseling Client-Centered Counseling Directive Counseling Tell me what you've heard about how HIV is transmitted. Let me tell you how HIV is transmitted. What has happened in the past when you have tried to use condoms? Why aren't you using condoms? HIV Screening and Women’s Health

9. 9 Client-Centered Counseling Principles 1.Talk with, rather than to, the client 2.Individualize counseling to meet the client's needs by asking questions that:  Focus on issues and circumstances that the client identifies  Elicit, accept, and support the client's ideas about changing her behavior  Acknowledge the client's feelings as an important consideration 3.A neutral, nonjudgmental attitude is maintained by the counselor HIV Screening and Women’s Health

10. 10 Client-Centered Counseling Principles 4.Client is in charge/control 5.Clients are responsible for their own decisions and behavior changes 6.Options, rather than directives, are offered 7.Counseling is not interviewing or educating 8.Focus on feelings as much as information 9.Behavior change is a process HIV Screening and Women’s Health

11. 11 Client-Centered Counseling Techniques  Active Listening  Attending  Open-ended questions  Paraphrasing  Reflecting feelings  Clarifying  Articulating non-verbal messages HIV Screening and Women’s Health

12. 12 Client-Centered Counseling Techniques  Reframing  Third-personing  Weighing HIV Screening and Women’s Health

13. 13 Client-Centered Counseling Techniques  Confronting  Rehearsing/Role Playing  Giving Information  Summarizing and Closing HIV Screening and Women’s Health

14. 14 Stages of Behavior Change HIV Screening and Women’s Health (Prochaska, DiClemente, & Norcross, 1992)

15. 15 Using the TM Precontemplation  Increase awareness of need for change  Personalize risks and benefits Contemplation  Motivate  Encourage to make specific plans Preparation  Assist in developing concrete action plans  Setting gradual goals HIV Screening and Women’s Health

16. 16 Using the TM Action  Assist with feedback  Problem solving  Social support  Reinforcement Maintenance  Assist in coping  Reminders  Finding alternatives HIV Screening and Women’s Health

17. 17 HIV Counseling Goals Goal # 1 = all women know their HIV status Goal # 2 = all healthcare providers know the HIV status of the women they are treating Goal # 3 = 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 support a client needs to make decisions  If indicated, negotiate a realistic incremental plan to further reduce risk HIV Screening and Women’s Health

18. 18 Steps in HIV Counseling 1.How do you bring up HIV?  Just as you would any other routine test  Within CONTEXT of family planning and STI testing  Offer as a service to EVERYONE  Assure CONFIDENTIALITY HIV Screening and Women’s Health

19. 19 Epidemiology of Women and HIV HIV/AIDS in 2005  Women account for 26% of the estimated 37,930 diagnoses for adults and adolescents.*  High risk heterosexual contact was the source of 80% of an estimated 9,893 women infected with HIV.*  Of the 127,150 women living with HIV/AIDS, 64% are Black, 19% are White, 15% are Hispanic, 1% are Asian/Pacific Islander, and less than 1% are Native American.* *All data are based on information from 33 states with long-term, confidential name-based HIV reporting. Source: Centers for Disease Control and Prevention, http://www.cdc.gov/hiv/topics/women/overview_partner.htm http://www.cdc.gov/hiv/topics/women/overview_partner.htm HIV Screening and Women’s Health

20. 20 Steps in HIV Counseling 2. Assess and enhance client’s perception of risk  What can you tell me about how HIV is transmitted?  Follow-up with appropriate prevalence information  Has anything happened that you think might have put you at risk?  If so, can you tell me what happened? HIV Screening and Women’s Health

21. 21 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 (eg, sharing needles, body piercing, tattoo)  Perinatal transmission during pregnancy and delivery, or after birth through breast feeding HIV Screening and Women’s Health

22. 22 Steps in HIV Counseling 3. Discuss prevention and risk reduction  Discuss risk factors  What are you doing to protect yourself from HIV / STIs?  Support any positive efforts HIV Screening and Women’s Health

23. 23 Steps in HIV Counseling 4. Negotiate a plan  How would you most like to reduce your risk for STIs and HIV?  Can you think of some small step you could complete in the next week to help you come closer to reducing your STI and HIV risk?  Tell me how you could go about making this happen.  What could make it more difficult for you to complete this step? HIV Screening and Women’s Health

24. 24 Steps in HIV Pre-Test Counseling 1. Explain the term “window period” and the meaning of test results  Explain that it can take 2-12 weeks for a person's body to indicate infection.  If the test is positive using rapid testing, you will have to be tested with a different test.  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. HIV Screening and Women’s Health

25. 25 Steps in HIV Pre-Test Counseling 2. Discuss reactions to test results  If blood is sent to the lab and you have to wait for two weeks, what are you going to do for support? HIV Screening and Women’s Health

26. 26 Steps in HIV Pre-Test Counseling 3. 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. HIV Screening and Women’s Health

27. 27 Steps in HIV Pre-Test Counseling 4. 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. HIV Screening and Women’s Health

28. 28 Steps in HIV Post-Test Counseling Negative test result 1. Disclose the test result  Your HIV test was negative. 2. Assess the client’s reaction  How does it feel to hear that it is very likely that you are not infected with HIV? HIV Screening and Women’s Health

29. 29 Steps in HIV Post-Test Counseling Negative test result (continued) 3. Discuss possible need for retesting  Remember, it is important to get retested if you’ve had a recent risk.  Testing is recommended yearly. 4. Review and discuss the client’s risk factors  How do you plan to stay negative?  Support the client’s intentions  Review other options, as needed  Encourage implementation HIV Screening and Women’s Health

30. 30 Steps in HIV Post-Test Counseling Positive test results 1. Disclose the test result  Your HIV test was positive.  Wait for the client to talk  Assess the client’s reaction and understanding of the test results  Do you understand this test result?  How are you feeling about this test result?  What does this test result mean to you? HIV Screening and Women’s Health

31. 31 Steps in HIV Post-Test Counseling Positive test results (continued) 2. If Rapid Test was used, immediately discuss doing a confirmatory test. If Rapid Test was not used, move into more in-depth counseling. HIV Screening and Women’s Health

32. 32 Steps in HIV Post-Test Counseling Positive test results (continued) 3. Validate feelings and offer hope  I can see you’re feeling...  There’s a lot to learn about living with HIV, and there’s plenty of time and lots of people to help you. 4. Assess emotional stability and coping  Who in your life do you feel is supportive of you?  When you go home, what are some things that you can do to take care of yourself? HIV Screening and Women’s Health

33. 33 Steps in HIV Post-Test Counseling Positive test results (continued) 5. Discuss disclosure to partners, family, and friends.  Who can you share your results with?  We can talk about how and when you might tell them. 6. Discuss need for continued risk reduction  It’s important to avoid re-infection and other illnesses. What are some things you can do to protect yourself? HIV Screening and Women’s Health

34. 34 Steps in HIV Post-Test Counseling Positive test results (continued) 7. 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… HIV Screening and Women’s Health

35. 35 Steps in HIV Post-Test Counseling Indeterminate test results 1. Disclose and explain test result  Your HIV test was indeterminate, which means the lab couldn’t determine if you were infected with HIV. 2. Assess the client’s reaction  How are you feeling about this test result? HIV Screening and Women’s Health

36. 36 Steps in HIV Post-Test Counseling Indeterminate test results (continued) 3. 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. 4. Determine the client’s window period  When was the last time you… HIV Screening and Women’s Health

37. 37 Steps in HIV Post-Test Counseling Indeterminate test results (continued) 5. Recommend retesting  Retest at 6 weeks  Retest at 6 months  At this point, we need to retest you in order to get a clear result.  Provide (or schedule visit for) retesting  Check manufacturer's guidelines HIV Screening and Women’s Health

38. 38 Steps in HIV Post-Test Counseling Indeterminate test results (continued) 6. Discuss need for continued risk reduction  What are you doing to protect yourself? 7. Assess emotional stability and coping  Who in your life do you feel is supportive of you?  When you go home, what are some things that you can do to take care of yourself? 8. Offer interim contact until results are back  In the meantime, you can reach me at… HIV Screening and Women’s Health

39. 39 Services for People Living with HIV  Primary Care  Case Management  Dental Care  Drug Reimbursement  Legal Assistance  Substance Abuse Counseling  Rent & Utility Assistance HIV Screening and Women’s Health

40. 40 Resources  AIDS Education and Training Centers www.aidsetc.org www.aidsetc.org  Title X Family Planning Regional Training Centers http://opa.osophs.dhhs.gov/titlex/ofp-training-grantees- listing.html http://opa.osophs.dhhs.gov/titlex/ofp-training-grantees- listing.html  Adolescent AIDS Program, Children's Hospital at Montefiore Assess, Consent, Test, Support (ACTS) http://www.adolescentaids.org/healthcare/acts.php http://www.adolescentaids.org/healthcare/acts.php  Centers for Disease Control and Prevention  Project RESPECT http://www.cdc.gov/hiv/topics/prev_prog/rep/packages/re spect.htm http://www.cdc.gov/hiv/topics/prev_prog/rep/packages/re spect.htm  Healthy Relationships http://www.cdc.gov/hiv/topics/prev_prog/rep/packages/Hea lthyRelationships.htm http://www.cdc.gov/hiv/topics/prev_prog/rep/packages/Hea lthyRelationships.htm HIV Screening and Women’s Health

41. 41 References Bradley-Springer, L. (1996) Patient Education For Behavior Change: Help From the Transtheoretical and Harm Reduction Models. JANAC, Vol. 7, Supple. 1, 23-33. Centers for Disease Control and Prevention, Division of HIV/AIDS Prevention, Project RESPECT. Retrieved June 21, 2007 from http://www.cdc.gov/hiv/topics/prev_prog/rep/packages/respect.htm http://www.cdc.gov/hiv/topics/prev_prog/rep/packages/respect.htm National Network of STD/HIV Prevention Training Centers Curriculum Committee, Behavioral Counseling for STD/HIV Risk Reduction. Retrieved June 21, 2007 from http://depts.washington.edu/nnptc/core_training/clinical/PDF/B EHAVIORAL%20COUNSELING.pdf http://depts.washington.edu/nnptc/core_training/clinical/PDF/B EHAVIORAL%20COUNSELING.pdf Prochaska, J.O., DiClemente, C.C., & Norcross, J.C. (1992) In Search of How People Change: Applications to Addictive Behaviors. American Psychologist, Vol. 47 (9), 1102-1114 HIV Screening and Women’s Health