Session 3:Fundamentals of HIV Testing Services
Counselling for HTS
In this section, we will be learning how to provide counselling to clients coming in for HTS. We will review some general counselling information before we dive deeper into the HIV counselling that is needed for pre-test and post-test counselling. We will discuss how to deal with the emotions that come up for clients during counselling and also review the tools that are used.
Learning Objectives
By the end of this session, you will be able to:
- Describe the principles, skills and techniques used in counselling.
- List the two major approaches/theories used in counselling around HTS.
- Implement the proper stages of counselling in the HIV and AIDS context.
- Describe the elements of effective counselling.
- Describe the different types of counselling in HIV.
- Explain how to handle emotions resulting from positive results.
- Demonstrate use of counselling tools.
Learning Activities
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Introduction to Counselling (5 min)
Patience is a 19-year-old student. She has a boyfriend who is older and married. He pays for her school fees and gives her spending money, so she is fine with the arrangement. When he is not around, she has a boyfriend from school.
A year ago, Patience had an STI, which was treated. She tested negative for HIV at that time.
Today, she has come to your facility because recently she had unprotected sex with someone she hardly knew and is now “itching down there”. While she was waiting for her turn to see the clinician, there was a group information session on HIV, so she decided it would be a good idea to get tested again.
When a client like Patience shows up, there may be a lot of issues that come up during her HIV counselling. Whether she tests positive or negative, you can find an opportunity to help her to make better choices in her life. As we go through this section, we will discuss tips and techniques for counselling that will help to make her feel more comfortable and allow you to provide the best care possible. We already know what some of our triggers are from the earlier section on self-awareness. We will need to keep that in mind when we work with clients who are very clearly not making good decisions. It is not for us to judge, but for us to help the client see what they are doing and support them in making changes.
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Counselling (5 min)
Watch this short video on counselling.
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Critical Communication Skills for Effective Counselling (5 min)
It can be challenging to provide counselling to clients. There are a number of communication skills that enable the counsellor to be more effective. Below is a list of communications skills with a short description of what they look like in practice.
Attending: listening while observing, communicating attentiveness, providing verbal follow-up (“yes"), eye contact, and non-verbal cues.
Paraphrasing: restating client’s previous statement, determining the basic message of the client’s statement and then rephrasing it in your own words.
Reflection of feeling: focusing on the emotional content of client’s message, empathising with the client, identifying the feelings of the client and formulating a response based on the feelings identified.
Summarising: reviewing the main points discussed, which ensures continuity and emphasises main points. Select the main points and bring them together in a complete statement.
Probing: identifying a subject or topic that needs further discussion or clarification, using open-ended questions to help counsellor and the client to examine the situation in greater depth.
Self-disclosure: sharing (appropriately) personal feelings, attitudes, opinions, and experiences for the client’s benefit. This can increase the intimacy of the communication between counsellor and client.
Interpreting: adding ideas to client’s ideas to present alternative ways of looking at circumstances, determining client’s basic message and adding ideas.
Confrontation: using questions/statements to encourage client to face issues. Pointing out contradictions in the client’s behaviour and/or statements, or guiding the client to face an issue that you feel is being avoided. However, you should not accuse, judge, or devalue client’s beliefs.
Open-ended questions: posing questions that encourage answers that are not just “yes” or “no” but open the conversation.
‘Client-centred’: using strategies that place the client as the focus of the counselling process. The counsellor will take his/her cue from the language and behaviour of the client, and will adapt the counselling process according to the individual they are counselling.
Silence: waiting for the client to think about their response. Not asking any questions or talking about yourself.
Body Language: making lots of eye contact, having attentive posture.
Non-verbal prompts: nodding your head.
Subtle verbal prompts: saying “Yes”, “I see”, “uh huh”, “and?”, etc.
Key Points statements: showing that you have been listening carefully by making Key Points statements throughout the conversation.
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Techniques in Counselling (10 min)
Along with the effective communication skills, there are techniques used in counselling that will help to connect with the client. It is not necessary to be able to employ all of these techniques, but it is helpful to have some that you feel most comfortable using.
Questioning
Questions are the primary tool counsellors use to obtain information or seek clarification. There are two types of questions:
- Closed-ended questions are sometimes called ‘yes or no questions.’
- They demand short or one-word answers.
- They are very useful for collecting information like demographic data and medical information.
- When used too much, they lead to interrogation rather than counselling.
- The use of closed-ended questions should be limited in counselling.
- Open-ended questions are the foundation of good counselling because:
- They invite the client to talk and lead a conversation.
- They elicit longer, more explanatory answers–they cannot be answered in one word.
Listening
Every client has a story to tell and how the counsellor responds to the story depends on how he or she listens. Listening involves attending carefully to the clients’ verbal and non-verbal messages. It is important for the counsellor to be in touch with her/his thoughts and feelings and how these are interacting with those of the client.
Empathy
Empathy is the ability to see the world through the other’s eyes without judging them. You can only empathise when you have listened to the other’s story and understood it. Empathy helps the client feel understood and empowered and is reflected in the way we ask questions, comment and seek clarification.
Clarifying
A counsellor should always check understanding of what the client has said by seeking clarification.
Commenting on the process
If you sense a client’s change of mood when a particular topic is raised, or a discrepancy between what the client says and his or her body language, comment on what is happening.
Summarising
Summarising is a way of sifting out the less relevant material and summing up the client’s concerns or issues discussed so far.
Use of silence
It is important to be comfortable with silence. Silence forces the client to speak and to share more. When you pose a question and the client does not respond immediately, the temptation is to simplify the question or to ask another one. The fact that the client does not answer does not necessarily mean that the question is too hard.
Widening the system
When people are in a crisis they usually forget the other people who can be there for them. Widening the system is looking for support from the given systems surrounding the person. When looking for support we usually start from within the immediate family, and then move out to the other systems.
Taking a “one down” position
This is a way of acknowledging that the client already has problem solving skills. A good counsellor will take a one down position and say something like: “How do you normally resolve such problems in the family? According to your culture, what is expected of you when you deliver?”
Taking a “one-up” position
This is when a counsellor takes the expert position and gives information that the client may not have or corrects a client’s misinformation/ misconceptions.
Enacting
One way to make a counselling session different from being merely a talking session is to ask the client to show what happens when the problem arises. A client can act out solutions. The counsellor can then help the client to modify the approach or the response in order to get the desired results.
Prioritising
A client can present with about two or more problems at the same time. The counsellor should work with the client to prioritise and deal with the most urgent ones first.
Empty chair
The empty chair technique is used to symbolically bring into session absent members of the family or any other significant persons. The counsellor might say to the client, “If your husband was sitting in this chair, what would you like to tell him? How would he respond to this?” While the empty chair helps the counsellor to hear the voices of absent people, it also helps in the enactment of solutions.
Blocking
In cases where you have two people in session and one member is more vocal than the other and keeps interrupting, it is important to use blocking. Blocking can be done verbally, by telling the other person to wait for their turn. Alternatively, you can use body language – slightly turn away from the person you are blocking.
Shifting alliance
Each person in the session knows she or he is listening and demonstrates interest and understanding in each person’s position.
Using exceptions
There are times when there is no problem and what the client is sharing maybe an exception. Ask the client what the situation will be like when the particular problem is not there. eg when your husband is not drunk, there are good things that he does, what are some of them? So that the client appreciates that besides the problem, there are also positive things about her husband that she can concentrate on.
Reframing (Re-labeling)
Reframing is used to normalise a situation that a client thinks is abnormal or taking a set of events described by client and give them back in a different frame. It makes the client see the other side of the story, but not necessarily make him/her accept the counsellor’s opinion.
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Stages of a Counselling Session (5 min)
The counselling process can be divided into three stages. The outlined stages are only a guide. There is no fixed time or number of counselling sessions required to complete each stage. Remember, counselling is a process whose pace is determined by the client. A counselling session is structured with a distinct beginning, middle and an end. Tap on each stage in the timeline to learn more.
Beginning stage
Greet the client and makes them feel welcome. As the counsellor, it is your responsibility to start the introductions and establish the reason the client has come. You should clarify the client’s expectations and assure the client of confidentiality and shared confidentiality within the health care setting.
During this beginning stage it is important to build rapport. Relationship-building begins when you first meet a client and continues throughout the session. The way you welcome the client, your body language, and tone of voice contribute to establishing trust, which will determine how the client will open up to you.
A few tips for building rapport:
- Be culturally appropriate.
- Use the courtesy behaviour you would use with a guest in the home.
- Greet the client; shake their hand if appropriate.
- Offer them a seat.
Middle stage
During the middle stage of counselling, the client shares their own feelings and views about problem at hand. You should listen reflectively, encouraging the client to elaborate as much as possible on their central concerns and issues. Assess the client’s readiness to engage in behaviour change steps and explore the pros and cons of making change decisions.
If the client is not ready, you should work with them to identify the reasons for not being ready and for their resistance to change. If the client is ready for behaviour change, help them explore the behaviour patterns of concern.
Assist the client in understanding their underlying attitudes and belief systems that support behaviours of concern, and provide information about key concerns, as necessary. Work together in creating a plan for action toward behaviour change and discuss available resources to support the plan.
End stage
At the end summarise what happened in the session. Work on tasks for behaviour change and review plans on management of health or illness. You should also check on the client’s support systems and refer them if necessary and when ready. Remember to assure the client that the door is always open for them to come back if they want to.
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Key Elements of Effective Counselling (5 min)
It is extremely important to understand the key elements of effective counselling. Effective counselling:
- Is always voluntary.
- Is private and confidential.
- Does not persuade or coerce.
- Meets clients where they are.
- Respects clients.
- Views the client as the expert on his or her own life.
- Avoids telling the client what to do.
- Asserts that clients come to counselling with extensive strengths and knowledge upon which to build.
- Does not judge.
- Understands that client lives in a social setting that influences choices and decisions.
- Views social relationships as a resource for coping with HIV and AIDS.
- Involves commitment and hard work.
For each statement about counselling, move the slider to indicate whether you should do it or not.
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Types of Counselling (10 min)
There are many types of counselling in HTS. Use the Job Aide (found in the resources section) and counselling tools (such as the soldier game and our story). Tap on each type to learn more.
Pre-test session
Group information sessions have considerably reduced the time needed for providing individuals with information before rapid HIV testing and providing post-test counselling. Group sessions (with skilled facilitation) or individual sessions can be used prior to CITC and PITC services. The aim of pre-test sessions is ensure clients can make an informed decision about getting tested. At this session, counsellors describe HIV and AIDS, discuss modes of transmission and prevention, and explain the testing procedure, possible results, disclosure, and available post-test services. It is not meant to persuade people to get tested.
Pre-test sessions are followed by quality individual post-test counselling sessions.
Note:Individual counselling is not required before testing. Quality individual post-test counselling, which includes individual risk assessment and reduction, is available.
In the pre-test information session, identify the target group (patients, caregivers, etc.). Make sure the group is comfortable and assure privacy and confidentiality. Notify clients of routine offer of HIV testing and counselling and ensure a clear understanding of the benefits. Explain the basics of HIV (transmission, prevention, treatment, care, and support) and that testing and counselling is an entry point to prevention, treatment, care, and support. Be sure to cover testing and counselling procedures, possible test results, and linkages to prevention or treatment. Finally be sure to discuss disclosure and referral options.
Post-test counselling session
Individual post-test counselling is provided for both HIV-positive and HIV-negative clients. This session assesses the client’s readiness to receive results. Start the session by confirming the client’s identity and preparing the client for their results.
Some of the important points to remember when giving post-test results are to:
- Give results promptly once you have checked whether client still wants to receive results
- Allow time after giving results
- Check understanding of results
- Assess the client’s emotional state
- Discuss disclosure of results
- Discuss connections to post-test services
The job aide has more details about what is included in the pre- and post-test counselling sessions.
Follow-up counselling and referrals
Follow-up counselling must be provided to both HIV-negative and HIV-positive clients. It empowers HIV-negative clients to continue with their risk reduction strategies so as to remain HIV negative.
Adherence counselling
This is a process that aims to reduce the impact of stressors and develop coping strategies, as well as prepare and support clients during management of chronic conditions.
Some other types of counselling that are part of HTS include counselling for ART, prevention, nutrition and young child feeding, TB, and STI. Those topics will be covered in other sessions.
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Delivering Positive Test Results (10 min)
It is never easy to deliver positive HIV test results to clients. There are some essential elements to keep in mind when you are delivering positive results.
You should give results after assessing client’s readiness to receive them. Once you have given the results, allow time for the news to sink in. You may need to provide emotional support and help the client to express their feelings and explore what seems overwhelming.
Break down problems into manageable pieces, set priorities, help tackle pressing issues. You can do this by helping the client to develop an action plan for coping in the immediate and near future.
Emphasise that partner should be tested. Discuss the importance of HIV prevention during pregnancy and breastfeeding (with pregnant mothers).
Work with client to collaboratively carry out a risk assessment and risk reduction plan. Link client with health services and correct any misconceptions.
Often the client will be very emotional receiving the positive test results. Tap on the tabs below to get some tips on how to deal with some of the common emotions arising from positive results.
Crying
If the client breaks down and starts crying, it is important to let them cry; give them space to ventilate these feelings. Offering the client some tissues is a way of telling them it is okay to cry. Reflect their feelings: “This must be difficult for you.” “What are you feeling?”
Anger
The client might start swearing or exhibit outbursts of anger. Do not panic. Stay calm and give the client space to express their feelings. Acknowledge that their feelings are normal and let them talk about what it is that is making them angry.
No response
This could be due to shock, denial, helplessness, disbelief, etc. Check that the client understands the result. Be on the alert for suicidal thoughts. Find out immediate plans for when they leave the room.
Denial
This could be verbal or non-verbal. Counselling should acknowledge the client’s difficulty in accepting the information. Let them talk about their feelings.
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Counselling Tools (5 min)
Counselling requires a variety of skills and techniques for adults, children/adolescents. As we strive to reach the 90-90-90 targets and test and treat all, there is need to strengthen counselling skills to ensure understanding by clients and patients. Creative, visual strategies are powerful tools for providing clients of all ages with an opportunity to freely express themselves. These strategies assist the counsellor to understand more about the clients. Counselling tools can be used in settings where testing services and psychosocial support are provided by counsellors, CATS, expert clients, or BCC personnel at facility and community levels. (Refer to OSDM and Job Aide for a variety of counselling tools).
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Key Points (5 min)
- Counselling is an important intervention in managing the psychosocial impacts of HIV and AIDS on an individual, family and community.
- Knowledge, skills and techniques are important aspects for one to be an effective counsellor.
- HIV counselling includes: pre-test information giving session, pot-test counselling, follow-up counselling and referrals, adherence and disclosure.
- Group information sessions can be used prior to CITC or PITC with the goal of providing general information about HIV and AIDS.
- Quality individual post-test counselling is offered which includes risk assessment and risk reduction planning.