Not many things in life could be as stressful as going back for HIV test results. For many clients it feels as if the counsellor holds the key to the future in his or her hands.
Although the post-HIV test counselling interview is separate from the pre-test counselling interview, it is inextricably linked to it. The pre-test counselling interview should have given the client a glimpse of what to expect in post-test counselling. Pre- and post-test counselling should preferably be done by the same person because the established relationship between the client and counsellor provides a sense of continuity for the client. The counsellor will also have a better idea of how to approach the post-test counselling because of what he or she experienced in the pre-test counselling.
Counselling after testing will depend on the outcome of the test - which may be a negative result, a positive result or an inconclusive result.
The counsellor should always ask the client if he or she is prepared to receive the results. In the case of the rapid HIV antibody test - where the results are available within minutes - ask the client if he/she is ready to receive the results immediately. Some clients need time to prepare for the results.
Counselling after a negative HIV test result
- For both the client and the counsellor, a negative HIV result is a tremendous relief.
- A negative test result could however give someone, who is frequently involved in high-risk behaviour, a false sense of security. It is therefore extremely important for the counsellor to counsel HIV-negative clients in order to reduce the chances of future infection. Advice about risk reduction and safer sex must therefore be emphasised.
- If you practise high risk sex behaviour and test negative, it does not mean that you are “immune” to HIV and that precautions are therefore unnecessary. Nobody is immune to HIV and everyone risks being infected if they do not change their behaviour.
- The possibility that the client is in the “window period” or that the negative test result may be a false negative should also be pointed out. If there is concern about the HIV status of the person, he or she should return for a repeat test after about three months and ensure that appropriate precautions are taken in the meanwhile.
Note to councellors: Don’t underestimate the extreme importance of counselling a client who tested HIV negative. This may be your only chance to talk to this person about his or her sexual practices, potential drug abuse and other risk behaviours, and to educate him or her about safer sex practices. Free condoms can be given out at this session together with advice on how to use them and where to get more when needed. Use this counselling session to prevent a future situation where somebody else has to give the client a positive HIV test result!
Counselling after a positive HIV test result
To communicate a positive test result to a client is a huge responsibility. The way people react to test results depends to a large extent on how thoroughly the counsellor has educated and prepared them both before and after the test.
When a test is positive, the following guidelines for counselling may prove useful for counsellors:
1. Sharing the news with the client
- Positive (as well as negative) test results should be given to the client personally.
- Feedback should take place in a quiet, private environment and enough time should be allowed for discussion.
- The news of a positive result ought to be communicated openly, honestly and without fuss. Simple and straightforward language should be used. Do not give the individual false hopes and (alternatively) do not paint a hopeless scenario.
- Choose neutral words when conveying a positive HIV test result. Don’t attach value to the news by saying “I have bad news for you” - because such an attitude reflects a hopelessness in the mind of the counsellor. Rather say: “Mr Peterson, the results of your HIV test came back, and you are HIV positive”.
- A positive result is NOT a death sentence and the counsellor's task is to convey optimism and hope.
- There are a few Don’ts that we need to observe when sharing a positive HIV test result with a client.
- Don't lie or dodge the issue.
- Don’t beat about the bush or use delaying tactics. Come to the point.
- Don't break the news in a corridor or any other public place.
- Don't give the impression of being rushed, distracted or distant.
- Don't interrupt or argue.
- Don't say that “nothing can be done” because something can always be done to ease suffering.
- Don't react to anger with anger.
- Don't say “I know how you feel” because you don't.
- Don't be afraid to admit ignorance if you don't know something.
2. Client reaction to a positive HIV test result
- Clients’ responses to the news usually vary from one person to another, and may include shock, crying, agitation, stress, guilt, withdrawal, anger and outrage - some clients may even respond with relief.
- The counsellor should allow clients to deal with the news in their own way and give them the opportunity to express their feelings.
- The counsellor should show empathy, warmth and caring.
- Maintain neutrality and respond professionally to outbursts. Don’t show surprise or make value-laden comments such as “There is no need to be upset with me!” Because the loss of health is a bereavement, it manifests with all the components of denial, anger, bargaining, depression and acceptance. The counsellor must respect the personal nature of an individual's feelings.
3. Responding to client needs
- People's needs, when they receive an HIV positive test result, vary, and the counsellor has to determine what those needs are and deal with them accordingly.
- Fear of pain and death are often the most serious and immediate problems and these can be dealt with in various ways. Talking to clients about their fears for the future is one of the most important therapeutic interventions that the counsellor can make.
- Often it is enough for the counsellor just to be “there” for the client and to listen to him or her.
- One of the major concerns for HIV positive people is whom to tell about their condition and how to break the news. It is often helpful to use role-play situations in which the client can practise communicating the news to others.
- In responding to a client's needs, an attitude of non-judgmental empathic attentiveness is more important than doing or saying specific things. Listening is more important than talking; being with more important than doing.
4. Crisis intervention
- Crisis intervention is often necessary after an HIV positive test result is given
- Make sure that the person has support after he or she leaves your office. A person in crisis should never be left alone: he or she should have somebody with whom to share the burden.
- Ask the client where he or she is going after leaving your office. Let the person think about and verbalise his or her plans for the next few hours. Although it is better for the client not to be alone, personal needs should be taken into consideration: Some people prefer to be alone and work through a crisis all by themselves.
- Be sensitive to the possibility of suicide. If the client shows any suicidal tendencies, emergency hospitalisation should be arranged if a friend or family member cannot be with the client.
- Make sure that your client does not leave your office without support to help him or her through the first few days.
- Don’t ever give an HIV-positive result on a Friday, because there are often no support systems available over weekends.
5. Follow-up visits
- When people hear that they are HIV positive, they usually experience so much stress that they absorb very little information.
- Follow-up visits are therefore necessary to give clients the opportunity to ask questions, talk about their fears and the various problems they encounter.
- Significant others, such as a lover, spouse or other members of the family, may be included in the session. During follow-up visits, clients should be offered a choice concerning their treatment.
- If health care professionals are not in a position to do follow-up counselling, information about relevant health services should be given. If there is a concern that the person might not return for follow-up counselling, information about available medical treatments such as anti-retroviral therapy, treatment of opportunistic infections, and social services for financial and ongoing emotional support should be given.
- Give the client a handout with whatever relevant information that he or she may need (such as the telephone numbers and addresses of Aids centres and other social services).
6. Support systems
- Find out what support systems are available to clients.
- Refer clients to support systems where people meet on a regular basis to talk about their difficulties or simply to relax and enjoy each other’s company.
- Information about support systems such as the buddy system is usually available at the nearest Aids centre or from the offices of NGOs (non-governmental organisations) who work in the community.
7. Advice about health and sexuality
- Convey information about safer sex, infection control, health care in general and measures to strengthen the immune system.
8. Medical check-ups
- Encourage clients to go for regular medical check-ups to their family doctor or health clinic. Infections and opportunistic diseases can be prevented if treated in time.
Counselling after an indeterminate HIV test result
- In some cases an HIV test result can be “inconclusive”, meaning that the result is ambiguous or indeterminate, and it is not possible at that stage to say if a person is HIV positive or not. (Explanation: A test result may be inconclusive because the test is cross-reacting with a non-HIV protein or because there has been insufficient time for full sero-conversion to occur since the person was exposed to HIV.)
- When a test result is inconclusive, other testing methods may be used to try to achieve a reliable result.
- The test can also be repeated after two weeks. If it is still inconclusive, it should be repeated at three, six and 12 months. If it is still inconclusive after one year, it should be accepted that the person is not infected with HIV.