Integrated HIV Training for Healthcare Workers

Session 3: Fundamentals of HIV Testing Services

Couples Counselling

So far, we have discussed counselling that has focused on the individual. This section will look at how to provide HTS for couples. We will define couple counselling, both in general and in the context of HTS, and then review some of the myths and clear up misconceptions about discordant results. We will then cover some techniques and skills to use when working with couples.

Learning Objectives

By the end of this session, you will be able to:

  • Define a couple in counselling.
  • Define couple HIV testing.
  • Clear myths and misconceptions in discordant results.
  • Describe advantages and disadvantages of couple counselling.
  • Apply specific techniques and skills used in couple counselling.

Learning Activities

  • Couples Counselling Definitions (5 min)

    Isaac and Rumbi Chundu have been married for 15 years. Isaac is 39 years old and Rumbi is 34 years old. He is a farmer now but in the past he had taken a job as a truck driver for a number of years.

    While he was a truck driver, Isaac returned home every four to six weeks. While he was home, Isaac would often drink many beers, telling Rumbi that driving a truck was very stressful and he needed to relax. One time when he was home, Rumbi found condoms in his pockets. She asked him if he was having sex. He became very angry and denied it, but Rumbi always felt that Isaac wasn’t telling the truth, and this has been troubling for her. They have now come to your clinic after learning about HIV in a community education programme and are ready to be tested.

    Definition of a couple

    Before we discuss couples counselling, let’s define what a couple is. A couple is two people in an ongoing sexual relationship. Each person is referred to as a partner in the relationship. How individuals define their relationships varies according to cultural and social contexts. Anyone who is in a sexual relationship, wishes to test with their partner, and mutually discloses their results should be supported to receive couple HIV testing services (CHTS). Health care workers should ensure that services are inclusive and non-judgmental, and support partners to test together, irrespective of the length or stability of their relationship. In premarital counselling, the two individuals may not be having a sexual relationship, but can receive couple counselling services, with the assumption that they will be having a sexual relationship in the future or after they are married.

    Definition of couple HIV testing services (CHTS)

    CHTS refers to HTS for two or more sexual partners together. They could be married, cohabiting, regular sexual partners, or intending to have sex. They undergo counselling and testing in the same sitting and receive results together. The service is intended to facilitate both mutual knowledge and disclosure of one’s HIV status to their sexual partner(s).

  • Advantages of CHTS (5 min)

    Couples HIV testing and counselling (CHTS) should provide an environment that is safe for couples to discuss risk concerns, and partners hear the same information and messages together. If issues arise, the counsellor has the opportunity to ease tension and diffuse blame.

    The graphic below shows the many connections that can happen because of couple HIV testing and counselling.

    image

    When results are received, counselling messages are based on the results of the couple, so the individual is not burdened with the need to disclose results and persuade their partner to be tested. Counselling facilitates the communication and cooperation required for risk reduction and allows for care and treatment decisions can be made together. Therefore, couples can engage in decision-making for the future.

  • Couple Test Result Scenarios (5 min)

    There are a number of possible couple test result scenarios. Here are the types of scenarios seen in couples:

    Seroconcordant positive couple: Both partners are HIV positive

    Seroconcordant negative couple: Both partners are HIV negative

    Serodiscordant couple: One partner is HIV positive and the other is HIV negative. The need for disclosure in serodiscordance cannot be overemphasised. Explain the need for retesting of the HIV-negative partner with the couple.

    Risk reduction should be emphasised to couples so as to maximise chances of the HIV-negative partner remaining HIV negative. It is possible for couples to stay HIV serodiscordant indefinitely if they consistently practice safer sex using condoms correctly and consistently.

    For positive individuals, start ART and encourage adherence to treatment to prevent transmission to the negative partner. If the male partner is HIV negative, offer VMMC.

  • Myths and Facts about Discordance in CHTS (10 min)

    For each statement about discordant couples, move the slider to indicate whether it is a myth or a fact.

    In discordant couples, the positive partner may have been infected before they became a couple.
    Discordance means the same thing as the window period.
    Discordance is a sign of infidelity.
    Transmission risk through sex is extremely high among steady discordant couples who do not take preventative measures, such as using condoms.
    Discordant couples is not possible.
    The positive partner may have other partners outside the relationship or may have acquired HIV non-sexually.
  • Johari’s Window for Couples (5 min)

    Earlier we discussed using Johari’s Window as a tool for self-awareness. This version is used for couples.

    Talking about issues often helps the counsellor establish a rapport with the couple. As the couple discusses issues they are comfortable with, they begin to open up to the counsellor. This also gives the counsellor a chance to show interest in the couple and to validate their situation. Tap on each quadrant of the graphic to read more.

    map
    rectangle rectangle rectangle rectangle
    Open

    Issues that are open, shared, discussed.

    Privately Discussed

    Issues that are understood, acknowledged, or privately discussed.

    Hidden

    Issues that are hidden, protected, and kept secret.

    Not discussed

    Issues that are imagined or believe, and rarely, if ever discussed.


    Take a moment to think about your own Johari’s Window in relation to your relationship (marriage or otherwise). Consider which issues you would share readily and which you would keep to yourself.

    Understanding how to address open, privately discussed, not discussed, and hidden issues is extremely important for couple counsellors.

    What are some open issues you can think of that might be discussed in a CHTC session?

    Examples of statements and comments counsellors can use to begin discussing open issues:

    • "Tell me about your relationship."
    • "Tell me about your children."
  • Couple Counselling Skills (5 min)

    Couples counselling skills are important to help maintain a positive atmosphere during the CHCT session. By remaining neutral, conveying respect for the couple’s relationship, and facilitating balanced participation by each partner, the counsellor helps to build and sustain an important and trusting alliance with the couple.

    Here is a list of skills that are needed in order to provide effective couple counselling:

    • Demonstrate neutrality and non-biased concern for both members of the couple.
    • Convey respect for the couple's relationship.
    • Facilitate balanced participation of both partners.
    • Model appropriate listening and communication skills.
    • Facilitate dialogue between the couple.
    • Raise the difficult issues that the couple may need to address.
    • Ease tension and diffuse blame.
    • Educate and counsel on prevention.
    • Create a couple risk-reduction plan.
    • Assess plans on future pregnancy and family planning.
    • Counsel on family planning or refer (if the couple desires a child, counsel risks and refer to PMTCT services)
  • Mediation Skills (5 min)

    Sometimes when couples receive HTS together, there may be a lot of stress and anxiety that comes up, making it difficult to continue counselling. When this happens, you should strive to model and encourage respectful interactions and balanced participation of the partners.

    Here are some mediation skills for easing tension and diffusing blame:

    • Normalize feelings, reactions and experiences.
    • Effectively use silence, while conveying a supportive and calm demeanour.
    • Remind the couple that HIV infection is common.
    • Focus on the present and future. The past cannot be changed.
    • Avoid and deflect questions aimed at identifying at the source of infection.
    • Express confidence in the couple’s ability to deal with HIV-related issues.
    • Admire the couple’s willingness to contend with the challenges of HIV in their lives.
    • Acknowledge the feelings expressed or observed. Predict that in time their intensity will likely change and shift.
    • Redirect and reframe questions and discussions that are blaming or potentially hostile. Identify underlying non-hostile feelings, such as fear or anxiety.
    • Calmly and gently name and acknowledge the behaviour being observed.
    • Remind the couple of their roles and responsibilities outlined at the beginning of the CHTS session.
  • Providing Test Results (5 min)

    Couples results are given as a Key Points of their combined results. First, tell couple if they are concordant or discordant. If the couple is concordant, say “Both of you have tested HIV positive (or HIV negative).” If the couple is discordant, inform them that their results are different and provide the result for the HIV-positive partner first.

    For the discordant couple, you should discuss infection risk of the HIV-negative partner. Describe effective risk-reduction options (condoms, abstinence, separation, STI treatment). Additionally, you should assess pregnancy plans and contraception (counsel on family planning or refer, counsel on risks and refer to PMTCT if they desire a child). You should always provide follow-up and ongoing counselling.

    When providing test results, use pronouns like “we” and “our” rather than “I”, “his” or “hers”.

  • Milton and Thandiwe (10 min)

    Milton is a 28-year-old computer technician. His wife, Thandiwe is a 25-year-old secretary. They have been married for three years and have two-year-old twins, a boy and a girl. Milton and Thandiwe are dedicated and faithful to one another. While they are at work Milton’s mother, who lives nearby, helps with the children.

    Thandiwe lived in the village as a young girl, up until six years ago when she moved to the city to live with her sister. She has had a few sex partners since moving to the city, and usually used condoms, but occasionally did not.

    Milton has had a number of girlfriends and has sex with and without condoms over the years. He has always been in monogamous relationships.

    Mitlon and Thandiwe were recently listening to a radio drama in which the couple went for an HIV test. After hearing the couple in the drama, they decided they should go in for HIV testing together. The results have come back and Thandiwe is HIV-positive and Milton is HIV-negative.

    1What should do when you enter the room to share their results?

    2Which of the following do you do after giving the discordant results to Milton and Thandiwe? (Select all that apply.)

    3Both Milton and Thandiwe are very upset and seem shocked. How can you help promote coping and mutual support? (Select all that apply.)

    4What are some other topics that you will cover in this session with Milton and Thandiwe? (Select all that apply.)

    5You should cover all of the following family planning topics with Thandiwe and Milton, except:

  • Key Points (5 min)
    • Couple counselling facilitates both mutual knowledge and disclosure of one’s HIV status to their sexual partner.
    • Couple counselling helps to ease tension and diffuse blame.