LABORATORY DIAGNOSIS OF HIV INFECTION AND ACCESS TO HIV TESTING IN ITALY
Criteri di standardizzazione dell'intervento di counselling nella diagnosi di infezione da HIV
Anna Maria LuziI; Barbara De MeiII; Anna ColucciI; Pietro GalloI
ICentro Operativo AIDS, Dipartimento di Malattie Infettive, Parassitarie ed Immunomediate
IICentro di Epidemiologia, Sorveglianza e Promozione della Salute, Istituto Superiore di Sanità, Rome, Italy
In the present work, we outline basic health counselling skills, specifically, those for performing pre-test and post-test counselling for HIV infection. The ultimate goal is to propose that counselling be performed in facilities that carry out screening for anti-HIV antibodies, following standardised (and thus replicable) criteria, with consistent focus on the quality of the relationship between the healthcare professional and the individual undergoing testing and on the individual's specific needs.
Key words: HIV infections, counselling, pre-post test.
Il presente lavoro intende delineare gli aspetti peculiari dell'applicazione delle competenze di base del counselling in ambito sanitario, con particolare riferimento all' intervento effettuato nel pre e post test HIV La finalità principale è quella di proporre l'applicazione dell'intervento di counselling nei Servizi dove si effettua lo screening per la ricerca degli anticorpi anti-HIV, secondo criteri standardizzati e, pertanto, replicabili, mantenendo costantemente l'attenzione alla qualità della relazione e alle specifiche esigenze del singolo individuo.
Parole chiave: infezioni da HIV, counselling, pre-post test.
In the present work, we outline basic health counselling skills, specifically, those for performing pre-test and post-test counselling for HIV infection. The ultimate goal is to propose that counselling be performed in facilities that carry out screening for anti-HIV antibodies, following standardised (and thus replicable) criteria, with consistent focus on the quality of the relationship between the healthcare professional and the individual undergoing testing and on the individual's specific needs. To this regard, it should be stressed that all healthcare professionals can be trained to perform standardised basic counselling.
For healthcare professionals, counselling skills are fundamental for creating effective relationships with clients, in diverse areas of healthcare (e.g, health promotion, disease prevention, communicating diagnosis, developing a therapeutic plan, crisis management, and functional adaptation to a pathology). An effective relationship cannot be improvised, and the healthcare professional must apply cognitive and relational skills and individual qualities, with the objective of activating the clients' resources, so that they can choose solutions that are consistent with their needs.
In this relational process, counselling represents a fundamental tool. In 1989, the World Health Organization (WHO) defined counselling as "a decision-making and problem-solving process which involves a counsellor and a client. The client is in need of help, and the counsellor is an impartial person who is not attached to the client and who has the capacity to listen and to provide guidance and support. Through dialogue and interaction, counselling helps persons to resolve or control their problems, to understand them, and to face psychosocial difficulties and needs in the most rational way possible. Counselling is intense, focussed, limited in time, and specific" .
Thus health counselling can be defined as a well-structured intervention that is particularly effective in helping a person to use his or her own resources to actively face important difficulties and changes for maintaining health. Counselling focuses on the individual, the specific experiences recounted, and the problems posed; it also focuses on the resources and opportunities that emerge from the individual's narration. In performing counselling, the healthcare worker applies the knowledge specific to his/her profession and uses his/her personal qualities to facilitate the communication process; the counsellor must also control personal communication styles and traits that can hinder counselling.
Of particular importance are the knowledge and application of the basics of verbal, non-verbal, and paraverbal communication, relational skills, and communication strategies [2-4].
The objective of counselling is to activate and reorganise a person's resources, to make possible choices and changes in situations that the individual perceives as complex or to actively confront problems and difficulties through empowerment, consistently respecting the individual's values and capacity for self-determination .
As mentioned, counselling is a process that has the following qualities:
- intense, in that the relationship between the healthcare worker and the individual must be conducted in a climate of acceptance and total mutual respect, which is a prerequisite for a relationship of trust and collaboration;
- focussed, in that counselling must concentrate on the "here and now" of the individual's current and emerging problems;
- limited in time, in that counselling must be performed within a certain time frame;
- specific, in that, based on the individual's emerging problem, a specific and realistic objective is gradually identified and agreed upon;
- active, in that both the healthcare worker and the individual play an active role in the relationship; in fact, through listening, the healthcare worker remains focussed on the needs and experiences of the individual, thus facilitating the process of becoming aware, which is indispensable for facing the problem and for autonomously and responsibly activating choices.
- integrated, in that counselling can be learned by all healthcare workers, favouring integration among diverse professional figures and thus facilitating teamwork .
All healthcare workers, regardless of their specific profession or area of expertise, must learn and perfect their basic counselling skills, so that they clearly understand the main characteristics of the intervention and how it is performed [7-9].
To this regard, some basic qualities that healthcare workers should possess to perform counselling are listed below:
- knowledge of the scope of counselling, which does not consist of "giving advice" or "quick solutions to the problem" or providing "additional generic information" but instead focuses on activating an individual's resources, so that he/she can responsibly face problems and difficulties and make conscious choices;
- self-awareness of qualities that can favour communication (e.g., acceptance of others, sensitivity, authenticity, spontaneity, warmth, consistency, availability, creativity, and respect), and of the qualities that could hinder the relationship (e.g., sarcasm, short temperedness, pity, antipathy, and aggressiveness), as well as self-awareness of personal communication style in relationships;
- awareness of and capacity to apply relational skills (active listening, empathy, self-awareness) and the specific communication strategies used in counselling, in particular:
- informative counselling, for providing personalised information;
- problem-solving counselling, for facilitating solutions to problems;
- crisis counselling, for providing support during crises;
- decision-making counselling, for facilitating decision making;
- knowledge of the procedures necessary for structuring counselling.
Relational skills (empathy, self-awareness, active listening) are an integral part of counselling, and given that these are actual skills, they can be learned and perfected with specific training.
Empathy is the ability to know how to enter into another person's scheme of reference, the capacity to see the world through the other person's eyes and have information from his/her rational and emotional point of view (thoughts, experiences, emotions, and meanings), so as to be able to understand the person's requests and needs. Empathy is the ability to open oneself to another's experience, to follow, grasp, and understand as fully as possible the subjective experience of the "person", from that person's point of view. In other words, the healthcare worker lives as if he/she were the other person. Empathetic healthcare workers must, however, remain separate from the other person's world, given that they would no longer be able to help the person and thus not meet that person's needs.
Self-awareness is an essential skill in the professional relationship. For communication to be effective, the healthcare worker must be aware of his/her own cultural reference scheme, motivations, value system, prejudices, perceptions, emotions in the "here and now", and personal conceptual maps. It is very important that the healthcare professional be very familiar with his/her "inner world", so as to be able to constantly contact, control, and distinguish it from that of the other person. It is also important to be aware of the context that is at the foundation of every relationship. The capacity for self-observation and self-monitoring in the relationship is also essential, as is knowledge of nonverbal and paraverbal language, which express the emotional states underlying the verbal content. In actuating self-awareness skills, it is important to analyse in-depth the setting of counselling. The setting is the framework in which the relationship develops, and it plays a fundamental role in the success of counselling. In particular, relationships between a healthcare worker and an individual require a specific "external" and "internal" setting.
The external setting is a well-defined time-frame and space, whereas the internal setting is that of the healthcare worker, that is, "disposition", "listening", and "openness" towards the given individual, in a given moment, in a given place. Even when the external setting is not ideal, a good internal setting can facilitate the entire counselling process. Particular importance must be placed on the specific attitude and behavioural style of the healthcare worker, who should not be judgmental or demanding, but open, welcoming, authoritative, clear, confident, and respectful of the other person as an autonomous individual who is able to communicate the resources that he/she possesses and to use them.
Activity listening is a communication skill based on empathy and acceptance and on the development of a positive relationship and a non-judgmental climate. It is the first step in a relationship. Its purpose is to create a relationship of trust and collaboration, which is necessary for developing an alliance, demonstrating interest, and helping the individual to communicate, with the objective of better understanding his/her needs. When a healthcare worker knows how to listen, the individual perceives him/herself to be the focus of attention and is thus encouraged to continue communicating and is more willing to reveal his/her experiences and provide more detailed information on his/her current health status.
What is listened to
- contents: that which the individual says with words (verbal) and silences, the tone of voice, how something is said (paraverbal), listening/ observation of facial expressions, gestures (nonverbal), and how the individual presents him/ herself and moves;
- context in which the individual lives: family, social, work, school, experiences, cultural reference schemes, and values, and "his/her narration";
- self-listening: listening to oneself in the here and now, to one's own context of reference, to the extent to which one attributes what belongs to him/her to the other (self-awareness).
How to listen
For active listening, it is necessary to adopt empathic mirroring, a basic active-listening technique which consists of: reformulation, clarification, investigative skill, and use of messages in the first person.
Reformulation is a communication technique that consists of repeating that which the individual just said, using the same words or paraphrasing, without additional content. In this way, the healthcare worker can obtain the individual's consent, and the individual is ensured that the healthcare worker has been listening. When the individual finishes a sentence, the healthcare worker can repeat that which was just said ("So you're saying that "You mean that "In other words "So in your opinion ..."). If the individual recognises him/herself in the reformulation, he/she is certain of having been listened to and understood and is encouraged to continue to communicate and collaborate. This also helps the individual to remain focused on the problem and on how it is experienced.
Clarification facilities self-understanding, also stressing the experiences that accompany the verbal content. Much can be understood from both verbal and non-verbal communication, as well as from paraverbal communication ("From the look on your face you seem to be worried" "From the tone of your voice, I have the impression that you're confused regarding ."). Investigative skill consists of knowing how to ask questions, which depends on the specific phase of the relationship. At first, open questions are preferable because they leave ample possibility for answers; they tend to expand and deepen the relationship; and they stimulate the individual to express opinions and thoughts. Closed-ended questions (When?, Where?, Who?) are circumscribed; they demand a single specific response; they narrow down and focus communication, requiring only objective facts, and at times they can seem limiting and hindering. When questions begin with "Why?", the individual may feel that he/ she is being blamed or accused and should thus be avoided.
The use of messages in the first person helps to distinguish between that which the healthcare worker thinks and feels and that which regards the individual, allowing conflictual interpretations and situations to be avoided and favouring a non-judgemental and positive climate ("I think that...";"In my opinion..."). It should also be considered that some conditions, whether mental, verbal, visual, aural, olfactory, or spatial, hinder listening and become actual barriers. Counselling allows the professional relationship to be structured into well-defined, though not rigid, phases, which over the course of the relationship vary in terms of importance and duration, based on the specific situation, the emerging problem, and the individual's experiences. This structuring is the common denominator with respect to the variability of the intermediaries with whom the healthcare worker comes into contact, the specific characteristics of each specialised environment, and the socio-cultural context of reference [2, 10].
COUNSELLING FOR HIV TESTING
Counselling takes on particular importance for dealing with issues regarding HIV infection and AIDS, in that it allows healthcare workers to address the complex problems inherent to the prevention of at-risk behaviours and to diagnosis and treatment. In this context, basic counselling skills are an essential tool, in that they ensure that the relationship between the healthcare worker and the individual is not improvised and is instead based on principles and strategies that focus on the individual's needs and requests, as well as on his/her specific resources and potential.
The importance of HIV counselling was already stressed by the major international organisations early in the epidemic. In fact, as early as 1989, the Global Programme on AIDS (GPA) of WHO indicated counselling as a tool for offering both practical and psychological support, in order to provide accurate and personalised information geared towards preventing further transmission of HIV . In 1990, WHO developed guidelines on HIV/AIDS counselling, specifying its nature, role, and principles .
In 1993, the GPA included counselling, together with clinical treatment, nursing care, and social support as one of the main components of an integrated care continuum, with the intention of strengthening the capacity and resources of the health system for facing problems caused by AIDS and AIDS-related pathologies . In 1994, the GPA reaffirmed the usefulness of counselling as a vital component of care in HIV/AIDS and as a fundamental part of good clinical management, as well as "an important means of prevention". The following eight objectives of counselling were also developed:
- to provide support in times of crisis;
- to propose realistic actions adapted to diverse persons and circumstances;
- to help persons to accept health information and act in accordance with this information, for maintaining health;
- to communicate, in a comprehensible and culturally suitable and acceptable manner, the need to change unsafe behaviours and thus prevent infection;
- to encourage change when necessary for the prevention and control of infection;
- to reduce the risk of infected persons' transmitting the virus to others;
- to contribute to maintaining the best possible state of emotional and physical health and to provide social support to persons with HIV infection and those who care for them;
- to ensure to the greatest extent possible the maintenance of productivity of HIV-infected persons and their integration in society. (WHO/GPA 1994) .
Finally, in 1995, the GPA defined HIV/AIDS counselling as a confidential dialogue between a client and a counsellor geared towards putting the client in a condition to face stressful situations and make autonomous decisions regarding HIV infection and AIDS .
It is evident that the diverse definitions of HIV/ AIDS counselling reported above are consistent with the 1989 WHO indications on health counselling in general and with that which was proposed by the British Association for Counselling in 1992 [1, 15]. What distinguishes HIV/AIDS counselling are the characteristics of the modes of transmission, the infection, and the disease, which require specific behavioural choices to avoid becoming infected, as well as physical, psycho-social, sanitary, legal, and economic implications, which require that infected persons constantly adapt to the diverse needs that distinguish their complex condition. Nonetheless, the general objective of counselling remains the creation of a professional and structured relationship, which is at the same time flexible and personalized, between a healthcare worker and an individual, aimed at stimulating the individual's resources to consciously face emerging problems and activate autonomous decision-making processes. It should also be stressed that the counselling skills applied in this relationship do not constitute an added or isolated intervention but are instead an integral part of the relational process and that for communication to be effective the healthcare worker's involvement in the relationship must be authentic and empathetic, accepting the individual and all of his/her anxieties, doubts, and convictions .
Today, 30 years after the first reported cases of AIDS, despite the changes in clinical history and in infected persons' needs, HIV/AIDS continues to be a fundamental tool for reaching the goals of prevention and support, which are intertwined in efforts aimed at primary and secondary prevention (pre-and post-test phase) and in the condition of seropositivity and full-blown AIDS. Moreover, the objective of HIV/AIDS counselling correspond to the eight general objectives of health counselling in general of WHO/GPA, listed above, which must gradually be integrated with the specific objectives agreed upon with the individual, based upon his/her needs and resources .
Main objective of HIVIAIDS counselling
The main objective of HIV/AIDS counselling is to provide personalised information (informative counselling), in order to activate processes of awareness and empowerment, so as to encourage the individual to make autonomous and responsible choices regarding at-risk behaviours or the suitability of undergoing HIV testing (decision-making counselling). It is also aimed at strengthening an individual's resources so that he/she can live with the disease (coping) and improve adherence to therapy, facing emerging problems (problem-solving counselling) and crises (crisis counselling). The choice of specific strategies is made by the healthcare worker based on the specific individual and condition in the "here and now" that emerges during counselling.
HIV/AIDS counselling for testing takes place during two or more interviews, pre-test counselling (before the test is performed) and post-test counselling (when the result is provided), conducted by adequately trained healthcare workers, who are capable of structuring the professional relationship based on the principles and phases of counselling and who can integrate specific knowledge and skills, personal qualities, and relational capabilities such as self-awareness, active listening, and empathy [17-20].
Pre-test counselling consists of a brief interview between a healthcare worker and an individual who is considering undergoing testing. Its goal is to determine whether or not the individual has engaged in at-risk behaviour, allowing him/her, if necessary, to make a conscious, autonomous, and responsible decision to undergo testing (accepting and signing the informed consent form) and preparing him/her for the test result (Article 5 of Law 135/1990. Piano degli interventi urgenti in materia e prevenzione e lotta all'AIDS and Decreto marzo 2008) . In fact, individuals can request testing for different reasons, which are often accompanied by psychological repercussions which begin when the persons starts to think about the need to be tested. For this reason the healthcare worker, together with the individual, through an effective professional relationship, must evaluate the specific risk and the actual need to undergo testing.
Thus pre-test counselling constitutes an important opportunity for primary prevention aimed at the individual's acquiring personalised information and indications for adopting safe behaviours. It is also important for secondary prevention, encouraging the individual to carefully reflect upon the risks taken, the suitability of changing his/her habits, and the necessity of undergoing testing, specifying that the test for anti-HIV antibodies must be performed after a window period . Testing for persons with at-risk behaviour is important because it allows for early diagnosis, which is fundamental for interrupting the chain of transmission . Moreover, it allows infection to be adequately monitored and appropriate anti-retroviral therapy to be started.
Another integral part of pre-test counselling is that of facing, together with the individual, the wait for, and the concerns regarding, the test result, which can elicit emotional reactions and thoughts that require optimal management skills on the part of the healthcare worker, which is made possible by acquiring counselling skills [2, 3].
The general objectives of pre-test counselling are:
- to allow an individual to describe his/her situation and the potentially at-risk behaviours;
- to identify an individual's risk factors and his/her perception of them;
- to provide personalised information on HIV infection, with particular reference to the modes of transmission and ways of preventing it;
- to provide indications on testing for anti-HIV antibodies and on the window period required for the specific test;
- to prepare the individual for facing the test result;
- to facilitate the individual's ability to make a conscious decision on whether or not to undergo testing;
- to control the individual's anxiety and support him/her in actively facing the problem that he/she is experiencing.
The healthcare worker must be constantly aware that the objectives of pre-test counselling be gradually modified and focussed on the characteristics of the specific individual and situation and that they be flexible, so that they can be modified based on the specific, concrete, and realistic objectives agreed upon with the individual.
In performing counselling, the healthcare worker can refer to a structured model which consists of phases or steps, which provides him/her with a conceptual and operational reference map, so that counselling is both flexible, taking into consideration the specific individual and situation, and homogenous among different healthcare workers.
Thus pre-test counselling consists of well-defined steps whose importance and duration change over the course of the relationship, depending on the specific situations and the individual. The qualities and skills that can be developed at different times can be differentiated. The outline provided below must absolutely not replace the strongly relational nature of counselling but instead serve as an important reference protocol based on which the healthcare worker can comfortably manage the diverse factors of the individual and the context that affect the relationship and can elicit emotional reactions, depending on the individual's personality and the problem being faced in that particular moment.
Steps of pre-test counselling
Preparing the external and internal setting
- Counselling should take place in a welcoming and silent atmosphere, with no distractions, and the healthcare worker should prepare him/herself emotionally, preparing his/her internal space for each new meeting.
Adequately introducing oneself - The healthcare worker should provide his/her last name and professional qualifications. The first words (verbal communication), tone and pitch of voice (paraver-bal communication), gestures, looks, and posture (non-verbal communication) used by the healthcare worker are important for creating a comfortable environment, which allows the individual to feel at ease and to begin discussing his/her problem. The ultimate goal is to establish a relationship based on collaboration, trust, and empathy (alliance).
It is important to clarify the reasons for which the individual wishes to undergo testing. The individual's specific experiences, problems, and requests can only be understood through careful attention and active listening, demonstrating cognitive and emotional empathy, attempting to enter the individual's scheme of reference "as if" it were the healthcare worker's own. In this way the healthcare worker begins to explore and defined the individual's "true" problem or request, which is not always expressed clearly, identifying the actual reasons for wanting to undergo testing.
In this phase, the use of active listening techniques (messages in the first person, reformulation, clarification, and investigation) allow the healthcare worker to understand the individual's concerns regarding his/her behaviour and the possible consequences of this behaviour and, if necessary, to provide emotional support.
Clarifying the problem, identifying a shared objective and agreeing upon alternative solutions
If based on the individual's behaviour it is deemed that testing is not necessary, the actual problem that led the individual to consider him/herself at-risk must be clarified. This can be the result of misinformation or lack of knowledge regarding HIV infection and AIDS. In this case, the individual must be provided with accurate, updated, complete, and personalised information, so that he/she can adopt behaviours or make decisions that would allow him/her to decrease anxiety (informative counselling). Individuals may also request testing because of great apprehension regarding the possibility of becoming infected and emotional suffering. In this phase it is important to continue focussing on the relational process, avoiding false reassurances and helping the individual to contain his/her anxiety.
Clarifying the problem is crucial for developing a shared objective that is both concrete and feasible and based on which diverse alternatives for solutions can be proposed and agreed upon. At this point the individual may consciously decide to not undergo testing, given the absence of risk, or to take to time reflect or to undergo testing nonetheless.
It is important that the healthcare worker be able to stimulate the individual's own resources, so that he/she can make an informed and anonymous decision regarding the best solution to the problem at-hand (problem solving counselling / decision making counselling).
In cases in which the individual has engaged in at-risk behaviour and should undergo testing, the healthcare worker must determine the individual's knowledge of infection, provide information where lacking, evaluate the individual's perception of the risk, and propose testing, providing information on testing and discussing the possible individual and social implications, agreeing upon strategies for modifying at-risk behaviour.
Moreover, in this phase it is important to provide adequate support for favouring the decision-making process (decision making counselling). Informed consent is proposed, and the individual is encouraged to return for the test result and prepared to face this result.
Any decision or choice regarding the solution to a problem or change is possible only if the individual him/herself comes up with proposals for change and finds within him/herself the reasons for actuating these changes. For a decision to be autonomous and motivated, it is necessary to assume personal responsibility, which must be shared and elaborated upon with a healthcare worker who possesses the skills for doing so, who the individual trusts, and with whom the individual can collaborate and form an alliance. During this process it may be necessary to provide emotional support and evaluate the internal resources that the individual is capable of using in this particular moment (crisis counselling).
Summarising, verifying, and saying goodbye
At the end of the interview, it is useful to summarise what emerged and was agreed upon and to determine the extent to which the indications have been understood and whether the individual has additional doubts or concerns. The healthcare worker should express his/her availability for additional contact, say goodbye in a suitable manner, and conclude the meeting by immediately making an appointment for picking up the test result, stressing the importance of doing so. Appointments for post-test counselling should not be made right before the weekend .
Post-test counselling consists of an interview between a healthcare worker and an individual who has undergone testing, to provide the test result. It constitutes a continuation of pre-test counselling and when possible should be conducted by the same healthcare worker. During post-test counselling, more than one interview may be necessary, for example, when the test result is undetermined .
If the test result is negative, post-test counselling focuses on prevention and on helping the individual to identify reasons for discontinuing at-risk behaviour, by activating "life skills". If the test result is positive, post-test counselling focuses on providing support to the individual and on either providing care at the healthcare facility or referring him/her to a specialised facility. Finally, if the test result is undetermined, post-test counselling focuses on containing the individual's anxiety, managing his/her feelings of uncertainty, and repeating the test. Diverse interviews may be necessary while waiting for the test result.
Although the objectives of post-test counselling differ depending on the test result, some general and share objectives exist:
- to provide the test result immediately after the individual has been greeted;
- to recognise the individual's emotions and provide support;
- to address the significance and immediate and future implications of the test result;
- to help the individual to activate suitable strategies for confronting the situation and modifying at-risk behaviours.
As with pre-test counselling, during post-test counselling the healthcare worker must be able to modify the objectives of counselling based on the individual's characteristics, personalising these objectives according to the specific, concrete, and feasible objectives agreed upon with the individual. Again, the healthcare can refer to a standardised model structured into well-defined steps, which would allow him/her to feel more at-ease in this complex relational context. However, for post-test counselling, the steps differ depending on the test result.
Post-test counselling if the test result is negative
If the test result is negative, post-test counselling focuses on prevention by helping the person to change those behaviours that led him/her to undergo testing.
Steps of post-test counselling in cases in which the test result is negative
- greeting the individual;
- immediately communicating or explaining the test result;
- helping the individual to express his/her feelings;
- determining whether the person has understood what he/she has been told;
- discussing the implications of a negative test result;
- agreeing upon prevention strategies for modifying at-risk behaviours;
- concluding the meeting, expressing availability for further contact.
Post-test counselling if the test result is positive
If the test result is positive, post-test counselling focuses on providing support, helping the individual to deal with the emotional impact (crisis counselling), providing clear information on the condition of seropositivity and on treatment and care options (informative counselling), as well as helping the individual to identify, plan, and manage the most urgent issues related to this situation (problem-solving and decision-making counselling). The steps of post-test counselling in cases in which the test result is positive are:
- greeting the individual (importance of the external and internal setting);
- immediately communicating or explaining the test result;
- ensuring that the individual has a realistic perception of the situation;
- helping the individual to express emotions and providing support;
- stimulating the individual's resources (empowerment);
- strengthening cognitive restructuring (regaining control of the situation);
- evaluating and favouring social support;
- providing information, only if the person is capable of absorbing it;
- developing a care plan and promoting safe behaviour;
- providing information on Partner Notification and Contact Tracing;
- making additional appointments to meet or referring the individual to specialised facilities;
- concluding the meeting.
Regarding partner notification, the healthcare worker makes him/herself available for providing support so that the individual can notify current and past sexual partners or persons with whom he/she shared syringes. For contact tracing, the healthcare worker directly attempts to identify, trace, and contact partners who had engaged in at-risk behaviour with the seropositive individual, to inform that person of the risk and of the need to undergo testing. Both partner notification and contact tracing require the consent and collaboration of the individual and must respect privacy.
Post-test counselling if the test result is undetermined
If the test result is undetermined, post-test counselling focuses on containing the emotions related to the uncertainness and helping the individual to undergo another test, containing the anxiety caused by the wait .
The steps of post-test counselling if the test result is undetermined are:
- greeting the individual;
- immediately communicating the test result;
- explaining the significance of the test and determining whether the individual has understood;
- recognising the individual's worries and providing support;
- analysing the implications of the result;
- managing the individual's uncertainty;
- agreeing upon prevention strategies;
- concluding the meeting.
The above considerations demonstrate the evident complexity of the issues related to testing for anti-HIV antibodies. To this regard, certain aspects regarding the performance of rapid tests should be mentioned, and these aspects should be communicated during pre-test counselling. In general, pretest counselling for rapid tests is performed in the same way as that for the test for anti-HIV antibodies. Nonetheless, during pre-test counselling the individual must be informed of the method used and its reliability, and, if the result is positive, of the need for a second-level confirmation test . It should be stressed that for all relationships, regardless of the specific test used and the test result, it is necessary to take into consideration the specific individual, his/her age, the emerging problem and how it is experienced, as well as his/her socio-cultural background, which is particularly important for non-nationals.
Another approach, known as "opt out", should also be mentioned . In 2006, the US Centers for Disease Control and Prevention developed guidelines for the opt out approach. In this case, the healthcare worker informs the individual that HIV testing is one of the routine tests performed. Informed consent is not necessary, and the individual is only asked to sign if explicitly refusing to undergo HIV testing. In the opt out approach, there is no pre-test counselling for evaluating risks or for favouring awareness in the choice to undergo testing. However, in 1997, this approach was reevaluated, given that some studies showed that the need to undergo testing should always be accompanied by informed consent, confidentiality, and counselling .
TRAINING OF HEALTHCARE WORKERS INVOLVED IN PERFORMING HIV TESTING
The acquisition and/or improvement of counselling skills for healthcare workers in HIV-testing facilities can constitute fundamental training for being able to effectively communicate, so as to address the needs of individuals who are directly or indirectly affected by HIV infection and AIDS [7-9, 26]. training can be done through courses that are structured based on the specific objectives and the teaching methodology used. In the initial phase, the objective is to provide basic training in counselling skills by teaching the principles and scope of counselling, the procedures, and the necessary relational skills. This objective can be reached with a 24-hour course for diverse professionals, using classroom training which includes, in addition to providing information, brief lessons, above all didactic experiences: small-group exercises, accompanied by observations, evaluation of behaviours in analogue role playing and case studies.
The teaching method used is interactive and is based on the principles and criteria of the andragogical model (geared towards adult education) of the American scholar Malcolm Knowles , who places at the centre of training the experience of the individual healthcare worker, who becomes the central element as a person, as the subject of learning, and as a professional. the objective is to stimulate in the participant new cognitive schemes, conceptual elaborations, and links to practical experience, aimed at allowing not only rapid and accurate responses to the demands of individuals undergoing HIV testing but also specific interventions in relation to the complexity of pre- and post-test HIV counselling. the basic prerequisite of training activities in this specific environment is the actual willingness and deep-down motivation of the healthcare worker to create an intense relationship with the individual, based on trust, collaboration, unconditional acceptance, authenticity, and empathy.
Training in basic counselling must include propaedeutics focussed on one's own personal and relational dimensions, on the qualities that favour and hinder communication, and on the acquisition of relational skills such as active listening, empathy, and self-aware-ness. this focus is fundamental for managing the internal setting, so that thoughts, prejudices, convictions, and personal emotions can be recognised and managed. Self-awareness, including that of one's own conceptual maps, individual limits and needs, and the ability to confront one's own cultural prejudices and those of the individual, are the foundation of effective counselling. It is difficult to be empathetic and engage in active listening if not in touch with one's emotions or recognising those personal aspects that can be elicited by another's feelings, situation, experience, and ethic and moral convictions.
Moreover, in addition to learning, of great importance is the application of the counselling intervention, that is, the reference scheme. In fact, after initial training, additional in-depth training is needed, using blended training, characterised by classroom training and remote training, together with supervised field training. Finally, this training methodology can provide good opportunities to test tools for evaluating HIV counselling based on previously established indicators [7-9, 26].
In conclusion, 20 years after the first guidelines on HIV counselling were written by WHO, we have attempted to focus attention on the need for healthcare workers involved in testing for anti-HIV antibodies to commit to the rigorous application of the methodology used for pre- and post-test counselling. the goal is to stimulate healthcare workers to reflect upon the need to follow a reference protocol, so that counselling is not inappropriately performed or not performed at all. In fact, it is well known that there are numerous and complex implications for persons deciding to undergo testing and that providing adequate information and emotional support to activate an informed and responsible decision is extremely important.
Mark Kanieff for revising the manuscript and providing useful suggestions.
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Address for correspondence:
Anna Maria Luzi
Unità Operativa "Telefono Verde AIDS"
Dipartimento di Malattie Infettive
Parassitarie ed Immunomediate
Istituto Superiore di Sanità
Viale Regina Elena 299
00161 Rome, Italy.
Submitted on invitation.
Accepted on 14 January 2010.