HIV/AIDS Counseling Skills and Strategies: Can Testing and Counseling Curb the Epidemic?

OBJECTIVES: The human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) epidemic is in its third decade and has reached to alarming proportions worldwide. According to the Centers for Disease Control and Prevention, more than one million people are living with HIV with an estimated 56,300 infections happening each year in the United States. Diagnosis of HIV/AIDS via early testing along with pretest and post-test counseling is important for psychosocial stabilization and destigmatization. Risk reduction counseling as a preventive counseling method is equally important in high-risk individuals such as adolescents, substance abusers and in gay and bisexual population. The purpose of this review is to address a number of counseling strategies used for education and counseling of individuals at risk of getting HIV/AIDS and also among those who are HIV-infected.
METHODS: In order to collect materials for this review, a detailed search of CINAHL, MEDLINE, ERIC, Academic Search Premier, Scopus, Web of Science and Social Sciences Citation Index databases was carried out for the time period 1995-2010.
RESULTS: Some of the various dimensions of counseling are negative approach counseling, assessing readiness to change, and motivational enhancement therapy.
CONCLUSIONS: Multiple approaches are used by counselors in providing education and prevention counseling to 'at risk' individuals and also individuals who have been infected with the virus. No one method is superior to another and some gamut of techniques are practiced by HIV/AIDS counselors.

INTRODUCTION

The epidemic of human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) is in its third decade and has reached to alarming proportions worldwide. According to the Centers for Disease Control and Prevention, more than one million people are living with HIV with an estimated 56,300 infections happening each year in the United States. Men who have sex with men (MSM) population account for more than half (53%) of all the new HIV infections, and blacks represent almost half (46%) of people living with HIV in the United States.1 Most of the HIV-related research is targeted towards high-risk groups such as prostitutes, gays and substance abusers but there is evidence that it is increasing in college students and adolescents as well.23 In 33 states with confidential name-based HIV reporting, of the 17,824 persons 13-24 years of age, 62% were males and 38% were females.2 An early step in preventive HIV counseling is behavioral risk assessment especially among high risk individuals in resource-limited settings.4 Psychosocial stabilization as a means of coping among HIV infected individuals can not be overemphasized. Besides the trained HIV counselors, family physicians, who are trained in psychosocial and community medicine, are equally poised to meet this demand.5 Patient-provider relationships, when it comes to HIV positive patients, are ironically constrained as risk-reduction counseling falls woefully short of required percentage.6 Si-milarly, counseling for HIV positive individuals who are on treatment for maintaining treatment adherence is quite poor.7 Some of the barriers may be providercentric, such as dealing with emotional issues surrounding HIV and doubtfulness of providing good care.8 These barriers faced by counselors need to be addressed by techniques such as interactive counseling, motivational interviewing and application of stages of change.9 The USA Preventive Services Task Force made a recommendation few years back of counseling all adolescents and adults about risk reduction after they have been advised about risk factors for HIV infection and sexually transmitted diseases,10 and sexual history taking.11 Some of the risk factors for engaging in unsafe sexual activities among the college students are use of alcohol,12 partner characteristics such as age,13 and substance abuse.14 The determinants of safer sex in adult population vary from whether they are HIV positive males, HIV positive females, gay or a bisexual population. The risk factors in a study which looked at HIV positive gays and bisexuals were mainly unprotected anal sex, which has a higher risk of HIV transmission. Some of the strategies tried in this population were problem solving exercises that attempt to increase perceived benefits of safer sex. Counselors also made the participants aware of alternative to regular use of male condoms.15 The reason for engaging in unsafe sexual practices especially in this gay population was pleasure seeking. Some of the barriers for attaining safer sex are inaccurate risk perception, and gender inequalities, like women being powerless to negotiate their sexual safety.16 Risk perception can be improved by using social interactions. Social network formation which includes spousal communication related to AIDS risk has been proven to improve diffusion of behavioral change through the society.17 Protection from getting HIV/AIDS consists of abstinence, consistent and correct condom usage and having just one sexual partner (monogamy). Several studies have found that pregnancy prevention rather than disease prevention was the impetus for condom use.1819 Health education in the form of information about pregnancy prevention can unintentionally increase condom use. HIV/AIDS knowledge provided to individuals does not help in generating behavior change. It was found that Nigerian undergraduates, who had very good knowledge about HIV/AIDS, had low condom use to prevent its transmission.19 Further evidence of knowledge-behavior gap comes from a study, which used a random sample survey of students in which the level of student knowledge was very high but did not lead to protective condom behaviors. However, knowledge was found to be an enabling factor in maintaining a comfort level when asking partners about their sexual histories and in requesting their partners to take an AIDS test.20 In a pilot project, which looked at the effect of HIV/AIDS prevention related messages in improving protective behaviors among Indonesian participants, it was found that those exposed to the intervention were significantly more likely to use condoms to avoid AIDS. They also felt that these messages had a great impact on them to a point of wanting to change their lifestyle.21 This study did not show conclusively that there was actual behavior change on part of the participants. This helps to conclude that HIV/AIDS education related programs are not enough for generating a behavior change and can help in awareness of the disease to certain extent. Furthermore, from the point of view of clarifying risk perception, one needs to provide counseling which includes risk reduction or harm reduction as its integral part. The purpose of this review is to address a number of counseling strategies used for education and counseling of individuals at risk of getting HIV/AIDS. Moreover, later in this paper are discussed some of the counseling strategies used in individuals already diagnosed with HIV or AIDS and these strategies were used in preventing further transmission of the disease.

METHODS

In order to collect materials for this review, a detailed search of CINAHL, MEDLINE, ERIC, Academic Search Premier, Scopus, Web of Science, and Social Sciences Citation Index databases was carried out for the time period 1995-2010. A Boolean search strategy where the key words entered for search were “counseling” and “strategies” and “HIV/AIDS” and “HIV/ AIDS” and “counseling” in differing orders was used to extract studies related to counseling skills and strategies for risk reduction as well as strategies in HIV positive people.

Counseling Skills and Strategies

Counseling for Risk Reduction

HIV prevention counseling is a very important mode of behavioral intervention especially in the absence of an effective vaccine or a curative treatment. It consists of dealing with a variety of issues such as medical, psychological and social. Client-centered counseling changed the focus of counseling from a sole educative one to one focusing on client's needs and circumstances. The word ‘client-centered’ meant that counseling should be tailored to needs, circumstances and behaviors of a specific client which entailed active listening, to provide assistance and determining client's specific prevention needs.22 Prevention counseling primarily consists of risk reduction counseling, pretestcounseling and post-test counseling. In terms of adolescent counseling, the risk reduction approach to HIV counseling can be divided into various phases such as, exploring clients feelings about sexual activity, using their existing HIV knowledge as an engaging tool, addressing the barriers they have for safer sex, focusing on perceptions that might affect risky behaviors, focus on safe sex planning and in the end, referral making.23 Risk reduction counseling is used as a harm reduction technique quite effectively.24 Other interesting approaches used were information-motivation-behavior change model. Results showed that men who received the full information motivation behavior (IMB) model showed greater risk reduction skills and relatively lower rates of unprotected intercourse over 6 months of follow-up and had fewer Sexually-transmitted infections.25 Hierarchical counseling technique as opposed to single-method counseling in a group of women showed that there was a tendency for increased protective behavior among the group which received hierarchical counseling as compared to the other two groups.26 Canadian counseling guidelines for counseling related to safer sex and contraception, mention using scaled questionnaire format. In this technique, the emphasis is on the clients or patients, as they are the best judge of what is important to them personally and how they would incorporate any change in their behaviors.27

Counseling in Infected Individuals

Counseling for safer sex is used in individuals who are HIV infected to prevent further transmission of the disease. Motivational interviewing has been used as an effective technique by some of the HIV care providers. In this counseling technique, the health care provider takes into account the readiness of the client to change his/her risky behavior and helps them resolve the ambivalence associated with changing the behavior.2829 One-on-one counseling was used in these studies. A meta-analytic review of effects of counseling and testing on sexual risk behaviors concluded that serodiscordant couples reduced unprotected intercourse and increased condom usage more than HIV-negative and untested participants.30 Similarly, a multi-clinic safer sex behavioral counseling intervention using loss-frame intervention by emphasis on negative consequences of safe sex reduced the number of sexual partners among HIV positive patients compared with the control arm.31

CONCLUSION

There are several examples of one-on-one counseling methods used for risk reduction counseling among HIV positive individuals. The various dimensions touched upon were use of a negative approach,31 assessing readiness to change,32 and motivational enhancement therapy.33 Hence, we see multiple approaches used by counselors in providing education and prevention counseling to ‘at risk’ individuals and also individuals who have been infected with the virus. Internet-based counseling has gained some popularity over recent years but has to deal with issues such as lack of visual and verbal cues, confidentiality, accessibility problems by those in great need and increased client separation.34 Counseling related to using spiritual coping techniques have been well established in cancer literature but has limited evidence in HIV related counseling. It is mainly applicable as a psychosocial adaptation technique.35