HIV / AIDS / STD COUNSELLING TRAINING MANUAL
Item
- Title
- HIV / AIDS / STD COUNSELLING TRAINING MANUAL
- extracted text
-
Acc. No.
i
Class Codj
3^
t
2
DOC WENTfiT
centre
N
IN
INTERNATiq^L SERVICES ASSOCIATION
» . 3536633, 3536299.
_______FAX : 91-80-3536633.
HIV/AIDS/STD
COUNSELLING TRAINING MANUAL
\
V
National AIDS Control Organization
(Ministry of Health & Family Welfare)
Government of India
New Delhi-110001
"
1994
1=
CONTENTS
PAGE NO
TOPIC
Facilitator's Guide
i
Module 1: HIV/AIDS/STDs Information
1
Module 2: Values, attitudes and cultural issues
33
Module 3: HIV/AIDS Counselling: Basic Principles & goals
50
Section 3 A: Communication Skills in Relation to Counselling
52
Section 3B: Counselling: Basic Principles and Goals
70
Section 3C: HIV/AIDS Preventive & Supportive Counselling:
Objectives & Methodology
92
Section 3D: Unresolved Ethical, Legal Issues
Related to HIV Antibody Testing
128
Module 4: Sexuality & Psychological issues
138
Module 5: Special Issues
167
Module 6: Staff Support, Documentation & Networking
197
Appendix 1
I
Appendix 2
IX
Glossary
XIII
List of References
XVII
ACKNOWLEDGEMI-NT
1.
Alka Bhutlan. Nurse Counsellor, All India Instituie of Medical Sciences. New Delhi
Vineela Chitale. Lecturer. Department of Medical and Psychiatric Social W ork, Tala
Institute of Social Sciences, Bombay.
3.
Shankar Choudhary, Department of Community Medicine, All India Institute of
Medical Sciences. New Delhi.
4.
Jacob John. Professor, Department of Psychiatry. Christian Medical College. Vellore.
5.
Saro j J ha, Ag. Regional Adviser, WHO/SEARO, New Delhi
6.
Sujata DcMagry, Director, INSA, Bangalore
7.
Vimla Nadkarni, Head, Department of Medical and Psychiatric Social Work
S.
Nalini Sahay, Deputy Director (IEC), NACO, New Delhi
9.
Kusum Sehgal, Consultant in Counselling for NACO, New Delhi
10.
Chitra Subramaniam, HIV/AIDS Counsellor, Bombay
ADDITIONAL RESOURCE PERSONS
11.
Rajiv Dua, faculty. Department of Medical and Psychiatric Social Work, fata
institute of Social Sciences, Bombay
12.
Jasmecl Kaur. Counsellor. Bombay
13.
Phani Prabha Kumar, Counsellor, Bombay
14.
Carol l.arivce. Health Education Specialist, WIIO/GPA. New Delhi
15.
Geeta Sethi, Consultant, NACO, New Delhi
Special recognition to the Tata Institute of Social Sciences for coordinating the
finalization of this manuscript and to WHO for their financial and technical support.
FACILITATORS GUIDE
WORKSHOP OBJECTIVES AND DESIGN
*
INTRODUCTION
Counselling is an important component of all AIDS/STD control programmes because of
the nature of HIV infection and transmission. There are no simple solutions to this new and
complex pandemic. For this reason, both this Manual and the training workshops for which it is
intended arc designed to explore different approaches and to make all those responsible for
counselling aware of the need for psychosocial support, prevention and resource mobilization as
components of a holistic approach in AIDS prevention and control.
Supporting persons with AIDS and preventing further spread of the disease will require
long-term efforts on the part of many individuals and specialities within the country. I hesc
efforts must be effectively managed and in some cases will require new skills on the part of
existing personnel. In order to augment the skills available within the country for
counselling, NACO has developed this HIV/A1DS Counselling Training Manual to help trainers
who are asked to organise training programmes for HIV/AIDS counsellors. The various
modules are designed to upgrade the skills of practicing individuals and those interested in
providing counselling services to the HIV infected.
Generally speaking, HIV/AIDS counselling training workshops have two major themes:
O
o
i
counselling for prevention of HIV transmission:
counselling for support of those affected by HIV.
Both of these themes are presented within a “psychosocial perspective that views clients
in relation to other people, and never as isolated individuals. A psychosocial perspective
ensures that counsellors will help their clients to become aware of their own resources and
strengths as well as their fears, and of the potential support from other groups of people like
family, friends and others, and related health care services. Having completed the programme, the
trainees should be encouraged to practice the skills they have learned over a significantly long
period. The counselling they do may be in their work place, in a health facility or in their
conununity.
This Manual has been designed for use in India. It comprises of 6 modules. To each
module is annexed Trainer resource material.
During the workshop, participants will be expected to do a certain amount ol reading.
While textbooks and training manuals arc useful, they arc not sufficient in counselling training.
Counselling is a complex and active procedure, and can be learned only through practice and
dynamic interaction. However, the Manual can be used as an overall guide in training workshops.
Il provides the basis for discussions about various aspects of preventive counselling, presents a
variety of counselling approaches, and provides basic information on counselling techniques.
Participants should be urged to read and reread the Manual sections assigned before each meeting
of the working groups.
They should also asked to remember throughout that the words of the Manual w ill be
translated into action and counselling skills only if they participate actively in the w orkshop and
take the steps which, they as counsellors with some degree of training, w ill shortly be asking their
clients to take.
In short, a workshop should be organized on the assumption that counselling is
learned by doing. Trainees attending a counselling workshop inevitably bring w ith them a
mixture of expectations and anxieties about the experience, but these should not be allowed to
interfere with the contributions they can make to the workshop or with what ibex can learn from
it. How much is learned will depend on the degree of openness, involvement in activities, risk
taking with colleagues and the facilitator, as well as a careful examination of personal values,
prejudices and beliefs.
SPECIFIC TEACHING OBJECTIVES
At the conclusion of a training workshop, each participant should be able to :
1.
Describe the various levels of preventive counselling, and to discuss clearly, factually,
and confidently with persons waiting (HIV-infected persons, persons al risk, family
members, and people in the community) to know how to prevent infection, means of
transmission, necessary changes in behaviour, forms of‘"safer sex” and ""safer drug
use”, beliefs and fears about infection and illness, and the potential personal and social
consequences of a diagnosis of AIDS.
2.
Discuss the concerns and issues related to risk reduction, pre-test and post-test
counselling, and identify the ethical and practical difficulties involved.
3.
Build on and update information about the physical and psychosocial needs of people
who fear that they may be infected and of HIV-infected people.
4.
Select and adapt culturally appropriate counselling techniques and
communication styles.
5.
Identify and discuss their personal attitudes and feelings about sexuaiity which make
the counselling process easier or more difficult for them to conduct.
ii
6.
Identify and mobilize both informal and formal human and material resources in the
community for prevention, support and control.
7.
Apply knowledge of the legal and ethical issues involved in testing, partner
notification confidentiality and informed consent.
8.
Address issues of HIV/AIDS infected individuals in long term care, e.g. problem
solving, decision making and care of the terminally ill.
9.
Be aware of special needs of certain groups (IVDUs, women, children, and
individuals innon-heterosexual relationships).
THE TARGET AUDIENCE
This manual has been designed for individuals who are trained in either Social Work or
Psychology. This manual provide further training in HIV/AIDS counselling in order to train other
health care providers. Therefore this manual is to be used for training of trainers. The trainees
could be health professionals who are dealing with HIV/AIDS in their work or health workers
from both governmental and non-governmental organisations interested in developing skills in
counselling. Trainees may also include staff of de-addiction centres, teachers etc who need to
learn more about HIV/AIDS to assist them in their current work or in community development
programmes. Those dealing with STD cases in their work would also find this Manual helpful.
Group size should be a maximum of 20 participants.
OVERVIEW OF THE MANUAL
This manual gives counselling trainers, counsellors, health care workers and others
involved with HIV/AIDS-related work a model for HIV/AIDS counselling training. This model
can be adapted to local needs and circumstances for use in training those who will subsequently
provide counselling to those affected both directly and indirectly by HIV inlection and disease.
This manual is intended to be used in training workshops and is designed for two
purposes. These include:
O
Training of trainers. In this course, participants who are
already practising counselling are provided with new skills
specific to HIV counselling; and, more importantly, trained
to act as trainers in similar workshops. The trainers are then
encouraged to adapt the educational material to socio
cultural circumstances and to provide skills to local formal
and informal health and social workers, involved in HIV/
AIDS related work.
iii
O
Training of formal and informal health and social workers in
counselling skills relevant to their level of knowledge and
local conditions.
Small group exercises have also been designed and included to facilitate this process while
at the same time promoting group cohesion and direction. These exercises should be regarded as
a core component of the training process, be reasonably informal, and be adapted as appropriate
to specific settings and cultures.
ORGANISATION/CONTENT OF THE MANUAL
The Manual is designed to be used as a series of separate modules. The modules may be used
in any number and order, depending on the aims, the participants of each training workshop, and
the time available for training. Each of these modules includes activities. These activities are the
“core” of the training workshop for which the Manual is designed - they raise and explore issues
in the modules in an experiential and challenging but non-threatening way.
In order to achieve the training objectives, six modules have been identified and developed in
this Manual. These are:
Module I : HIV/AIDS/STD Information
This module seeks to raise the trainee’s awareness and to improve their knowledge of
HIV/AIDS. It seeks to help them understand and perceive the risk situations that lead to HIV
infection and sexually transmitted diseases.
Module 2: Value, Attitudes and Cultural issues.
This module deals with the response of the community to the AIDS pandemic, the ways in
which cultural attitudes and beliefs of infection arc influenced by this response, the role
of trainees in decreasing these effects and strengthening community resources. In order to
sensitise the trainees to the complex psycho-social ramifications of HIV/AIDS it is essential to
help them clarify their own feelings and attitudes toward HIV/AIDS related issues.
Module 3 : H1V/A1DS Counselling, Principles, Skills and Methodology'.
This module deals with HIV/A1DS related counselling. Trainees are not only made
familiar with the principles and goals of counselling, but they are also exposed to the skills
needed in preventive and supportive counselling with regards to HIV/AIDS. This module also
covers legal and ethical issues in HIV/AIDS counselling.
iv
Module 4 : Psychological Issues and Sexuality.
This module seeks to provide a conceptual clarity on myths and facts about sexuality.
Trainees will be given opportunities to develop competence to discuss the issues regarding
sexuality without embarrassment. Trainees will also be made aware of the various psychological
issues that arise with regards to an HIV infected individual.
Module 5 : Special Issues.
This module seeks to expose trainees to the various issues that arise while working with
special groups of people. This module aims to make the trainees aware of the counselling
needs of women, children, substance users and individuals in non-heterosexual relationships.
Module 6 : Staff Support, Networking and Documentation.
This module seeks to-sensitise trainees of the importance of staff support, networking and
documentation. Counselling can be challenging and problems can arise. This module offers
strategies to trainees so that they can develop skills in staff support, networking and
documentation.
The manual contains Appendix 1 which give practical advice and information lor people
with HIV infection or disease and Appendix 2 which gives practical information on universal
health precautions.
SUMMARY
In training workshops for HIV-AIDS counsellors, the emphasis must be on learning
counselling by doing it rather than through passive listening or formal study. Small working
groups must be established for this purpose, since such groups provide effective means of active
learning. Ideally each such group should be assisted by two facilitators, one of whom is a
trainer and the other could be a counsellor or co-trainer familiar with local or regional conditions.
EVALUATION
No training programme is complete without evaluation. The areas to be evaluated can be
briefly summarised as pertaining to the trainer/training/trainee.The trainee-specific areas to be v
evaluated are broadly knowledge, attitude and skills.
Various methods of evaluation are available, particularly relating to knowledge and
attitudes. Skills are more difficult to evaluate and involve methods that are often cumbersome,
expensive and time consuming but equally important.
It is desirable to have trainees evaluate the usefulness and applicability of each section as
well as the efficacy of the trainer in dealing with it. One such format is available at the end of this
module Evaluation of some of the skills, for example making the client feel at ease, using openv
ended questions, active listening, supportive statements, etc. is also important. However this may
be belter done during follow up contact programmes rather th^n immediately alter the first
training. Evaluation of counselling activities, management and professional issues are also
possible. However, this is not being recommended at this stage.
Follow up training
Orientation and some basic skill building for counselling is only the first
step. Counsellors need the opportunity to practice their skills over a period
of time. Not only is practice needed, but also the opportunity to discuss
how they are doing with a supervisor or a colleague, and sharing new or
different ideas with other counsellors. As a trainer it is crucial that this
important stage of training to become a counsellor is recognised and
encouraged.
Some counsellors may want to participate in more training to develop
the skills to counsel more difficult cases, or where they are spending a lot
of time counselling and need more skills. This is a further stage of training
for which different materials and methods are needed.
It would be unrealistic to expect that this Guide would help produce
full fledged counsellors at the end of the training period.
Trainees w'ould need to further acquire and refine their counselling
skills under supervision and support.
ORGANIZATION OF THE TRAINING WORKSHOP
The training workshop differs from other training courses in that:
O The material in the course will not be presented by lecture. Instead, each participant will
be given the manual divided into a set of instruction booklets called modules, that have
the basic information to be learned and will participate in a series of activities/exercises
which will facilitate learning of the course material.
O The modules are designed to help each participant develop specific skills involved in the
emotional support of HIV infected and ill persons and motivating people to reduce their
risk of getting infective.
O Each participant is encouraged to discuss any problems or questions with a facilitator, and
to receive prompt feedback from the facilitator on completed activities (that is. to be told
how well they did the exercise and what improvements could be made).
vi
The first session should focus on a general discussion and understanding of the
participants' expectations from the workshop, and their practical experiences in the places from
where they come This helps the facilitator appreciate view points of the participants. It would be
important for the facilitator to ask for the trainees doubts and concerns regarding implementation
of the various issues covered by this manual in their work settings.
This will increase the impact of the training and encourage participants to work out how
they can apply the acquired knowledge and skills to their role as a HIV/AIDS counsellors.
The workshop should start with a series ol general discussions aimed at inlorming
participants about the medical, social, psychological and political aspects of the countrywide
crisis created by HIV, AIDS and related diseases. Each of the following days should begin with a
plenary session designed to review factual information, research reports, or elaboration of themes
covered in the Manual the previous date. Each day should end with a review of that day s plenary
and group activities and the assignment ol reading for the participants (ol the chapters that will be
covered the next day).
During small group work, it is important for the facilitator to make sure that the groups of
participants working together over the course of the workshop in either pairs or small groups, is
constantly changing. The facilitator will need to supervise the rotation of the participants so
everybody gets to work with everybody in the full group.
Working with co-facilitators
When you are working as a team of trainers, assist one another in providing individual
feedback and conducting group discussions. For example, one facilitator may lead a gioup
discussion and the other may record the important ideas on the flipchart.
While one or two facilitators are conducting the activities of a particular module, the other
facilitators should be present and not move away or talk among themselves. All the
facilitators should be debriefed either at the beginning or at the end of the day so as to:
1. Discuss any problems (for eg. training styles) that may have occured during the day.
2. Prepare and plan for the next day.
3. Support and reinforce each other.
Checklist of supplies and space needed for the workshop
Supplies needed for each trainee include:
O Name tags with pins
O Paper
O Ball point pen
O Pencils
O Copy of NACO Counselling Module
O Condoms to accompany activity.
vii
Supplies needed for the workshop include:
O Flipchart stands with paper and felt pens or blackboard with chalk
O Scotch tape
o Scissors
o OHP and transparencies/OHP sheets
o TV and Video casctte player (optional)
Space Required for Workshop:
There should be a very large room for plenary sessions involving the group as a whole.
Small group work will require the availability of small rooms. In the best circumstances there
should be one small room for each group of 4 to 8 participants. When die rooms for the working
groups are close to the plenary room, the working groups can be integrated smoothly and less
time is wasted in the process of forming groups and finishing group work.
Use of tables or desks for participants within the large and small rooms must take into
account the need for varying seating arrangements for group work. Besides this the furniture
should be easily rearranged.
From previous experience with similar workshops, it is recommended that the
accommodation and workshop be located together outside a city in the case of the residential
workshops. This allows the facilitators and participants to socialize more easily and diminishes the
external distractions for everyone.
Suggested Workshop schedule
Encourage participants to arrive the day before the workshop and have a social evening of
introductions. A copy of the training manual with only the content should be given to each
of the participants with a basic introduction to it. The trainer should have twenty sets of manuals
with only the content section xeroxed, to be distributed to each trainee al the beginning of the
workshop. These xeroxed manuals should be returned to the trainer at the end of the workshop.
On completion of the workshop each trainee should be given the complete manual (including
activities and worksheets). The group is expected to read the Modules that arc to be addressed
next day before the next morning session. Finally, it is hoped that the participants in training
workshops will each be given a copy of the Manual and they will use it in their day-to-day work.
It is suggested that the workshop be from 9 a.m. - 5.30 p.m., with a 1-hour lunch break
and a half hour tea break for the morning and afternoon sessions. Participants are expected to be
punctual for the sessions and present throughout the working hours.
viii
NOTE FOR TRAINERS/FAC1LITATORS
What is a facilitator?
A facilitator is a person who helps the participants learn the skills presented in the course
materials, usually through individual or group discussions. For facilitators to give enough
attention to each participant, a ratio of 1 facilitator to each 3 to 6 participants is desired. In your
assignment to teach this manual, YOU are a facilitator.
As a facilitator, you will need to be very familiar with the material being taught. It will be
vour job to answer questions, talk with participants about the exercises, lead group discussions,
and generally give participants any help they need to successfully complete the course. You will
not be expected to leach the entire content of the course through formal lectures. Hence the
experience of and careful planning of experiential exercises (like role plays, simulations etc) is
very necessary.
As a facilitator, you should:
O
read the modules to be discussed before and work through the exercises.
O
plan the schedule for the day,
o
plan how the work within each module will be done and what major points
you should make,
o
think about sections that participants might find difficult and
questions that they may ask,
O
plan ways to help with difficult sections and to answer possible questions.
O
think about the skills taught in the module and how they can be applied in
each participant's place of work,
o
plan questions to ask participants so that they will also think about how the skills
can be applied in their cities and districts,
o
Allocate responsibilities and section/exercises among co-facilitators if you are
working as a team of trainers so that everyone is clear about their roles and area of
work.
How does the facilitator instruct, motivate and guide the participants?
O
by demonstrating enthusiasm for the topics covered in the course and for the work
O
that the participants are doing,
by being receptive to each participant’s questions and needs.
ix
As a facilitator, you should encourage the participants to come to you al any time with
questions or comments. Always be available during scheduled times, and avoid working on other
projects or carrying on discussions not related to the course.
\ou need to promote a friendly, cooperative environment. You should respond positively
to questions (lor example. “Yes, I see what you mean,” or “That is a good question.'*). You
should also avoid using facial expressions or making comments that ridicule participants.
Always take enough time with participants to fully answer their questions (that is. so that
both you and the participant are satisfied). Finally, you should not always wait for participants to
ask for help. Instead, watch the participant looking troubled, staring into space, not working on
activities, not writing answers, or not turning pages.
Suggestions to facilitators for motivating participants.
How to encourage interaction : During the first day, interact a least once
with every participant, and encourage the participants to interact with you
frequently. As a response, it is likely that the participants will overcome
their shyness, they will realize that you are willing to interact and expect
the interaction and will continue to interact with you throughout the
remainder of the course.
Look carefully at each participant’s work. Check to see if participants are
having any problems, even if they do not ask for help. If you show interest
and give each participant attention, the participants will feel more
motivated to do the work. Also, if the participants know that someone is
interested in what they are doing, they are more likely to ask for help if
they need it.
Be readily available to the participants at all times; remain in the room and
look approachable (for example, do not read magazines or talk constantly
with other facilitators).
How to keep participants involved : Frequently ask questions or for
reactions of participants to check their understanding and to keep them
actively thinking and participating. Questions that begin with “what”,
“why”, “how” require more than just a few words to answer. Avoid
asking questions that can be answered by just one word (for example,
questions that begin with “Do”).
After asking a question, PAUSE. Give participants time to think and
formulate a response. A common mistake is to ask a question and then
answer it yourself. If no one answers your questions, rephrasing it can help
break the tension of silence. But do not do this repeatedly. Sometimes
silence is productive and powerful.
x
r
€
Acknowledge all participants' responses. This will make the participants
feel valued and encourage them and others to continue to participate. Do
this with a comment, a "thank you” or a definite nod. If you think a
participant has missed the point, ask for clarification or ask if another
participant has a suggestion. If a participant feels his comment is ridiculed
or ignored, he may withdraw from the discussion entirely or not speak
voluntarib again.
Use names when you call on participants to speak, and when you give them
credit or thanks, Use the speaker’s name when you refer back to a
.previous comment,
Always maintain frequent eye contact with all the participants so everyone
feels included, Be careful not to always look at the same participants,
Looking at a participant for a few seconds will often prompt a reply, even
from a reticent participant,
Write key ideas on a flipchart as they are offered. This is a good way to
acknowledge responses, The speaker will know his/her suggestion has been
heard and will have the gratification of having it recorded for the entire
group to see.
When recording ideas on a flipchart, use the participant’s own words if
possible. If you must be more brief, paraphrase the idea and check it with
the participant before writing it, You want to be sure the participant feels
you understood and recorded his/her idea accurately,
At the beginning of a discussion, write the main question on the flipchart,
Having the question visible will help most participants keep themselves on
track. When needed, walk to the flipchart and point to the question,
Paraphrase and summarize frequently to keep participants focused on a
clear idea and to keep discussions on track, Ask participants for
clarification of statements as needed,
Do not let several participants talk at once. When this occurs, stop the
talkers and assign an order for speaking, (For example, say "Let’s hear Dr,
Arun’s Comments first, then Dr. Neela, then Dr Lal’s,") People usually
will not interrupt if they know they will have a turn to talk.
Thank participants whose comments are succinct and to the point,Try to
encourage quieter participants to talk, Ask to hear from a participant in the
group who has not spoken before, or walk towards someone to locus
attention on him/her and make him/her feel he/she is being asked to talk,
xi
TRAINING PLAN OPTIONS
\\ orkshops that are organized using this Training Manual in its complete form would be
lor a 6 day duration. Alternatively, specific modules can be chosen and used to cover the specific
areas if a group of trainees need inputs on certain topics oni\. The trainer responsible for the
workshop should select the relevant modules and activities if the workshop is to be for less than 6
days.
When designing HIV/AIDS counselling training workshops, the trainer should select the
modules that are most appropriate to the objectives and learning level of the workshop, then
select the relevant activities, and use these materials as required. He/she will ^ilso have the
responsibility of adapting the activities and the information in the modules if local circumstances
and conditions indicate the need to do so.
The present Training Manual can be used for workshops of different time frames i.c.
residential programmes, day workshops for workers in the same city or workshops for full
time workers. In case the trainees are already trained counsellors and only need to
learn the issues and skills specific to HIV/AIDS counselling, shorter workshops can be organised.
Following are some Training Plan Options :
1) A continuous residential workshop of 6 days, covering 1 or 2 modules each day can be
organised. It is important to organise some field visits to agencies working in the HIV/
AIDS field and to invite experts working in this field for guest talks during the workshop.
The evenings can be used to screen films.
W-
2) The workshop can be also conducted as a non-residenlial workshop for a 6 day duration
where the manual is used in it’s complete form.
3) The workshops can be phased into 1 day workshops to cover one module at a time where
the meetings are once a week and span a period of 6 weeks.
4) Another way to phase the manual-training would be to organise weekend workshops i.e.
meetings on Sat-Sun. for 3 consecutive or 3 alternative weekends. However, it is
recommended that all the modules should be covered within 3 months so as to avoid
loss of continuity.
The phased approach is also particularly useful for training social workers, health-care
professionals, counsellors, teachers and pschologists who are already working full-time in the
same city and may not be able to devote 6 full days for the training.
xii
The phased-workshop approach helps trainees to practice sonic ol the skills learnt in the
field before they attend the next session. It is recommended, that trainees are given opportunities
to see and work with clients in the health care or community settings during the 2-3 week gap
between workshop sessions. They can report back and discuss their cases in the sessions in the
next phase.
Trainees must seek field experience of working with 5-6 clients within the 3 months ol
training so as to strengthen and reinforce the skills learnt during the training. 1 rainees should
maintain case records and submit them to the trainers so that these records can be reviewed by the
trainer. If possible the trainee should see the trainer in person for feed back on their case records.
In case this is not feasible then the trainees should mail the case records. For field work
opportunities trainees should be encouraged to tie up with NGOs. PHCs, Civil Hospitals etc. 1 he
trainees should be encouraged to seek the help of the training center or the state AIDS office for
information regarding field work opportunities.
xiii
WORKSHOP FEEDBACK FORM
1. What arc the two most important things you have learned about AIDS and SID?
2. What are the two most important things you have learned about counselling?
3. Your greatest worry about AIDS as an issue is
4. The time period of the worshop was (please circle any one):
Just right
Too short
Too long
J.
5. The handouts and written materials provided were (please circle any one).
Informative
r
Repetitive
1
Inadequate or incomplete
Any suggestions
xiv
6.In your opinion was the informalion covered in each module:
Useful
Not useful
a. Module 1: HIV/A1DS/STD Information
b. Module 2: Values, Attitudes and Cultural issues
c. Module 3: H1V/A1DS Counselling:
Principles, Skills and Methodology
d. Module 4: Psychological Issues
and Sexuality
e. Module 5: Special Issues
f. Module 6: Staff Support,
Networking and Documentation
7. Which module session did you like the best?
8. The best thing about this programme was
I
1
9. The worst thing about this programme was
I
I
I
I
I
XV
10. Please rate the Resource Trainers (Please tick one column for each trained
Name
Excellent
Good
a.
b.
c.
d.
e.
f.
gh.
i.
j-
1
xvi
Fair
Needs more
experience
MODULE 1:
HIV/AIDS/STD INFECTION
EXPECTED OUTCOME
On completion of this module the trainees will have a basic understanding of HIV and
AIDS and its relationship with STDs, impact of the pandemic in India and the importance of
preventing further spread of infection.
MODULE AT A GLANCE
TOTAL TIME - 3 HRS 55 MINS
CONTENT SECTION
THE NATURE OF THE VIRUS
STAGES OF HIV INFECTION
TRANSMISSION OF HIV
PREVENTION OF HIV INFECTION
SEXUALLY TRANSMITTED DISEASES (STDS)
IMPLICATIONS OF HIV/AIDS IN INDIA
ACTIVITY SECTION
INTRODUCTION
QUIZ
CONTENT PRESENTATION
RANKING EXERCISE
ROLE PLAY
< REVIEW QUESTIONS
1
15 mins
20 mins
2 hours
30 mins
30 mins
20 mins
OVERMEW
The first cases ofAIDS were seen in the L'nited States in 1981 but the virus responsible
for the disease was not isolated until 1983. In India, the first HIV positive cases were recorded
in April 1986. The virus causing AIDS is known as the Human Immunodeficiency Virus (HIV').
HIV infects the CD4 white blood cells; these are an essential part of the body's immune, system
so that, when they are destroyed, the infected person becomes susceptible to a range of
opportunistic infections and cancers. HIV can also infect nerve cells and cause brain damage.
HIV is a retrovirus, i.e., its core consists ofRNA. When (his is injected into a human cell, an
enzyme called reverse transcriptase converts the RNA into DMA, which is (hen inserted into the
DNA of the human cell. Replication takes place when the infected cells are activated infighting
another disease. Although antibodies to HIV are produced by the body, they do not inactivate
HIV
The natural history of HIV infection can be divided into five stages, each with its own
clinical manifestations. Current evidence suggests that about 20% of those infected with HIV
may go on to develop full-blown AIDS within five years and about 50% within ten years. HIV
can be transmittedfrom an HIV positive women to the foetus during pregnancy and birth, and
sometimes to the newborn, from breast-feeding. Sexual intercourse is the most frequent mode of
transmission of HIV; parenteral transmission also occurs through the transfusion of infected
blood or the use of blood-contaminated skin-piercing instruments.
STDs refer to communicable, sexually transmitted diseases which have a direct
relationship with HIV infection. STDs are an indicator ofhigh risk sexual behaviour and
increase the chances of HIV transmission particularly among those with genital ulcers. Thus,
early and effective treatment of STDs becomes crucial in reducing the risk of HIV transmission.
2
BASIC INFORMATION ABOUT IHV/A1DS FOR COUNSELLORS
Counsellors must know the basic facts about HIV infection and its manifestations.
Information regarding the causes and epidemiology of 111V infection. AIDS and related diseases is
increasing rapidly and busy counsellors will be aware of the limits of their knowledge. This
module aims at providing the essential facts about the infection and its implications based on
present day knowledge.
While reading and thinking about this basic information, trainees should plan how they
would talk about symptoms and infections to the people of their own state and to persons from a
variety of cultural backgrounds and traditions. The San Francisco AIDS Foundation has
explained the acronym AIDS in a way that may be helpful when talking to concerned or affected
people, families and others.
AIDS stands for:
not bom with
body’s defense system
not working properly
a group of signs &
symptoms
Acquired
Immune
Deficiency
Syndrome
As evident from its name, AIDS is not a single disease, but a syndrome - a cluster of
symptoms which results from the destruction of the body s defenses by HIV-the Human
Immunodeficiency Virus.
Every human being has an efficient body mechanism to protect it against disease. I his
mechanism is called the “Immune System”. Unknown to us, the immune system is at work,
recognizing foreign bodies (eg. bacteria, virus, micro organisms) and fighting them. It does this
with an array of cells and by producing specific chemicals called antibodies which neutralize the
foreign bodies. Each disease stimulates the production of antibodies specific to it. The detection
of these antibodies is therefore used to determine past and present infection.
As HIV causes damage to the immune system itself, the antibodies detected in the blood
of the HIV carrier are unable to fight the virus, which may be present in large numbers in the
body. Therefore, the body cannot be protected against other infections and cancers, some vyhich
then become the direct causes of death. These infections are called “opportunistic infections.”
3
THE NATURE OF HIE VIRUS
1 he first cases of AIDS were recognized in the United Stales in 1981. 1 he virus that
causes it, now called HIV, was first isolated in 1983 at the institute Pasteur in Paris. In India. !11\'
seropositivity was first recorded among lOJemale prostitutes in Tamil Nadu in April 1986.
A new virus has recently been identified in West Africa, India and Srilanka. This virus,
which is related to the virus first discovered acts in a similar way, with similar routes of
transmission and is spreading to other parts of the world. The first AIDS virus is now called
HIV-1 and the second, HIV-2.
HIV selectively infects specific white blood cells (CD4) that are an essential part of the
body s immune system. When the CD4 cells are destroyed, the infected person becomes
susceptible to a range of opportunistic infections, diseases and cancers and the group of such
conditions is called AIDS. HIV may also directly infect nerve cells and cause neurological
disorders. HIV infection is presumed to be lifelong and the infected person is likely to remain
infectious for life.
Structure of HIV
HIV is a member of the retrovirus family of viruses which has been known to cause a
number of different diseases in animals. Like all retroviruses. HIV contains RNA in its core; the
virus itself is surrounded by a protein and lipid envelope or “coat”.
To replicate itself in human cells, the virus first needs to select cells to which it can attach
itself; these cells carry a speciaP’receptor” known as the CD4 antigen. This receptor occurs on
cells in the body’s immune system, called the CD4 cells, and on some macrophages. There is
some evidence that other cells can support the growlh of HIV, such as those in the lining of the
bowel (bowel epithelium) and in the brain (microglia cells).
Replication
When the virus has made contact with a CD4-antigen-carrying cell, it sheds its lipid coat
and injects its RNA into the human cell. The single-stranded RNA then makes a copy of itself
with the aid of an enzyme called reverse transcriptase. This yields double-stranded DN A, which
then inserts itself into the DNA of the human cell. As HIV becomes part of the human cell’s
genetic material, infection of the cell is irreversible. Although it may be possible to develop a
drug that suppresses the activity of the virus (thus keeping an infected person relatively healthy),
there is no prospect of cure in the sense of eliminating the integrated viral DNA.
4
I he viral DNA starts to instruct the human cell to produce viral components such as viral
proteins and R.NA - the two main components of HIV. The viral proteins migrate to the surface
of the infected cell. Then, by a process known as budding, enormous numbers of new virus
particles detach themselves from the infected host cell, and are taken away in the bloodstream to
become attached to other cells carrying CD4 receptors.
The virus may remain dormant for months or even years. In the event of another infection,
the infected cells get activated by the body's immune syotem and the HIV begins to make copies
of itself that go on to infect more human cells.
Any other infectious disease, by activating the immune system, is therefore likely to lead to
viral replication. However, there is some evidence that a few common viral infections such as
those caused by herpes simplex virus and cytomegaloviral disease virus can specifically increase
the replication of HIV. Increased replication of the virus means that an infected person is more
likely to develop full-blown AIDS. This is because such replication leads to progressive
destruction of infected cells, thus destroying the body’s immune system and decreasing its ability
to fight off infection from other diseases. The advice given to those who are infected with HIVto lead a healthy life-style - therefore has a firm scientific basis, (see “Practical information for
People with HIV Infection or Disease in Appendix I of this Manual”).
If the infection is primarily in the brain, viral replication may cause it to deteriorate, which
will often result in dementia associated with encephalopathy and possibly other opportunistic
diseases.
Although the body’s immune system does produce antibodies to the virus, they do not
seem to be able to inactivate the virus. The virus in circulation therefore, is able to spread to
other parts of the body and can be transmitted to sexual partners, and passed on to others through
infected blood, blood products,and other body fluids (semen, vaginal/cervical secretions), and
from an infected mother to her child before, during, or shortly after birth, and possibly also
through breast milk.
Life of the virus
HIV, like other viruses, is easily destroyed by boiling and steaming (autoclaving). The
virus can be destroyed by various chemicals used in standard disinfectants - hypochlorite,
glutaraldehyde and formaldehyde, normally recommended for hepatitis B virus - as well as
alcohols, acetone, phenol, household bleach and several detergents.
However, the lipid envelope can protect the virus from dehydration. This means that
contaminated fluid which has been allowed to dry may still contain infectious virus for hours or
even days if kept at room temperature. It is important, therefore, to ensure that any surfaces or
clinical instruments contaminated with body fluids are treated with effective disinfectants.
5
STAGES OF HIV INFECTION
HIV Infection
HIV infection progresses through several stages. It begins when an individual becomes
iniected with the virus. HIV infection causes a progressive impairment of both the immune and
nervous systems. Over time as this impairment worsens, it begins to show itself as symptoms.
Subsequently there are various increasingly serious stages in the life cycle of HIV infection. The
early, middle and late manifestations of HIV’ infection can therefore be classified. In addition,
once infected, the person is infectious (i.e. able to transmit the virus to other people) for life.
Acute Seroconversion Illness
Within 3-8 weeks after infection, some (but not all) people develop an acute illness lasting
2-3 weeks with symptoms such as fever, rashjoint and muscle pain, swollen lymph glands,
diarrhoea and sore throat. Symptoms may be mild which will eventually disappear completely.
This self-limiting condition is known as an acute seroconversion illness. During this period the
v irus continues to reproduce itself inside the body and tlie person's immune system responds by
developing antibodies to the virus.
Within 6-12 weeks after the infection, it is usually possible to detect HIV antibodies in the
blood. Unlike antibodies to most other micro-organisms, these antibodies do not destroy the virus
effectively. In some infected people, antibodies cannot be detected for 6 months or longer, yet
they are infected and infectious.
The 6-12 week phase between infection and seroconversion is
called “WINDOW PERIOD”. At this time the person is already
infected (as well as infectious) but the blood test will not indicate
presence of HIV. This is because the blood test only indicates
presence of antibodies and not HIV itself and formation of the
antibodies takes 6-12 weeks.
Asymptomatic Infection
The person may remain asymptomatic and feel and appear healthy for years, even though
he or she is infected with HIV. During this asymptomatic period, the person remains infectious (ie
able to transmit virus to others via sexual, blood borne and perinatal transmission) and as the virus
continues to replicate, it causes progressive damage to both the immune and nervous system. If
his/her blood is tested during this stage, it will test positive for HIV antibodies. Some individuals
will have persistently enlarged lymph nodes (persistent generalized lymphadenopathy or PGL)
during the asymptomatic stage of HIV infection.
6
Early Symptomatic Illness
Manv individuals eventually develop a variety of indicators of ill health due to HIV
infection without dexeioping opportunistic infections or secondary cancers. I hese constitutional
svmptoms and signs are sometimes referred to as the AIDS Related Complex (ARC). I hese
symptoms include complaints such as oral thrush, diarrhoea, weight loss, low grade intermittent
fevers, loss of energy etc. Various fungal diseases (eg. tinea infection) or viral diseases (eg
shingles) may be seen and individuals feel chronically ill during this stage of HIV infection.
Late Symptomatic Illness i.e. AIDS
Eventually, individuals will have episodes of AIDS specific opportunistic diseases, such as
Pneumocystic Carinii Pneumonia, encephalitis caused by Toxoplasma gondii and severe and
chronic diarrhoea caused by cryptosporidia and microsporidia. Pulmonary tuberculosis is
increasingly being recognised as one of the most common opportunistic diseases associated with
HIV infection, especially in the developing world (eg. India). Opportunistic cancers, such as
Kaposi Sarcoma and undifferentiated B Cell lymphomas may also be seen. In addition to the
above, there will be significant weight loss and both neurological and neuropsychiatric syndromes
may be present. This end stage of HIV infection is referred to as AIDS. Patients in this stage will
eventually enter a terminal phase and die.
DIAGNOSING HIV
The early diagnoses of HIV infection is through blood testts. The most widely used blood
test is the Enzyme Linked Immuno Sorbent Assay (ELISA) which detects the antibody generated
in response to HIV infection. Another blood test called Western Blot is more expensive and is
thus no longer recommended for routine testing. Spot tests are also currently being used.
It is essential to obtain the consent of all patients prior to being tested for IIIV antibodies.
The results of their test (and the fact that they were tested) must be kept absolutely confidential
and the patient must have both pre-test and post-test counselling. (See Module 3) One single
screening does not call for a positive diagnosis if the test is positive. The National AIDS Control
Organisation (NACO) 1993 policy recommends that one initial testing, in case the person/sample
is found positive. Then a specific test should be performed to ascertain the type of HIV antibody
i.e. anti HIV 1 or anti HIV 2 or both. This is to be followed by an ELISA/Western Blot test.
(Facilitators can write to NACO for policy updates).
History taking is vital in the diagnosis of HIV infection so as to determine possible risk
behaviours or factors. This will be determined by knowledge of how HIV is transmitted locally.
WHO has listed a few signs that help in provisional diagnosis of AIDS for public health
purpose. The presence of two major signs with one minor sign (with the presence of HIV
antibodies) can be an indication of AIDS provided that other causes of depleted immunity, like
malnutrition, etc. are ruled out.
7
The major and minor signs arc listed below:
Major signs:
Weight loss greater than 10% of the body weight
Continue fever for a period greater than one month.
Chronic diarrhoea (for greater than one month)
Minor signs:
Persistent cough for a period longer than one month
General itching dermatitis (skin irritation)
Recurrent Herpes Zoster (Shingles)
Oropharyngeal Candidiasis (fungus infection in the mouth/throat)
Chronic progressive and disseminated I lerpes Simplex Infection
General lymphadenopathy (Swelling of lymph glands)
Progression from infection to AIDS
Initially it was thought that only a small proportion (5-10%) of 111 V-infectcd persons
would ultimately develop AIDS. Today, there is evidence that about 20% of those inf ected may
develop AlDs within five years of becoming infected and about 50% within ten years. An
increasing proportion will probably go on to develop AIDS after ten years, as people with HIV
infection show progressive damage to their immune system over time.
CURE / VACCINE FOR AIDS
So far there is no cure for AIDS and a vaccine of
prevention of infection may be far away.
Neurological inanifcsatioiis
Neurological abnormalities such as peripheral neuropathy and memory loss in people with
111V infection arc being reported increasingly. In some patients, they may be the initial
manifestations of HIV infection and are often atypical in their presentation. I he most frequent
neurological disorder is a sub acute encephalopathy characterized by progressive behavioural
changes associated with dementia; it occurs in approximately I/3rd of people with late stage IIIV
infection. Its onset is usually insidious, and cognitive dysfunction initially predominates. C ommon
early signs include tremors, slowness and aphasia. The course is usually progressive toward
severe dementia. Mutism, incontinence, loss of vision and paraplegia may develop in the terminal
stage.
8
Other causes of neurological manifestations in people with HIV infection include
crvptococcal meningitis, cerebral toxoplasmosis, lymphoma of the brain, papovaviius and
cytomegalovirus disease.
Tuberculosis and HIV
One of the several opportunistic organisms that can attack people with HIV infection is
Mvcobacterium tuberculosis, the organism that causes tuberculosis (TB). Though this organism
is present in the bodies of one-third of the world s population, it generally remains dormant in
healthy individuals because of their healthy immune system. In people infected with HIV. it is
quick to sain an upper hand over the damaged immune system and spreads to various parts of the
body.
A parallel epidemic of TB following AIDS pandemic is already happening in many parts of
the developing world. In South-East Asia, where TB exists as a latent infection in nearly 40% of
the population, the deadlv duo of HIV and TB mean an additional drain on the meagre health
resources. Therefore effective treatment of TB is important.
TRANSMISSION OF HIV
HIV has been isolated from the body fluids of infected persons, including saliva and tears;
however, only blood, semen, "vaginal secretions, and breast milk have been implicated in
transmission. Detailed epidemiological studies throughout the world have documented only three
modes of transmission: sexual, parenteral, and perinatal.
Sexual Transmission
The virus can be transmitted from an infected person to his or her sex partner (man to
woman, woman to man and man to man). During sexual intercourse (vaginal, anal and possibly
oral), damage to the linings of sexual organs such as vagina or rectum can facilitate transmission
of HIV from the infected panner to the uninfected one by exchange of body fluids. It is easier for
the virus to be transmitted if the uninfected partner is already suffering from some sexually
transmitted disease, because in this case the lining is already damaged. Due to the high rate of
sexual transmission of this virus, sexual behaviour is the prime focus for interrupting transmission.
In India, sexual intercourse is the most frequent mode of transmission of HIV.
Parenteral Transmission
Parenteral transmission occurs through the transfusion of infected blood or blood
products, or the use of blood-contaminated needles, syringes, or other skin-piercing instruments.
The risk of acquiring HIV infection is related to the size of the inoculum. Recipients of a single
unit of HIV-infected blood have virtually a 100% probability of becoming infected.
9
Transmission through blood transfusion is a significant problem in aieas where HIV
infection is common and where I IlV-antibody screening ol blood donors has not yet been
introduced. Transmission through 111V-contaminated needles and syringes is a particularly
serious problem among injecting drug users, and where needles and syringes are not sterilized
before reuse.
The risk of transmission in health care settings i.c. from doctors/nurses to patients or vice
versa through needle pricks is very low - only 0.3% or 0%. if universal health precautions ate
taken (See Appendix 11 tor more details on Universal I lealth Precautions).
Perinatal Transmission
Transmission of 111 V from an infected woman to her focus/infant may occur before,
during and shortly after birth. The overall risk of I II V transmission from an HIV-infected woman
to her focus or infant in utero or during delivery is 20-40%.
Postnatal transmission through breast milk has been observed in a small number ol infants
whose mothers acquired HIV infection after delivery. The breast milk of mothers infected with
HIV contains small amounts of the virus. Researchers have found that one-third of babies born to
1 IlV-infccted women become infected. Although this occurs mainly during pregnancy or both,
and although a large majority of infants breast-fed by HlV-inlcctcd mothers do not become
infected through milk, recent data confirms that some transmission may occur through breast
feeding. 1 he risk to the baby appears to be “substantial” if the mother herself becomes infected
while breast-feeding, and lower if she was already infected at the time she gave birth.
BREAST MILK IS SULL PROMO TED
AS BREAST MILK OEEERS FAR MORE BENEFH S TO THE BABY,
ESPECIALLY IN AREAS WHERE INFANT DEA HIS ARE IIKJII
DUE TO INFECTIOUS DISEASES AND MALNUTRT1 ION.
Where the primary causes of infant deaths arc infectious diseases and malnutrition, infants
who are not breast-fed run a particularly high risk of dying from these conditions. In these
settings, breast-feeding should remain the standard advice to pregnant women, me udmg those
who are known to be HIV-infected, because their baby’s risk ol becoming infected through breast
milk is likely to be lower than its risk of dying of other causes if deprived of breast-feeding. The
higher a baby’s risk of dying during infancy, the more protective breast-feeding is and the more
important it is that the mother be advised to breast-feed. Women whose particular circumstanc
(economic, etc.) would make alternative feeding (formula milk) an appropriate option might wish
to know their HIV status to help guide their decision about breast-feeding. In such casts,
voluntary and confidential HIV testing accompanied in all cases by pre-test and pos. , ts
counselling could be made available, (for more details on breast feeding refer to Module .).
10
MOPES OF HIV TRANSMISSION
SEXUAL TRANSMISSION
PARENTERAL TRANSMISSION
PERINATAL TRANSMISSION
In summary, the tables given on the following page show the importance of transmission
of HIV infection through each route of transmission discussed above. It is evident from the table,
that sexual transmission is the most common mode of transmission in Asia.
Note: Numbers are misleading. They are usually the reported number of cases and
not actuals, therefore facilitators should use given statistics with caution.
Facilitators must also make it a point to update their statistics.
11
BREAKUP OF SERO-POSH IVE CASKS
Sero-Positivc
Category
Percentage of t otal
Heterosexual
Homosexual
Blood Donors
Dialysis pts
Antenatal women
Recipients of blood
or blood products
Suspected ARC/AIDS
IV Drug Users
Others
6,402
41
2,399
125
68
42.63
0.27
15.98
0.83
0.45
296
730
2,020
2,936
1.97
4.86
13.45
19.56
Total
15,017
100.00
AIDS CASES IN INDIA
(upto 31st March, 1994)
Indian
Male
Female
1 otal
Indian
551
162
713
Source: AIDS in India, Newsletter of NACO, Dated June, 1994.
Non-transinission of HIV
The range of present attitudes towards AIDS is similar to the attitudes once seen towards .
syphilis in the early 19th Century. Myths and emotional hysteria can be generated due to
misinformation about AIDS. Many myths about HIV today centre around the ways in which it
can be transmitted. Extensive research has shown that there are only three well defined routes of
HI V-transmission, as discussed above.
Studies show that IIIV Does Not Spread By:
O
O
O
O
Drinking water from the same glass as an infected person.
Swimming in pools used by people with HIV or AIDS.
Getting bitten by a mosquito that has already bitten an infected person.
Getting bitten by an infected person.
12
O Socialising or casually living with people with HIX' mieciion or Ah)'
O Caring and looking after people with 11I\ or AIDS
O Lise of the same toilets as AIDS patients or people iiilecied with i II\
O Shaking hands with people with AIDS or 1 IIV infection
O Hugging or kissing a person w ith HIV injection or AIDS.
O Casual contact such as sitting next to an infected person, or by coughing and sneezing,
or from water, food, clothing, cups, glasses, plates, torks. spoons and other shared
objects,
O Receiving and reviewing literature from areas oi the world where there iis AIDS.
O Donating blood.
O Bedbugs, flies, lice, fleas and other insects and pests DO NOT spread HIV.
MYTHS ABOUT HIV TRANSMISSION
(Source : Slides from Directorate of Health Services, Maharashtra]
0 ° ft AZ)
sBy
HANCbf
ASTV
fS i
J),
n*
IaWt
0
0
o
}
i
ft
w
13
PREVENTION OF HIV INFECTION
Al present prevention is the only cure for AIDS. AIDS prevention and control has thiee
main objectives: to prevent HIV infection, to reduce the personal and social impact of HIV
infection; and to mobilize and unify national and international efforts against AIDS. Prevention
is indisputably the most important objective. No curative drug or universally effective and
affordable preventive vaccine is likely to be available in the foreseeable future. Since AIDS is
essentially a sexually transmitted disease, sexual behaviour is the prime locus of action for
intenupting transmission. It is therefore important to have an information and education
programme aimed at all men and women, to have facilities for detection and treatment of other
sexually transmitted diseases and to have an environment which would promote condom use and
frank information dissemination without stigmatization and discrimination against people known
or suspected to have HIV/AIDS. In India, prevention of sexual transmission is an immediate
priority.
Safer sex aetivitics for prevention via the sexual route inelude:
O abstinence,
o non-penetrative sexual activities e.g. hugging, kissing etc,
o mutual masturbation i.e. anything that does not involve sharing of semen, vaginal
secretion or blood,
O long term mutually faithful relationship (the lesser the number ol partners the lower the
likelihood of getting infected), and
o proper and consistent use ol condoms from start to finish for penetrative sex (vaginal,
oral and anal).
For prevention of HIV transmission through infected blood and blood products, the
approaches that have proven effective include recruiting voluntary non-paid donors, screening all
donated blood for HIV and educating health care workers to reduce unnecessary transfusions.
Preventing transmission at health care settings rests on careful attention to infection .
control procedures including proper sterilization of equipment, proper adherence to procedures
based on “Universal Health Precautions”, and provision of necessary supplies and equipment.
Preventing blood-borne transmission among drug injectors should go hand-in-hand with
efforts to prevent sexual transmission among them. These should include reducing the demand
for drugs, the use of drugs by injection, and the sharing of injection equipment.
It is possible to screen blood and blood products, through testing of all blood samples for
HIV However this does not take into account blood screening done during the window penod,
where the person is already infected but his/her immune system has not ptoduced
against HIV. This would mean that the blood sample may or may not be free of HIV. In Bh
,
Indonesia and Thailand, all donated blood is now screened for HIV, while in other countries o
the South-East Asia Region, the proportion of blood screened is on the increase.
14
Cost effective approaches in HIV testing arc also being promoted, including testing ol pooled
sera, in populations where sero-prevalencc of HIX' is low. To avoid expensive tests, guidelines
for alternative and cost effective testing techniques have been developed.
The best strategy for preventing transmission from mother to child is of course, to
prevent the sexual transmission of HIV to women of reproductive age. Secondary prevention
would depend on the avoidance of child-bearing by women who know or suspect that they are
infected. Counselling and contraception services should be made available for all women.
WHO estimates that 16-17 million adults and children are infected with HIV in the world.
Most of these will develop HIV related illness and ultimately AIDS. Therefore we need to plan
for care of these patients at hospitals and at home. They must receive treatment for common
opportunistic infections such as tuberculosis etc. In addition, infected individuals need
understanding and compassion to enable them to maximize their health and human potential. As
AIDS effects people in their most productive years, the economic impact on families with HIVinfected members is enormous, especially on children who may be orphaned. 1 he impact of AIDS
on society would include enormous health care costs, decimation of the work force and loss of
skilled labour and educated professionals.
It is important, therefore, to recognize that AIDS is not just a health problem but it has
major medical, social, and economic consequences. In India, the challenge of denial and
complacency needs to be overcome in order that effective AIDS prevention programmes can be
put in place with the highest level of political commitment. A broad-based, multisectoral
response is urgently needed including the critical role that NGOs can play in promoting safer sex
practices, providing support to people with HIV/AIDS and combatting complacency and
stigmatization.
15
Key Interventions and Approaches at the national & state levels
Information, education and communication (1 EC)
In the absence of a cure or a vaccine, health education or IEC remains the primary tool foi
combatting the HIV pandemic. However, knowledge about HIV transmission and AIDS is
presently confined to a very few. Moreover, it is important to realize that knowledge does not
necessarily lead to action in terms of behaviour (in case of HIV/A1DS it is highrisk behaviour)
change. (More details on Risk assessment in Module 3).
In order for health education programmes to succeed, support services such as condom
promotion and counselling services must be available. Social and behavioural research is
necessary to assess the level of knowledge and to determine which channels of communication are
more appropriate and effective.
The flow of behaviour change proceeds like this :
Attitude change
Infonnation/Education
Behaviour change
While doing risk assessment, risk reduction or pre-test/post-test counselling the counsellor
should keep in mind the natural stages the client’s thinking and reactions will go through before
behaviour is changed. These are :
UNAWARE
I
~
AWARE
________ I
——
CONCERNED
UNCONCERNED
I
KNOWLEDGEABLE & INFORMED
~I
EXPLORE MOTIVATION & ATTITUDE TO CHANGE
~
~l_____________
NOT MOTIVATED TO CHANGE
MOTIVATED TO CHANGE
I
—
~~1________
NOT READY TO CHANGE
READY TO CHANGE
TRIAL OF NEW BEHAVIOUR
I
[
—
L . _ "~1____________
DISCOMFORT & BARRIERS
TOWARDS NEW BEHAVIOUR
REINFORCEMENT & SUCCESS
OF NEW BEHAVIOUR
SUSTAINED BEHAVIOUR CHANGE
16
i argctcd Interventions Among Intravenous Drug Users
The prevention and control of HIV infection in intravenous drug users (IVDUs) can be a
more daunting task due to the complex issues involved.
In all regions of the world, the first objective is to prevent drug abuse. In regions with
very low rates of use of illicit drugs and absence of trafficking networks, prevention of the
establishment of such a network through law enforcement is the first priority.
in other regions where drugs are widely used but rarely injected, namely most parts of
India, the first priority in containing the spread of HIV infection in drug users, is to prevent a shift
towards drug injecting. Public and mass media campaigns against injecting are probably counter
productive in such a situation since they tend to raise curiosity rather than deter from the switch
to injection in a group, which by the fact of being marginalized and criminalized, is unlikely to
follow advice from authorities. There is already an example to prove this point. A rapid switch to
drug injecting in Nepal followed a strong media campaign against injecting drug use. Only low
key, peer-to-peer programmes are likely to be effective in such situations.
Injecting drug use is already widespread in some states in India, although initiation into
drug use still occurs almost invariably by smoking/inhaling. In such situations, in addition to an
abstinence-oriented treatment approach, a series of subtle harm reducing strategies are being
promoted. These include oral opiate maintenance; peer-to-peer programmes for converting drug
injectors into drug inhalers; and education for decontamination of needles and syringes with
bleach (5 per cent sodium hypochlorite), especially for IVDUs in prisons. These measures should
be combined with outreach programmes for those drug users who are still untouched by the
existing systems of help. In regions where large droppers or syringes are used for injecting in
groups, thereby considerably increasing the amount of blood exchanged, as in some northeastern
stales of India, substitution with smaller droppers and/or syringes should be an immediate priority.
Sexually transmitted disease (STD) management
Epidemiological data worldwide as well as in India shows that the major mode of HIV
transmission is through sexual intercourse and that AIDS is primarily a sexually transmitted
disease. The relationship between STD and AIDS is twofold; (1) STDs are a marker for high-risk
behaviour; the same high-risk behaviour predisposing for STD, predisposes also for HIV
infection, namely unprotected sexual intercourse with multiple partners; and (2) STDs appear to
serve as an important risk factor facilitating the transmission and acquisition of HIV infection.
Thus control of STDs contributes significantly to a reduction in HIV transmission and are an^'
important component of AIDS prevention and control programmes.
17
SEXUALLY TRANSMH I E1) DISEASES (SI Ds)
STDs are Sexually Transmitted Diseases. Earlier, STDs used to be called veneral
diseases. STDs are communicable diseases which are transmitted by an infected man/woman Io
his/her partner during sexual intercourse. For this reason, they are called Sexually 1 ransmitled
Diseases. They are relatively easy to contract. STDs are serious and painful. Gonorrhea, herpes,
chlamydia, syphilis and AlDs are the most common STDs.
A person becomes infected with STDs when he/she has:
O vaginal sexual intercourse, or
O anal sexual intercourse, or
O oral sex with an infected person.
The vagina, penis, rectum and mouth are the sources from which the SID germs can
invade the body.
S I D Symptoms
Many STDs show early symptoms which disappear without treatment. But the germs
remain in the body, causing damage to different organs. Some S I Ds give mild or no symptoms at
all, particularly in women. Anyone with an STD may look and feel healthy, but can still infect
partners or unborn babies.
SOME SYMPTOMS OF STDs
WOMEN
O
O
o
o
Unusual discharge or foul smell from the vagina
Pain in the lower abdomen - between the navel and sex organs.
Burning or itching around the vagina.
When having sex, pain deep in the vagina.
BOTH MEN & WOMEN
o
o
o
o
Sores, lumps, blisters or rashes in or near the sex organs or mouth.
Burning pain while passing urine or having a bowel movement.
Fever, chills and aches - like flu.
Unusual swelling and itching ol and around pubic area.
MEN
O
Discharge from the penis.
18
yv A
Genital
In the absence of proper treatment, there may be various complications due to STDs. They
include:
o Complications of pregnancy - congenital syphilis leading to still birth.
Other STD infections may be responsible for other birth defects.
o Complications in infants - infection with gonorrhoea causing blindness, other
complications are conjunctivitis (an eye infection) and pneumonia.
O Complications in others - infertility, hepatitis, dementia and cancer.
o Sterility.
Some of the Misconceptions prevalent in India regarding STDs
Regarding STD transmission:
O Lack of genital hygiene for eg. visiting a dirty urinal, using a dirty sanitary pad, dirty
underwear, or an infected condom (which itself suggests the reuse of condoms)
causes STDs.
O Excessive heat eg. through spicy food and alcohol or through constitutional or
occupational reasons leads to STDs.
O Non-sexual contact with an infected person, eg. touch, sharing objects, urinating at the
same place as an infected person causes STDs.
Regarding STD prevention:
O The only way to prevent STDs is seen as avoiding CSWs or washing gepitals with
own urine, water, soda and lime juice.
19
Regarding S I D treatment:
O Home remedies are believed to be adequate tor S I D treatment, S'! Ds are viewed as
curable but there is poor awareness about places ol treatment.
O Sex with a donkey, a child, or with a virgin ol the opposite sex is said to cine S I D.
Regarding S I D disease:
O During infectious stage, it is believed that the urge to have sex and pleasure sex is high
for both sex partners (a particularly dangerous belief).
Prevention and Treatment of S1 Ds
Abstinence is a fool-proof method of preventing SIDs, but a really dillicult one. 1 he
following guidelines can do much to prevent S I Ds:
O Avoid sex with partners who have genital rashes, redness, sores or discharges.
o Stay away from casual relationships.
o Reduce the number of your partners as much as possible.
.
o Use condoms.
Urinate
and
wash
the
genital
area
after
intercourse.
This
helps
in avoiding some genital
o
o
o
infections.
Prevention of S I Ds would also reduce the risk of 1 II V transmission.
rreatment should not be stopped when symptoms disappear, but continued till blood
(VDRL) test reports are negative.
Early treatment is always desirable to prevent complications and further spread of
infection. Upon suspicion of infection, the person needs to consult a health clinic or the family
physician. Regular check ups arc also recommended if, safe sex is not practiced, or, as soon as
any sign of an STD is noticed. Most SIDs can be cured if correct treatment is given but 11 W
AIDS cannot be cured. It should be remembered that early diagnosis and treatment of S I Ds
would reduce risk of 1 11 V transmission.
IMPLICATIONS OF IIIV/AIDS IN INDIA
We have already seen how I IIV infection occurs and how this can lead to AI DS. Being a
fatal infection for which neither treatment or vaccines are available, AIDS, if unchecked, is i c y
cXaXificant influence on various aspects of daily lite. It can have a ser.ous nnpactmn the
demographic economic and social structure of our country in an unplanned and piecipita iv
manner which would offset a lot of the progress made over the years.
1.
Demographic Changes
. • i
bctw
i
ihr <exuallv active, which means the age group
“:^ZnA
A.DS
age segment would lead to :
20
i., llus
a.
Changes in the age structure of the population
Most studies in India and abroad show that the maximum number of ill V infected
individuals are in the 20 to 30 age group. This would mean that a disproportionate
number of those aged 30 to 40 years are likely to die. This will of course skew the age
structure of the population and lead to further effects.
b.
Increase in the number of dependents (elders & children).
This is oiten the age when people have young children and dependent elders at home.
c.
Increase in the number of orphans.
The Indian society has traditionally coped with orphans by having them cared for by their
uncles and aunts. Here it is also likely that most uncles and aunts would also be affected
or would be already overburdened by caring for others.
d.
Reduction in the productive work force.
This age group of people are at the peak of their productive life. As most HIV infected
individuals in this age group are likely to die, there would be a large reduction of the
number of people available to work.
2.
Economic Impact
The economic impact of AIDS can be considered in terms of its direct influences on the
economy as well as the indirect effects it can have. With increase in sickness and reduction in
work force, there is likely to be:
a.
Reduced availability of manpower.
b.
Reduced productivity in the country.
This reduction will involve people who are trained in various specialised skills and jobs.
The loss of investment in training along with the decreased availability of personnel will
have a direct impact on productivity. The effect of this will be obvious in the organised
sector like the industry, army etc as well as in the un-organised sector like agriculture.
c.
Loss of income to the family.
The death of the wage earner will lead to a loss of income for the family. Further, there
would have been other unanticipated expenses like costs for care, medicines, funeral, etc.
d.
Increase in poverty.
Increased costs to the family leading to increase in poverty. Besides this many more
families will slip into lower economic levels or even below the poverty line.
e.
Increased spending on health care.
The overall impact of AIDS in the country will also mean a higher allocation of resources
towards health to cope with the needs of the community.
21
f.
Diversion of resources from other priority areas.
g-
Negative impact on development.
These factors automatically follow and may slow down or increase the progress made by
the nation in various areas.
Health factors
3.
a. Increased infectious diseases and Increase in general morbidity.
b. Breakdown of National Control Programmes (increased prevalence and loss of
objectives. Negating gains made in health programmes eg. as in the case of
c.
Pressure on the health care systems to deal with the direct and indirect effects of HIV/
A1DS'
' ; a direct effect of HIV with dementia and
d. Increase in mental health problems both as
the increase
in the overall stress related
encephalopathic syndromes as well as t.._
.
problems in society.
e. Increase in child and adult mortality rates.
f. Reduction in overall life expectancy.
4.
a.
Social Effects
Ostracising the individual, family & communities from lack of awareness. A general fear of
AIDS as an unknown phenomenon easily ends up with society condemning those aheac y
infected This could extend to the families of those infected, and also to marginalisation of
certain groups, as those indulging in high risk behaviour. By marginalising and isolatmg those
infected or at risk of infection, it would practically drive such people underground, thus
making effective health education and prevention all the more dillicull.
or reduced productivity in key members of a family will lead to significant
b. Loss of employment
economic and social losses. Loss of esteem and of social support networks could lead to
significant hardships that a family will have to lace.
as a result of ill health and death can lead to the
break up of the traditional family roles. This will have its impact on family dynamics in many
c. Change in the traditional family structure
areas.
Relationships: Marital and other intra-familial relationships are significantly
stressed with the onset of HIV infection in one of its members
.
ii) Supports- the family network as it exists today probably oilers the most nnpoitan
i)
linnily dynamics arc likely In pul Illis support system Io sigmlicanl slum and
reduce its ellicacy.
22
iii) Norms, values and role models: when children grow up without parents or with
single parents, difficulties in identifying with social rolescan occur. Additionally,
when economically and socially deprived, norms and values learnt within a family
could get deficient. These factors have secondary effects like deficient
personality development, delinquency, increasing cases of school drop outs etc.
cl. Increased burden on family resources, or elders/children and in health care costs will result
in gradual increased burden on women, elders and unrelated adults.
e. Change in family structure/functions and roles lead to increased responsibilities and burden on
the community’s resources.
f.
Increased dependence on the formal sector for social support. This is already rudimentary and
unlikely to be able to cope with additional demands made on it. Non-formal organised sectors
like Non Governmental Organisations (NGOs) will be looked on as resources and need to be
strengthened.
g- An increase in other social phenomenon like migration, urbanisation, poverty, crime and
suicides can be envisaged.
Rolc of Counselling and Health Education
Counselling complements health education but serves a different purpose for the many
people who may not believe that they themselves are directly threatened, who find it hard to
change risk behaviour, or who are unable to apply general information to their own specific
circumstances. Counselling is essential in helping such people to:
1. Understand the consequences for themselves and others of their risk behaviour.
2. Define their potential for changing risk behaviour to protect both their own health and the well
being of others; and
3. Find and use the personal and social resources necessary for starting and maintaining
behavioural change or managing illness.
Education is an important tool for counsellors. A counsellor teaches constantly, giving
new information, separating fact from myth and informing clients about available resources. The
counsellor both guides and educates, whether in helping a client determine how7 to avoid infection,
deciding whether or not to take a test, or explaining how HIV infection is transmitted.
Counselling is therefore, geared to motivating people to interpret information, incorporate it, and
act on it. The aim is towards helping people cope with their stress and fears regarding their
potential or actual infection with HIV.
23
Health education and counselling aim at changing risk behaviours; and use two way
interaction and rely on communication skills. 1 lowever, beyond just education, which is
emotionally neutral, counselling involves strong emotional overtones. The role of the counsellor
then becomes to augment the coping capacity of the individual and family to deal with the
emotional impact of HIV inlection.
,
Counsellors must keep up with current knowledge and combine this knowledge with their
skills in listening, supporting and guiding.
Suggested Readings
Gordon. G., & Klouda. T. (1988) : Talking.ALPS- 1PPF, London.
Mann. J., Tarantola.
& Nettcr. T. W. (1993): A global report. AIDS in tliQ-Wurkl.
Pavri. K. (1992): Challenge of AIDS. New Delhi : National Book Irust of India.
24
AC'nvn Y SECTION
ACTIVITY 1: Introduction
rime: 15 minutes
Objective:
Trainees are able to familiarise with the workshop objectives and schedule and should be
able to verbalise their expectations from the workshop.
Procedure:
The trainer uses this time to introduce himself/herself and the other facilitators. He/she
welcomes the trainees and guests (an icebreaker can be used). Trainees are made familiar with the
objectives of the programme and of the schedule. Their expectations are noted.
ACTIVITY 2: Quiz
Time: 20 minutes
Objective:
Trainer becomes aware of the level of knowledge and the altitude ol the trainees regarding
H1V/AIDS.
Procedure:
Ask the trainees to complete the quiz given in Worksheet 1 by themselves. As they
complete the quiz, ask them to keep the paper with themselves for later use.
25
a
WORK SHEET 1
)
Quiz
SECTION:!
i
ARE THE FOLLOWING STATEMENTS CORRECT OR INCORRECT (write “Correct”
or “Incorrect” next to each sentence) :
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
People who have multiple sexual partners are responsible for AIDS.
You cannot get AIDS by casual contact.
AIDS is spread through insect bites.
Donated blood is being tested for AIDS.
Some traditional healers can cure AIDS.
Once a person is infected, blood testing will always indicate positivity.
HIV attacks CD4 lymphocytes only.
Blood donation will give you AIDS.
HIV infection will eventually develop into AIDS.
Condoms are 100% effective against HIV transmission.
The pregnant mother to foetus transmission rate of HIV infection is 89-100%.
Once a person is infected with HIV, his life is over.
I here is nothing that can be done lor a person with AIDS.
One can generally identify a person with HIV infection by looking at him/her.
Anyone who has unprotected sexual intercourse with multiple partners is at risk of
111V infection.
A pregnant woman infected with HIV might pass the infection to her unborn child.
Condoms when properly used, can help protect you from HIV.
AIDS can be cured if detected early
Should condoms be encouraged in regions, where there are few reported cases of
HlV infection?
Breast feeding in developing countries should be encouraged regardless of the
HI V status of the mother.
♦
26
SECTION::
TO ANSWER HIE QUESTIONS, CIRCLE THE RESPONSE X Ol1 THINK IS MOS I
CORRECT OR EILL IN HIE BLANKS.
1. What is the lull form for AIDS and HIV?
AIDS
HIV
2. The primary modes of transmission of HIV are:
a
b.
c.
3. In which of the following ways is. HIV transmitted?
a. Having unprotected sexual intercourse with an infect partner
b. Donating blood
c. Using public toilets
4. You can get HIV from:
a. Mosquito bites
b. Sharing food
c. Hugging someone with AIDS
d. Mosquito bites, sharing food and from
e. None of the above
5. For which of the following purposes do people share needles?
a. Tattooing
b. Steroid injections
c. Injecting drugs
d. Ear piercing
e. All of the above
27
ANSWERS TO SECTION:!
1
4
5
6
7
8
9
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
incorrect
correct
incorrect
incorrect- because donated blood is being tested for presence of HIV Antibody; the
individual's Response to HIV infection.
incorrect
incorrect- because of the window period 6 to 12 weeks
incorrect
incorrect
correct- eventually develops into AIDS
incorrect- 95% safe
K
incorrect
incorrect
incorrect
incorrect
correct
correct
correct
incorrect
correct
correct
ANSWERS TO SECTION:!
1.
2.
3.
4.
5.
Acquired Immuno Deficiency Syndrome; Human Immunodeficiency Virus
Sexual; parenteral; perinatal
a
e
e
(The Quiz has been adapted from HIV/A1DS Counselling d raining Manual AIDS Control
Programme. .Ministry of Health. Malawi and from WHO-SEARO (1993), An Orientation to HIV/
AIDS Counselling - A Guide for Trainers.)
28
ACTIVITY 3: Presentation
Time: 2 hours
Objective:
The purpose of this activity is for the trainees to get a basic understanding of HIV/AIDS,
and its relationship with STDs.
Procedure:
The trainer uses this time to do a presentation on HIV/AIDS information. The trainer
should cover basic information, including transmission and prevention of HIV infection and its co
relation with STDs. The trainer could use audio-visual aids like slides, OHP material, video films,
etc. during his presentation. The trainer could also invite an expert in this field for a guest talk.
ACTIVITY 4: Ranking Exercise
Time; 30 minutes
Objective:
Trainees should be able to identify high risk behaviours in relation to HIV/AIDS.
Procedure:
Ask the trainees to complete the “rank the risk” exercise(worksheet 2). They may rank
from 1-10(1 having the highest risk of getting AIDS and 10 having the least). Ask them to
compare the answers and brain storm. Please note that there are no wrong answers. It is the risk
behaviour which is to be highlighted, therefore the facilitators should locus discussion on high risk
behaviours.
29
WORK SHEET 2
V
Ranking of Risk Behaviour
Who of the following has the greatest or least risk of contracting HIV?
Instruction: Rank form 1-10(1 means having the highest risk of getting HIV and 10
means having the lowest risk for getting HIV). The same rank can be given to more than one
person listed below. Please remember that it is not what you are but what you do that puts you at
risk of getting HIX' infection.
School student with a classmate who has AIDS
□
□
□
□
□
□
□
Medical doctor
Family member of a person with AIDS
Someone with multiple sex partners
Traditional healer
The unborn child of an infected mother
Nurse
Sex worker
Voluntary blood donor
Intravenous drug use
Person with STD
30
ACTIVITY 5: Role plin on giving HIV/AIDS information
'l ime: 30 minutes
Objective:
Tins activity helps in summarising the basic information regards HIV/AIDS.
Procedure:
Instead of the trainer summarising for the trainees, select 6 volunteers (3 pairs') from the
group. One person plays the counsellor and the other the client. The counsellor explains one of
the three areas of information given below to the client. The client may ask questions as often as
necessary. Other group members observe and comment critically.
a) basic information about HIV (first pair)
b) modes of transmission (second pair)
c) methods of prevention (third pair)
ACTIVITY 6: Review Questions
Time: 20 mins.
Allow 10 minutes to the trainees to fill worksheet 3. Trainer to discuss the likely answers
with the trainees.
31
WORK SHEET 3
Review Questions
1. What are the stages of development of HIV infection and disease?
2. How is HIV infection transmitted?
3. How can HIV infection be prevented?
4. What are the differences between STDs and HIV/AIDS?
32
MODULE 2
VALUES. ATTIT UDES AND CULTURAL ISSUES
EXPECTED Ol'TCOME
On completion of this module, the trainee should be able to identify the psychosocial
factors that affect people with HIV infection and be aware of their role in relation to social
values, attitudes and culture and the need to be non-judgmental. The trainee will also be able to
identify cultural issues associated with HIV/AIDS transmission and prevention.
MODULE AT A GLANCE
TOTAL TIME - 3 HRS 25 MINS
CONTEXT SECTION
COUNSELLOR VALUES & ATTITUDES
CULTURE & TRADITION
PREVAILING SOCIAL POLITICAL & HEALTH RELATED ATTITUDES
MARGINALISED GROUPS
ACTIVITY SECTION
50 mins
1 hr
15 mins
1 hr
20 mins
DISCUSSION IN PAIRS
CONTENT PRESENTATION
EXERCISE
CASE DISCUSSION
REVIEW QUESTIONS
33
OVERVIEW
People from different backgrounds have different values, which influence their altitudes
towards HIV infection and AIDS. Counsellors also have their own values and share their
culture 5 prejudices, but must not allow them to influence their counselling. Therefore, they need
to examine and become aware of their internal values, biases and culturally determined
attitudes. Culture and tradition influence the way in which people respond to HIV infection and
AIDS, and counsellors should respect the cultural influences of others. They therefore must
explore the prevailing beliefs about illness and, in particular, HIV infection, and their efforts to
motivate behavioural change must take these beliefsystems into account. They should help
clients and their families to discover culturally acceptable ways of expressing emotions such as
anger, guilt, fear or sadness. As HIV infection is transmitted sexually, cultural attitudes towards
sex and sexuality are extremely important in advocating prevention; it may be difficult to change
culturally sanctioned behaviour and therefore becomes necessary to find other more viable ways
ofprotection.
34
COUNSELLOR \ ALUES AND ATTITUDES
People are influenced by the culture within which they live, develop and mature. L\er\
culture has certain kinds of behaviour, ceremonies, rites of passage and points of view that are
preferred above all others. These are called values. Some values are practically universal, for
example - preserving the lives of innocent people. - but the values which guide and direct day-today behaviour are usually specific to the culture in which they evolve.
.An HIX' AIDS counsellor must understand and accept that people from different
backgrounds have different values, and that these values influence attitudes towards HIX’
infection or AIDS. Values determine the degree to which a person asks for help, or attempts to
handle a problem alone. They also determine how people view health, illness, and death.
Counsellors will have their own values, attitudes and beliefs but have to work with clients
who may have values that are quite different. Fear and prejudice against people with AIDS
causes stigma, discrimination, hostility and oppression, and may even be stronger than the values
which underlie the humane care of the sick. Counsellors themselves may share their culture’s
prejudices, and must therefore examine and recognize their own prejudices and values.
Competent counsellors do not have to like all their clients, but should be keenly aware of their
own feelings, opinions, attitudes and prejudices. They must learn to recognise when they are not
communicating clearly, or are distracted by the background or appearance of their clients, or are
being influenced by bias rather than facts.
Counsellors must never allow their own personal values or prejudices to influence their
counselling. If a serious conflict seems likely, the client should, if possible, be transferred to
another counsellor. If this is not possible, the counsellor should consult a supervisor or colleague
for help in resolving the difficulty. Some institutions may benefit from developing and operating
a formal policy of reducing or eliminating prejudice or discrimination. Such a policy can be
implemented with the help of staff training at all levels, supervision or staff support groups.
Counsellors must explore and reflect on their own feelings and prejudices which can
interfere with the objective assessment of clients or, in the case of unremitting work with
distressed and dying clients, the counsellor can have severe depression and may be unable to
relate to other people. They will also need to decide how ready they themselves are to discuss
sensitive topics and to what extent their own inhibitions and attitudes will complicate the task.
The kinds of questions which counsellors might ask themselves are':
O What are my own feelings about people whose behaviour has placed them at risk of
infection?
O About people with HIV infection or AIDS? Am I afraid, critical, overwhelmed?
O In view of the ways in which the infection is sometimes contracted, can I treat certain
persons as fellow humans, or will I see them as being at fault and immoral?
o Which sexual practices would be most difficult to talk about, given my own personal
and cultural values?
35
o What everyday slang wolds would I use, 01 never use. Io explain lisk piaclices 01
behaviour, especially to clients who differ from me culturally or sexually, or are much
younger or older?
o Can I maintain my own values of individual worth and dignity lor everyone, even il
my client's cultural background and way of life are very different from mine?
o How would I explain the need to discuss behaviour that is seen as strange or deviant
in a particular society or culture?
o In this culture, to what extent am I ready to let clients do what they decide to do and
take responsibility for their own care? Will I involve others in decisions if it is the
accepted thing to do, or always try to be in control?
O How much do I want to influence, control or dominate other people?
O Are there some kinds of people or types ol behaviour ol which I disapprove so
strongly that I probably could not counsel those concerned competently?
CULTURE AND TRADITION
Persuading people that they should change their behaviour and motivating them to do so
are major counselling tasks. They will do so, or even consider doing so, only il the counsellor
appreciates the cultural importance of the behaviour to be changed.
“Culture” can be defined as the habits, expectations, behaviour, rituals, values and beliefs
that human groups develop over time. Through culture, people learn acceptable behaviour, what
is right and wrong. It determines or influences social status and the use of language. Culture is a
product of the interaction of people, ideas and the physical environment.
Human beings interpret the world and their place in it according to their culture. It
determines their feelings and beliefs about health and illness, about caring for the infirm, and
about death and loss. Traditions handed down from one generation to another, may be
particularly important at times of transition (puberty or marriage rituals) or stress (illness or
death).
Culture and tradition therefore influence how people interpret, explain, and respond to
HIV infection and AIDS. Counsellors must examine their own beliefs, so as to be able to listen
without prejudice and without censure to people from different backgrounds and cultures. 1 hey
must first and foremost learn about, and respect, the culture and traditions ol others, and not
forget that particular culture.
The Culturally - Sensitive Counsellor
A counsellor may sometimes unknowingly behave or speak in ways which a client from
another culture interprets as unusual, rude or even threatening. The client may then become silent
and seem to withdraw from the session. When this occurs, the counse lor should comment on it,
encourage an explanation, and change or adapt the counselling method.
36
It is large!) in the use of words, or language, that counselling is adapted to culture.
Language both expresses and shapes thought. Communication can take the form of speech
(verbal) or of body language (non-verbal). These methods of communication are influenced by
culture, which determines the form that they take and how they are accepted.
The counsclloi should acknowledge differences so that they do not hinder or block the
development of the counselling relationship. The counsellor must be sufficiently secure to admit
unfamiliarity with a client’s culture and to know how to question the client in order to decide
how to conform to the client's cultural norms.
Cultural Attitudes towards Health
There are various factors that affect people's attitudes towards healthillness and health
services and their perception and acceptance of the sen ices. In a Bombay based study it is seen
that slum dwellers are well informed about diseases and their treatment, but not about the need
for early inten ention to keep a problem in check nor about follow up and prolonged care to
prevent relapse. It is also seen that women’s health is traditionally neglected. It has been found
that different types of illnesses are referred to different categories of the health system for
example: sex-related problems are referred to traditional system of medicine. A HIV positive
person or an AIDS affected person may fall into this category.
USE CULTURALLY APPROPRIATE LANGUAGE
Cultural factors that affect the Health of the Community
Certain customs and practices, beliefs, values and religious taboos create an environment
that helps in both the spread and the control of certain diseases and the promotion and
maintenance of health. Illness or loss of health is attributed to more than one cause and hence the
treatment taken varies. The perceived causes of illness or ill health are often of two types,
supernatural causes and physical causes. Under the category of supernatural causes various
categories of causes can be included like Breach of Taboos, Wrath of Gods and Goddesses,
Sorcery, Evil eye and Ghost Intrusion. Diseases such as leprosy and sexually transmitted
diseases are believed to be the result of certain taboo behaviour.
37
Diseases or ill health aie altiibulcd to physical causes which include excessive heal oi
cold, wrong combination of food and impurity of blood. As per studies S I Ds are often attributed
to excessive heat, the treatment of which is generally in terms of intake ol cold products.
In the case of IIIV/AII )S, inlection may be viewed as being caused by siiprinatiiial
factors and treatment may be approached from that angle especially lor example; in the case of
repeated and unexplained fevers and diarrhoea. Beliefs related to food intake and impurity of
blood may also affect people’s approach to prevention, diagnosis and clinical services in relation
to AIDS. These need to be addressed in educational programmes in relation to IIIV/AIDS.
Cultural Beliefs and Practices that affect the spread of III V
1.
Skin piercing
Specific beliefs and practices in relation to health are likely to have a closer bearing on
behaviour that increases vulnerability to AIDS. They may pose as barriers against AIDS
prevention and control activities. Skin piercing practices fall within this category. In India
acceptance of the injection and skin piercing in general is almost universal except for
immunisation in some regions. Prescriptions of injections are sought after as they are viewed to
possess magical qualities. 1 his faith in skin-piercing is often abused by healers who even give
injections of distilled water to the ignorant. While these may have a placebo affect on people, the
trend is not to be encouraged.
Skin piercing lor decorative and ritualistic purposes (for example; car piercing, tattooing,
ear cleaning etc.) is also common among the rural areas, particularly among women and tribals.
Studies need to examine the possibility of transmission of HIV.
2.
Blood:
'Hie quantity and quality of blood in
the body are viewed as significant by the
general population to determine health,
status. Stemming from this belief is the fear
of loss of blood and of the belief of the
quantity of blood as related to body size and
health. Reluctance to donate blood and
paranoia regarding “spoill” or “defective
blood are a natural consequence. Bloo^
Donation has thus been projected as the
ultimate sacrifice in popular media (as
Indian films) as it involves giving a part of
one's sustaining fluid to another out ol
sense of sacrifice or duly. Blood Donation
is however, not popular in India. Beliefs related to the loss of blood as damaging to health aie
firmly entrenched and resistance to “losing” blood is strong.
38
3.
Cultural Attitudes Towards t raditional Healers
The role of health care providers belonging to alternative systems of medicine as well as
traditional healers and quacks who arc popular in India needs to be examined in the context of
their contribution to health care, especially in
relation to AIDS. The major Indian systems
other than allopathy are ayurveda, homeopathy,
VAID
unani and siddha. However, ayurveda and
unani are the most significant in India and
account for 75% of the total demand for
consultation within the population according to
studies. Many practitioners covered in a study
reported dealing with cases of vaginal bleeding,
anaemia, skin infections, sexual problems and
respiratory tract infections. Thus their value in
AIDS prevention and management cannot be
TANTRIK
under-emphasised and needs to be viewed
seriously.
Despite the advancement of medical science, or high level of education, quacks flourish
in any society, more so in societies like in India where rationality or high level of education is
not always the rule. Certain alternative medicine practitioners sometimes referred to as quacks
seem to enjoy a certain degree of popularity especially due to claims for reviving sexual potency
and rejuvenating the old and the “weak”.
The following characteristics explain to some extent the reasons for their popularity in treating
such problems:
1. They claim possession of some formulae for preparing remedies believed to be
efficacious in the treatment of certain diseases.
2. They claim that they possess certain cures for diseases for which modern medicines are
inadequate.
3. They are able to publicise their successful cures through “word of mouth”, testimonials
by previous successful users and advertisements.
4. They tend to exaggerate the “services” motive though they are obviously profit oriented.
In view' of these factors, health seeking behaviour in India is likely to lean towards these
groups.
Studies need to be conducted so as to examine the claims made by traditional healersY
Wnen no other medical help is available, a person will naturally seek help from a quack who
offers some promise of cure. To this could be added another category consisting of socially
marginalised groups that expect to be ill-treated by the system e.g. CSWs, unwed mothers, STD
patients etc.
39
An HIV positive person or an AIDS affected person would fall into any of these categories:
o When briefed that there was no cure for AIDS, the person would only dream of a
miracle.
o 1 fc/shc may know that nobody can really cure him but would be restless because of
the prospects of lingering death and want some immediate relief.
o 1 le/she would certainly be desperate enough to cling to any straw that he/shc thinks
would save his/her life. I bus the counsellor must make the counselee aware of these
feelings and drives so that the counselee does not get misled or cheated by such
quacks.
In sonic cultures, spiritual or traditional healers may not know how HIV infection is
transmitted. 1 hey might even harm an infected person with their remedies and cause the
infection to continue to be transmitted. The counsellor should make every effort to establish
contact with them and explain to them the modes of III V transmission, the nature of HIV
transmission and AIDS so that they can modify their practices.
Culturally Determined Rituals for Death and Cultural Sources
Often, the counsellor has to help clients and their families deal with major changes in
behaviour and living arrangements, disablement or disfigurement, or impending death. Clients
will react to HIV infection or the possibility of it, or to clinical AIDS, in various ways - fear of
abandonment, or pain, disfigurement, and helplessness. How these fears are expressed will be
partly determined by the culture.
Different cultures have different rites for terminal illnesses, death and bereavement. The
counsellor must ensure that those concerned can observe their customary riles and get in touch
with those who perform them. The counsellor should be acquainted with the use of ritual
observances for spiritual comfort or protection, and should know who administers or performs
the rites, or who can be approached in spiritual matters.
Cultural Attitudes Towards Prevention
The counsellor who appreciates the influence oftiadition and culture can establish with a worried
person or with a HIV-infected individual and family:
O a common definition of the problem;
O an acceptable way of explaining it; and
O a culturally acceptable way of handling it.
As HIV infection is transmitted sexually, cultural and personal attitudes towards sexuality
and other preventve options are extremely influential. The counsellor must also realize that some
people may hesitate for cultural, religious or moral reasons to consider the use of condoms, or
any form of contraception. It is particularly difficult to Change culturally and traditionally
sanctioned behaviour, such as male extramarital sexual relationships. The justification for
change in this context must be compelling c.g„ the protection of children from infection, 01 horn
deprivation or destitution which would be a result of the bread winner’s death at an early age.
40
Facts alone will often not be enough to change cultural altitudes, which must then be
accepted and the client helped to find other means ol protection -lor example, by weighing the
emotional costs and consequences of sexual abstinence against those of a morally proscribed
practice such as using condoms.
The attitudes of others, including those of the public authorities, towards prevention and
care, must also be considered, since these attitudes can determine whether the client will change
behaviour and cooperate in treatment. Fear of social stigma may lead to denial, resignation or
fear of abandonment.
Maintaining sensitivity to cultural issues and differences can be very demanding. The
counsellor must try and understand the sort of life another person has led. which includes
knowing the ideas, ideals and symbols that define the person’s identity and means of coping with
misfortune.
✓
Counselling can involve discussing behaviour or ideas that may be taboo in the
counsellor’s culture; it can go beyond tolerating differences to a genuine appreciation of the
critical importance to the client of something to which the counsellor may be very hostile. Even
a very experienced counsellor will sometimes feel shocked or offended. Counselling requires
self-discipline, as well as self-knowledge, familiarity with various cultures and beliefs, and
openness to different views and interpretations.
PREVAILING SOCIAL, POLITICAL AND HEALTH RELATED ATTITUDES
Trainees are members of the societies they live in and are influenced by prevailing
cultural, social and religious attitudes. This can sometimes affect their attitudes towards those
they care for and lead to conflicts with professional guidelines. Some factors are:
Health behaviour and beliefs
How people view and understand illness and their traditional practices for prevention, and
care of illness are important factors. If, for example, people believe in balanced nutrition as a
disciplined way of life (life style) and practice accordingly, it would positively effect prevention
and even in ceses with HIV infection.
Cultural beliefs, values and practices also affect people’s behaviour. Implication of such
beliefs and practices can be enormous and they may partly determine whether people are
vulnerable to HIV. For example if cultural values advocate monogamous, faithful sexual
relationships, and if the social practices confirm to these values, the odds against people being
vul™ rable to HIV infection would be low.
The Social and Political situation
Certain kinds of socio-political environments marginalise vulnerable weaker groups. It
increases their vulnerability to HIV infection. Some of these groups are migrant labour, street
children and such others. The life styles of those who belong to these groups also makes them
vulnerable to HIV infection. '
41
Availability of Health Care
This also determines the prevention and care-related practices in communities. Modern
health care is not easily accessible to many. If accessible, it is very costly and still not within
their reach. These groups turn to traditional medicine systems and sometimes even to quacks.
As primary health care provided by the state is still not accessible to many, they also turn to the
private sector which has a commercial base. Problems resulting from this situation are
indiscriminate use of injections, of blood transfusions and low reliability of injection control
methods. The utilisers are exposed to a risk of HIV infection.
MARGINALIZED GROUPS
Many social groups have become marginalised because of socio economic reasons. They
face social stigma and thus become more and more alienated from the mainstream of society,
fhe access to health care and other resources (eg. education) is reduced. These groups are
vulnerable to HIV infection. The issues these groups face in relation to HIV infection are
complex.
Commercial Sex Workers
Very often this is the group which is socially and economically at the lowest rung of
society. Access to information about health care regarding prevention is almost absent. Due to
the social stigma attached to this group, members may keep away from seeking this information.
At the same time their occupation makes them a high risk group for HIV infection. Very few
have the choice to change their life style due to the exploitative system and become the
“reservoir of HIV infection”. As eunuchs indulge in commercial sex they too arc at risk of HIV
infection. The community strives to maintain privacy and thus often has no access to health care.
Street Children
Exposed to hard living on the street the children very often are the target of sexual abuse.
Drug abuse is another hazard they face, apart from poor health and low nutritional status. I his
group becomes highly vulnerable to HIV infection. At the same time, access to services becomes
difficult as they are looked at with suspicion by the society.
Homosexuals
This group has a social stigma and was not even recognised openly uptil now as their
homosexual orientation was considered perverse and unnatural. However, urban and literate
homosexual population has access to information. I hat apart, very little is known about the rural
homosexual population.
42
intravenous drug users
In certain geographical regions, this group has been identified as one of the major high
risk groups in India. The danger of HIV infection is through their group norm of needle sharing.
The group is ncT. easily identifiable, as they remain hidden due to stigma attached to drug ausc.
and is difficult to reach. Many of them may also be of a sexually active age. thus increasing their
vulnerability tc HIV infection. The growing criminal nexus with drug abuse points out towards
the increase in intravenous drug-use.
Clients of sex workers
Research has shown that this group prefers sexual practices which increase the danger ol
HIV infection nor example anal sex without condoms). The group may largely comprise of
sexuallv active men of all ages. An added risk is that they may pass the infection to their spouses
or regular partners.
There are some other groups who also need special attention. They are:
Professional (paid) blood donors
The cultural and social beliefs do not encourage blood donation, thus creating a need for
the existence of this group. This is usually a socially alienated group due to other behaviours like
drug-abuse. Many of them also indulge in multi-partner sex. They are highly vulnerable to HIV,
and pass it on to their recipients.
Blood Product recipients
Illness like thallacemia, haemophillia, sickle cell anaemia are common in certain ethnic
groups, for example certain tribals. The nature of their illness necessitates receiving blood and
blood products regularly for survival, thus making them vulnerable to HIV infection. The groups
are not easily identified and are geographically dispersed. Many of them are ignorant of their
own vulnerability. This ignorance may lead to unsafe sexual practices, and then passing on the
infection to their spouses.
Some of these above groups have been given further attention in Module 5 on Special Issues.
Suggested Reading
Deraid. W. S. (1981): Counselling the Culturally Different: Theory and Practice.
John Wiley &. Sous.
Panos Dossier (1988): Blaming Others : Prejudice, race and worldwide AIDS London : Panos
Publications
Sabatier, R. (1990): The Third Epidemic : Repercussions of the fear Qf AIDS London : Panos
Publications.
43
A(nvn y six i ION
ACTIVITY 1: Small Group Work: Exploring Attitudes
Time: 50 minutes
Objective:
I his activity gives an opportunity to trainees to explore and clarify their own attitudes
towards HIV and AIDS.
Procedure:
Divide the trainees group in smaller discussion groups of 3-5 members, f irst have each
member fill in the sheet for himself/herself (allow 10 mins.). Then ask each group to elect a
leader who can record the group’s ideas after all members share and discuss their responses and
report them back to the class. Each group member will need a copy of the statements listed in
worksheet 1. It is important that the trainer does not seek to correct or criticize views that he or
she disagrees with at this stage, but allows free expression of them. I he trainer then discusses the
following issues with the group by going over the points given below: (allow 20 minutes).
Points of discussion:
♦
♦
♦
♦
♦
Why are these called controversial statements?
Have you heard of such statements being made by people? Which ones are most
frequently used?
Did you feel comfortable discussing your views with your partners?
Were you surprised when your partner disagreed with you?
Did you change any of your views af ter listening to your colleagues?
44
WORK SHEET 1
I
Controversial Statements
In the boxes fill in an (A) for agree and (D) for disagree based on your opinions about each
statement:
□
□
□
□
□
□
□
□
□
□
□
Women with HIV infection should not have children.
People with AIDS should not be allowed to continue work.
AIDS is mainly a problem of people with immoral behaviour.
Men who have sex with men indulge in abnormal sexual behaviour.
People with HIV infection should be isolated to prevent further transmission.
It is a collective responsibility to care for people with HIV infection.
1 would feel uncomfortable inviting someone with HIV infection into my house.
Surgeons should screen all patients for HIV infection before surgery.
1 would feel uncomfortable discussing sexuality with a person of the opposite sex.
Intranenous drug users should compulsorily be tested for HIV.
It is alright for men to have sex before marriage.
School children should not be educated about safer sex.
Women should never have extra-marital sexual relations.
All professional blood donors should be jailed.
It is difficult for male counsellors to talk to women clients about condom use.
45
ACTIVITY 2 : Briefing
Time: 60 mins.
Objective:
The purpose of this activity is to help the trainees to gain a better understanding of the
role that values, attitudes and cultural isues play in relation to HIV/AIDS.
Procedure:
The trainer highlights the points brought out in the content section of this module, and
that different backgrounds have different values which influence attitudes towards HIV infection
and AIDS. Trainer should draw from experiences of the trainees.
ACTIVITY 3: Need to be Non-judgemental
Time: 15 minutes.
Objective:
The purpose of this activity is to help trainees understand the need to be non-judgemental
in counselling.
Procedure:
Using the material presented in Activity 2, the trainer explains how being judgmental
adversely affects counselling. He/she gives the following examples:
Statement by Ajay (a col
lege student)
:
“I went to a prostitute last
night. Do you think I could have contracted AIDS?”
Vikas's (a friend) Reaction
:
“What can you expect if you indulge in this bad habit?”
Statement by Sheela
(a student)
“1 am going to have an arranged marriage
next month, but my parents and my future husband
do not know that I am having an affair with a boy in
my college. I don’t know what to do!”
Teacher’s Reaction
“I am ashamed of you. Shall I tell your parents?
46
Statement by Ravi (a patient) :
“For the past one year 1 have been taking drugs.
Now. I hear that people who take drugs get AIDS.
Is that true?”
Doctor's Reaction
Of course, it is true. \ ou should never take drugs.”
Nov\ ask the participants to volunteer to respond in a non-judgmental way to each of the
three statements given above. They may either verbalize or write their responses. Ask a few of
them to call out their responses for each statement and acknowledge the ones which are nonjudgmental and supportive.
ACTIVITY 4 : Case Discussion
Time: 60 minutes
Objective:
Trainees need to be able to identify and pick out the social and cultural issues by examining
the following cases.
Procedure:
Trainees break up into 3 groups. Each small group discusses a case scenario given to
them by the facilitator using the discussion questions/guidelines given below. After 30 minutes,
they come to the bigger group where each small group shares their case scenario and findings
with the big group. Allow 30 minutes for discussion.
Case Scenarios :
#1 Satindcr 40. is married and has just found that his wife is HIV positive. She
had a blood transfusion six years ago during an operation. They have two
children. Satinder is planning to send his wife to the village and marry again,
so that the house and children will be looked after.
#2 Vandana is working near a cinema theatre selling cinema tickets in black. She
has to do some work as she comes from a very poor slum family. The person
who controls the black market has sexual relations with Vandana. She is HIV
negative.
#3 Manish is a 24 year old youth. He is an alcoholic and visits prostitutes. He
is HIV positive. He refuses to treat his alcoholism and neglects advice about
condom use. His mother is worried about looking after him. Should his
vessels and clothes be kept separately?
47
Points of discussion:
♦
♦
♦
♦
Is this situation acceptable?
What are the implications?
Who is accountable/vulnerable?
What kind of resources can be mobilised to help the situation?
ACTIVITY 5 : Review Questions
Time: 10 mins.
Allow 10 minutes to the trainees to fill worksheet 2. Trainer should discuss some of the
likely answers with the trainees.
48
WORK SHEET 2
Review Questions
1) Why is it important for a counsellor to examine and understand his/her own attitudes?
2) Why is it necessary to be aware of cultural influences on counselling9
3) What are some of the cultural attitudes and beliefs that influence health in India?
49
i
MODULE 3
HIV/AIDS COUNSELLING : PRINCIPLES, SKILLS AND
METHODOLOGY
EXPECTED OUTCOMES
The trainees will :
1) gain a clear understanding of tlie essential principles and goals of counselling as well as
the basic counselling stages and activities;
2) develop a clear perspective of objectives and methodology of HIV/AIDS counselling;
3) develop effective verbal and non-verbal communication skills in relation to the
counselling process;
4) critically review the ethical and legal issues related to HIV testing and counselling
MODULE AT A GLANCE
TOTAL TIME - 8 HRS 55 MINS
SECTION 3A
CONTENT SECTION
COMMUNICATION SKILLS IN RELATION TO COUNSELLING
ACTIVITY SECTION
.
COMMUNICATION SKILLS
PAIRED EXERCISE
ROLE PLAY
CONTENT PRESENTATION
BRAINSTORMING
❖ SECTION 3B
20 mins
20 mins
40 mins
20 mins
15 mins
CONTENT SECTION
COUNSELLING : BASIC PRINCIPLES AND GOALS
ACTIVITY SECTION
BRAINSTORMING
; 25 mins
CONTENT PRESENTATION : 1 hour 30 mins
SECTION 3C
CONTENT SECTION
HIV/AIDS PREVENTIVE AND SUPPORTIVE COUNSELLING
ACTIVITY SECTION
GROUP WORK
GROUP WORK
ROLE PLAYS
GROUP DISCUSSION
GUIDED IMAGERY
ROLE REVERSAL (Optional)
SECTION 3D
CONTENT SECTION
45 mins
45 mins
1 hour
30 mins
I hour
25 mins
ETHICAL AND LEGAL ISSUES RELATED TO HIV
ACTIVITY SECTION
CASE STUDIES
45 mins
REVIEW QUESTIONS
20 mins
50
i
OrL'Kl IL'U
Counselling is both an art and a science, and requires not only a knowledge of the
subject matter but also self-knowledge, self-discipline and self-respect. It becomes an art when
the counsellor masters me use of various skills to foster the relationship of counsellor - client
and supports the client in achieving autonomy and high self-esteem. Counselling almost always
involves communication about sensitive isues and good communication depends on careful
observation. Throughout each session, the counsellor pays careful attention to both verbal and
non-verbal messages. Some essential communication skills (active listening, asking effective
questions, paraphrasing, reflecting feelings, appropriate use ofsilence) are employed to ensure
that the client and counsellor correctly interpret each other s messages and that their responses
are appropriate and satisfying. Some advanced counselling skills are also used once the
relationship has become deeper and complex issues are being worked through: these skills range
from interpretation, focussing to confrontation and modelling behaviours.
Counselling is a special form of interpersonal communication in which feelings, thoughts
and attitudes are expressed, explored and clarified. The approaches or models of helping may
vary but certain essential principles, including empathy, confidentiality and time management
are common to all counselling situations. Each counselling process is aimed at certain goals.
One can also observe specific stages in this process which can be termed as: the beginning
stage, middle stage and end stage or closure, each of which calls for certain actions and tasks to
be undertaken by the counsellor.
t
<
r
*
i
j
HIV/AIDS counselling has two general objectives - to prevent further spread of the
infection (by doing risk reduction counselling, pre-test counselling and post-test counselling) and
to provide psychosocial support to those already infected and their families (by doing supportive
counselling). Helping people assess their degree of risk of infection due to their behaviours,
preparing them for taking the HIV - screening test, educating and informing them about the
syndrome, explaining and supporting them through the result - declaring stage, guiding them
towards safer sex practices and ways to reduce further risk are all part of a counsellor's work
during preventive counselling. . As a supportive HIV/AIDS counsellor, the counsellor focusses on
supporting and helping clients to cope with the impact of the infection on their lives and
relationships, deal with progress of the infection, come to terms with terminal illness and deal
with feelings of death and dying, and helping family members to deal with their reactions as well .
as their caring for the infectedfamily member.
HIV/AIDS is a complex issue and brings to the forefront many issues involving ethics,
human rights and legal statutes. The critical issues that counsellors need to examine and
confront are: mandatory testing, informed consent, confidentiality, partner notification and
equal opportunity provisions.
I
51
DU- 32-S
H%
<
SECTION 3A
COMMUNICATION SKILLS IN RELATION TO COUNSELLING
INTRODUCTION
HIV/AIDS prevention counselling may be the only practical means for promoting change
and adoption of long-term low risk behaviours. Counselling programs can identify and promote
low risk behaviours, and. provide emotional and psychological support to people with HIV
infection, their families and friends. In order to do this effectively, counsellors have to focus and
work on their communication skills as communication is the only way counsellors can interact
with clients to evaluate, to focus on and to facilitate change. Good communication depends on
careful observation, correct interpretation of client’s messages, and making responses that are
consistent and helpful.
Communication is at two levels, verbal and non-verbal. Verbal is the most obvious and
recordable whereas the bulk of communication is generally non-verbal. Non-verbal
communiction is mostly through tone of voice, posture etc. The non-verbal mode is a very
powerful means of communication. Looking out for both these components actively, may help
the counsellor to see beyond what the patient is obviously stating. These skills can be developed
by practice and receiving feedback from colleagues. The essential skills are described in this
section.
ESSENTIAL COMMUNICATION SKILLS
L Non-Verbal Communication
Non-verbal communication is an important element in letting clients know that they are
being attended to, heard and understood. Counsellors convey this to the clients through:
O body language (for e.g. leaning forward to convey interest)
o calm body posture (no fidgeting, etc.)
o frequent eye contact (but no intense staring)
o encouraging conversation cues (for e.g. nodding, smiling)
o mirroring clients’ energy or emotional level
2. Active Listening
Active listening demands extremely concentrated listening on the part of the counsellor,
who must pay acute attention to the client’s verbal disclosures, non-verbal cues and feelings that
are indirectly expressed. Counsellors must maintain and communicate their active involvement
with the client through non-verbal communication such as eye contact, nodding the head, etc.
Using verbal skills like repeating the last few words of the client’s statements, encouraging
words like “Yes, I see,” and allowing the client to complete the incomplete sentences are very
helpful. Attentive behaviour enhances the client’s self-respect, establishes a safe atmosphere,
thereby facilitating free expression of whatever is in the client’s mind.
52
3. Asking Effective Questions
Counsellors use questions to obtain specific informaiion. to help the client communicate
ciearly, to encourage exploration and clarification of thoughts, feelings and attitudes. Openended questions (which require more than a yes or no answer) encourage this type of discussion
and communication because they allow for any response. Closed ended questions, by contrast,
cniy allow for a yes or no answer and discourage discussion or exploration. Counsellors probe
tne client through questioning to fully explore and discover the core issues of the client’s
snuation.
Examples of open-ended questions :
“Would you tell me more about how you are feeling? Can you tell me more about that?”
“What was that like for you?" “In what other ways may difficulties come up in
your life if you don’t change your sexual behaviour?"
Paraphrasing
Counsellors can paraphrase or restate in their words what the client said in order to let
the client know that her or she has been heard. Counsellors can paraphrase both content and
underlying feelings. This can help to clarify what the client has expressed. When employing this
skill, the counsellor attempts to tell the client the essence or content of what the client has just
said.
4
Example:
^So, what you are saying is that you can’t imagine how you could have been exposed to HIV."
5. Identifying and Reflecting Feelings
Counsellors can help clients identify and clarify their feelings and reactions by listening
ic the feelings being described and then reflecting them back to the client. Reflecting gives the
counsellor the opportunity to interpret, and then compare with the client, what the client has
expressed in terms of his/her emotional state, fhe counsellor recognizes the client’s feelings
(such as hun. anger, fear) and indicates this in a direct way to let the client know : “Your feelings
are very strong, and 1 accept them, and 1 accept you".
Example:
“You seem to feel very angry with your husband for becoming infected with HIV,
and very worried about him at the same time.
Can you tell me more about your feelings toward your husband? ’
6. Appropriate use of silence
Silence in a counselling session is important at times. It gives the client an opportunity to
reflect, integrate feelings, think through an idea or absorb new information. It is not always
comfortable to allow the silence to continue, but counsellors should not interrupt it prematurely
because of their own discomfort. There can be no specific guidelines as to when silence is
helpful but counsellors should consider whether they are motivated to use it because of their own
discomfort, or as a positive intervention with the client.
53
Al)\ ANCE1) COMMUNICATION SKILLS
1. Focussing
It is easy for the client to get sidetracked in the counselling session because many
thoughts and feelings emerge. The counsellor needs to help the client focus on the most
important issues at hand. The aim of focussing is to prioritize what needs immediate attention
and is the main task versus what can be put off until later; it brings clarity and perspective to
counselling.
Example:
“Let us come back to the issue of safer sex practices.”
2. Interpretation
Often people will avoid focussing on the real problem and will talk around the issue. The
counsellor helps to establish what is relevant by emphasizing the important points. Interpretation
goes beyond what is explicitly expressed to the meanings and feelings being implied by the
client’s comments and which are somewhat below the surface of the client s awareness. It
redefines or brings out more clearly feelings which are at the edge ol awareness.
Example :
Of all the things you talked about today, it seems to me you are most concerned about
3. Problem Solving
Counsellors often help clients to solve problems. This is most effectively done by
allowing the client to state the problem and then clarifying and defining it from the counsellor's
point of view. The counsellor may suggest possible solutions, facilitate the client s exploration
of these solutions and their consequences, as well as help the client in making decisions and
carrj’ing out the decided solutions. Here, the counsellor should guard against making
to solve the
assumptions about what is problematic to a particular client and should never attempt
<
problem for the client.
4. Repeating and Reassuring
At times of stress and crisis, people do not always understand at once everything they are
told because they may be overwhelmed or in a state of denial. The counsellor needs to be
repetitive at such moments. He/she should repeat statements of support or factual information as
often as necessary until he/she is sure that the client understands ciearly what is being said or
what needs to be done about risk behaviour, illness and health management. I he counsellor also
needs to reassure the client, verbally and non-verbally, that he/she is accepted and, whatever he/
she is feeling is normal and understood (by the counsellor).
54
5.
C'onfronting
Conlrontalion involves a direct examination of incongruities or discrepancies, in the
clients' thinking, feeling and/or behaviour. It calls attention to possible self-deception, games,
denial, resistance and evasion being done by the client. The counsellor shows how thoughts,
actions/behaviour and consequence are related and encourages the client to adopt new. less
destructive ways of behaviour. As it is a highly intrusive skill, timing is very important and it
should be delivered in a warm and caring manner.
Confronting the client may be an effective response when an issue is being denied or has
not come out into the open. Counsellors need to confirm the truth and facts of what the client is
lacing and experiencing, even when they may want to protect them or cushion them from harsh
reality.
Example:
“I know that it is difficult to understand how you can feel healthy,
but you have this virus inside of you that you are capable of transmitting to others.
And if you do not adopt safer sex practices your wife could become infected.”
6. Supporting and Modelling Behaviours
Counsellors can support and reinforce specific behaviours by modelling them for and
with the client. For example, if a goal of the counselling session is for the client to improve
communication skills, the counsellor can model clear and direct communication when he or she
interacts with the client. When the client responds with clear and direct communication, the
counsellor can comment on and support this type of dialogue.
7. Summarizing
People who are in shock or in a safe of anxiety talk very fast, seek more information and
ask a lot of questions such that the counsellor cannot keep pace or absorb all of the reactions.
The counsellor should then interrupt the session and summarize what has been said. It becomes a
time to pause, reflect on what has been discussed so far and to propose a similar or new direction.
A summary puts together a number of the client’s spoken paragraphs, or an entire phase of a
session or may even be used at the end to cover the full session. At the end of each session, the
counsellor should summarize the salient points of discussion and highlight decisions which have
been made and need to be acted on.
Example :
“So far we have discussed safe sex practices and your feelings about adopting some of them.
Do you feel we have completed discussing this topic for now?”
55
SOME COMMON COUNSELLING ERRORS
The principles of counselling arc easy to learn but can be difficult to apply. It requires a
combination of self-knowledge and constant practice to gain mastery over the principles
discussed throughout this Manual. People who understand their own prejudices, have
incorporated die values and attitudes of counselling, are flexible and adaptable, and have
mastered the basic principles are likely to become effective counsellors. However, even
counsellors who possess all these qualities can make mistakes. This could be due to fatique,
acceptance of an old stereotype, a client’s persistent rejection of information or guidance, or
some other cause. Some of the counsellor’s interventions readily support the counselling
process, while others can bring it to a halt very abruptly.
Some common counselling errors to watch out for and avoid are:
1. Directing and leading - controlling rather than allowing and encouraging the client’s
expression of feelings and needs.
3
Judging and evaluating, as shown by statements that indicate that the client does not meet
the counsellor’s standards.
3. Moralizing, preaching, and patronizing - telling people how they ought to behave or lead
their lives.
4. Labelling and diagnosing, rather than trying to find out the person’s motivations, fears and
anxieties.
5. Unwarranted reassurance, diverting a client’s attention from an issue and humouring the
client -trying to induce optimism by projecting the clients problem as minor issue.
6. Not accepting the client’s feelings - saying that they should be different.
7. Interrogating - using questions in an accusatory way. “Why” questions almost always sound
accusatory.
8. Encouraging dependence - increasing the client’s need for the counsellor’s continuing
presence and guidance.
Another important area where errors can occur is in the cultural context and the
background of different clients. It is largely in its use of words, or language, that counselling is
adapted to culture. Communication in counselling takes the form of speech (verbal) or of body
language (non-verbal). A counsellor may sometimes unknowingly speak or behave in ways
which a client from another culture interprets as rude, unusual or even threatening. This may
cause the client to become silent and withdraw from the session. When this occurs, the
counsellor needs to become aware of it, comment on it, encourage an explanation, and changer
adapt the counselling style.
A number of behaviours, listed as supportive and non-supportive, are given in the
following two tables. These are only reference pointsn and it should be remembered that there
will be cultural variations among these in some cultures. Counsellors will need to take note of the
types of behaviour that would be supportive or non-supportive in counselling in their respective
cultures. The counsellor must be secure enough in his/her self-concept to admit unfamiliarity
with a client’s culture (when that is true) and to question the client in order to decide how to
conform to the client’s cultural norms.
56
TABLE 1
Examples of Supportive Behaviour in a Selected Culture
Verbal
™"
Non-verbal
Uses language that the client understands
Uses a lone of voice similar to the client’s
Repeats in other words and clarifies
client's statements
Looks client in the eye
Explains clearly and adequately
Nods occasionally; uses facial experessions
Summarizes
Occasional gestures
Responds to primary message
Suitable conversational distance
Encourages by saying: “I see”,“yes, go on'
Does not speak too quickly or too slowly
Addresses client in a manner appropriate
to the client’s age
Gives needed information
Uses humour or other means of reducing
tension
Does not criticize or censure the client
57
TABLE 2
Examples of Non-Supportive Behaviour in a Selected Culture
Non-verbal
Verbal
Advising
Looking away frequently
Preaching
Inappropriate distance
Blaming
Sneering
Cajoling (persuading by flattery or deceit)
Frowning. Scowling and yawning
’’Why" questions
Unpleasant tone of speech
Directing, demanding
Speaking too quickly or too slowly.
Straying from the topic
Patronizing (condescending) attitude
Being distracted during
counselling is also a nonsupportive behaviour.
niOvJ
'That
i
8M THE wAM,
Do |TeU- ***1
Ate ‘lOU
--------
58
ACTIVITY SECTION
ACTIVITY 1 : Communication Skills
Time : 20 mins
Objective :
The purpose of tiiis activity is to introduce the participants to some essential
communication skills which enhance counselling. The need to pay attention to non-verbal
communication (body posture, facial expression, etc.) and active listening in the initial stage o.
the counselling relationship should be emphasized strongly. The skill of questioning is also
practiced by the participants in this activity.
Procedure:
The trainer asks the participants to find a partner and choose a comfortable place to sit
together. There should be an attempt to sit as far as possible from other pairs of participants, if
the size of the room permits. The pairs are asked to decide among themselves as to which person
will be the “speaker” and which the “listener” for this exercise.
After all the pairs have decided their roles, the trainer instructs the “speakers to choose
any issues/thought/experience that is alive in their minds/lives and speak for 3-4 minutes on the
topic. The “listener” has to just listen and should not use words or non-verbal communication
(facial expression, eye contact etc.) to respond and indicate his/her interest in the speaker s
conversation. The trainer then calls for the speaker to start. After 4 minutes, the trainer asks all
the speakers to stop and requests the listeners to ask the respective speakers 1-2 relevant
questions which seem very important, only based on the speaker’s conversation/comments.
The trainer emphasizes that the questions should be as open-ended as possible and not
begin with a “why” (“why” questions tend to put a client on the defensive as they make him/her
feel cornered or having to justify his/her feelings, thoughts or statements). The trainer allows 510 minutes for the listeners to think of and ask the questions of the speakers. The full group is
then re-assembled and the trainer conducts a general discussion.
Points of Discussion:
♦
For those acting as speakers : Flow did the speakers feel to have someone s undivided
attention and to be able to speak for four minutes without any interruptions?
♦
‘ ‘ the “listener• was listening to them? What did
For those acting as speakers : Did they feel
the listener do to indicate he/she was listening (or, did not seem to be paying attention both kinds of responses are important to explore).
59
♦
For those acting as speakers : Upon hearing the questions posed by (heir listener, did the
speaker in the pair feel that his/her topic or feeling had been understood accurately by the
listener? Did the questions help the speakers understand their own thoughts/feelings?
♦
For those acting as listeners : How did the listeners feel about conveying their interest
only in non-verbal ways?
♦
♦
For those acting as-listeners : How would it have been different if they had been talking
and responding actively from the start?
For those acting as listeners : Was it easy for the listener to formulate the questions? If
no, what were the difficulties?
The trainer concludes by stressing the importance of active listening, relaxed and
attentive body posture and the art of questioning in making clients feel comfortable and
uninhibited.
ACTIVITY 2: Paired Exercise : Paraphrasing
Time: 20 mins
Objective:
This exercise helps participants practice the skill of paraphrasing.
Procedure:
Each trainee should find a partner and choose a subject on which they and their partner
apparently disagree from the list of topics given below. 1 rainee “A can begin by making 1 -2
statements on the subject. Trainee “B”s job is to paraphrase the idea back, without adding any
judgement or interpretation. The facilitator gives a brief explanation of the meaning and use of
“paraphrasing” as a communication skill.
Trainee “A” should then give feedback to their partners whether his/her response was
accurate. If there was some misunderstanding, trainee A should make the correction and then
trainee “B” should feed back a corrected, new understanding of the statement.
60
Once “A" lias understood his/her partner correcllw reverse roles, and have I raince “If'
make 1-2 statements in response to uA’s” statements. Now trainee “A” should paraphrase his/her
partner’s statement. Once both Trainee “A" and “B" are satisfied that they have been understood,
discuss Lite following questions:
As a listener, how accurate was your first understanding of the speaker’s
statement?
♦ How did your understanding of the speaker's position change after you used
paraphrasing and received feedback?
♦. How did your feel at the end of the conversation? How does this feeling compare
to your usual emotional state after discussing controversial issues?
♦. How might your life change if you used paraphrasing at home? At work? With
friends?
♦
LIST OF TOPICS :
L.
2,
3,
4,
Women with HIV infection should not have children
People with AIDS should be allowed to continue work.
AIDS is mainly a problem in persons with immoral behaviour.
Men who have sex with men indulge in abnormal sexual behaviour.
61
ACTIVITY 3: Role Plays : Reflection of Feelings
Time 40 mins
Material: “Client Statement Worksheets" pencils, paper, markers, tape
Objective :
The purpose of this activity is to practice identifying and reflecting feelings. People have
man', emotional reactions to HIV infection. These reactions often affect their behaviour, their
aoilft. :? make decisions, and their relationships with family and friends. However, clients often
do nc'. understand their own feelings. Counsellors can help clients identify these feelings so that
thev co- cope with them better. One way to do this is by naming the feelings for the client. I his
skill i' called reflecting feelings. For example, a counsellor might say to a client, You say
everymung is fine, but; ou look very' sad”. This communications technique can help clients
identif-. their emotions and lalk more freely about what is bothering them.
Procedure:
Ask participants to complete the “Client Statements” Worksheet 1. Instruct.participants
to reaa each client statement, and write down the feeling or feelings which might be behind what
the client is saying in each statement. Next, they are to write down a possible reason the client
mmh: be feeling this way. Give participants approximately 10 minutes to complete the
worksheet. After the participants have finished, write on a large piece of paper the following
formula:
“You feel
(feeling word)
because
(reason)
Explain that counsellors can use this type of statement to identify and then reflect client s
feehrm Explain that it is important for each counsellor to find a comfortable way of expressing
this information. On a separate sheet of paper, write the following alternative phrases:
“You seem
(feeling word)
because
(reason)
because
(reason)
“I wonder if you’re
(feeling word)
Do you feel
______
(feeling word)
because
(reason)
“It seems you are feeling
(feeling word)
because
(reason)
62
Ask pailicipanls to brainstorm other phrases the\ might use to identify and reflect
feelings. Next, ask each participant to choose a partner. One partner should role plax the client
and the other, the counsellor. Explain that participants w ill be practicing identifyinu and
reflecting feelings using the “Client Statements Worksheet T*. The “client” is to "read
statement U 1 from the worksheet. The “counsellor sitould look at his/her own notes on the
Client Statement worksheet and use them as well as the feelings the “Client" is now’ presenting
to respond with a phrase that reflects the “client's” feeling.
W hen this is completed, the client and counsellor switch roles for statement # 2. The
pairs are io continue this process until they have completed all 7 statements on the worksheet.
Encourage participants to try different phrases each time they play the role of counsellor. Ask the
pairs to briefly discuss this activity and give feedback to each other. Once completed ask
participants to return to the large group and ask a lew discussion questions and close the exercise
with a summary of the major points.
Points of Discussion:
♦
♦
♦
♦
How easy and comfortable did you feel identifying and reflecting feelings?
What felt uncomfortable?
Tlow will identifying and reflecting feelings be useful for the client?
What were the differences in identifying feelings in the “Client Statements
Worksheet” and during the live role plays?
Summary of Major Points
♦
♦
Clients give many verbal and non-verbal clues about their feelings without
directly telling the counsellor what they are feeling.
When the counsellor puts the client’s feelings into words and connects the feeling
to a real problem or situation, the client becomes more aware of his feelings. This
will help him make effective decisions about his future.
63
WORKSHEET 1
Client Statements
INSTRUCTIONS : For each client statement write down the feeling or feelings you
think the client may be experiencing and a possible reason why he/she is feeling this way.
1. “I was so sick in bed. My mother was the only person at home. Instead of taking me to
hospital, she went to do business at the marketplace".
F eel ing(s)
______________
Reasons:
2. “Why is my antibody test taking so long? Why isn’t it here yet? You said it would take 2 or
3 weeks. It has already been 3 weeks. Do you think that means it is positive?”
F ee 1 ing(s)
Reasons:
_____ _
3. “Why. in the past when I visited home, everyone used to greet me. Now, since I have been
fured nobody does. Now I know who my true friends are”.
Feeling(s)
Reasons:
__________
4.
“I can’t ask my husband to use condoms. He will refuse. He will think 1 am accusing him of
something or that 1 am unfaithful”.
Fee 1 ing(s)
Reasons:
______ _
5.
“Oh no! How can I have this virus, HIV? I just got promoted. What am I going to do?”
F eel ing(s)
__ ________
Reasons:
_____
6. “I can’t decide whether to have the HIV antibody test. I'm not sure. What do you think 1
should do? I really don’t know ”
Fee 1 i ng(s)____________________________ _ __________
Reasons:
__
7. “1 was using condoms with other girls, but not with my wife. I didn’t think J had to worry
about HIV. I wish 1 had listened to what my wife was telling me”.
Feeling(s)
_____________
Reason s:
____________
64
ACT1V1TY 4: Presentation : Other Communication Skills
Time : 20 mins
Objective:
I'his presentation helps the participants learn about other advanced communication skills
that have not been covered in the exercises. It also puts into focus the real-life stages and
processes of counselling.
Procedure:
The trainer gives a brief presentation, with examples, on the remaining counselling skills
described in the content section.
ACTIVITY 5: BRAINSTORMING : SOME COUNSELLING ERRORS
l ime: 15 mins
Objective:
I bis brainstorming calls attention to the factors that aid counselling and those that may
be non-supportive including personal attitudes, qualities and communication issues. It also
allows for an expression of the participants’ understanding of counselling uptill now.
Procedure:
The trainer makes two columns on a flipchart or black board with the two headings
“Supportive Communication and “Non-supportive Communication”, lle/she asks the
participants to brainstorm and call out those behaviours or altitudes or verbal messages that •
could be seen as “supportive” by a client and the trainer lists them on the Hip chart/board.
I Ic/shc then invites the group to list out (hose behaviours or verbal messages that could
be viewed as “non-supportive” or “negative” by a client and lists these in the second column.
The trainer reviews both the columns and then uses OHPs # 1,2 & 3 to highlight the point
further, bring out elements that may have got left out and review some counselling errors for
participants to avoid.
65
OHP// 1
SUPPORTIVE COMMUNICATION
VERBAL
Using language that the client understands
Conveying interest
- remembering details
- addressing client by name
Conveying acceptance
- non judgemental attitude
Conveying willingness to help
Paraphrasing
- determine basic message
- rephrase in fewer words
Encouraging statements
- ‘yes’, ‘1 sec’, ‘go on’
Reflection of feelings
- locus on feeling and content
Giving needed infoi mation
Addressing client in a manner appropriate to his/her age
Using humour or other means of reducing tension
Speaking audibly, slowly, clearly
NON-VERBAL
Maintain suitable conversational distance
Maintain eye contact
Attentive body posture
Nod appropriately
Use facial expressions
Use occasional gestures
66
OHP #2
NON-SUPPORT1VE COMMUNICATION
VERBAL
Advising
Giving moralistic judgements
Criticizing or blaming
Scolding or threatening
Discussing your personal problems
Interrupting
Imposing your own values
Rejecting
Premature interpretations
Excessive curiosity
Asking question in a direct and embarrassing manner
Forcing unwilling disclosures
Taking sides
Arguing
Controlling
Labelling and diagnosing
Unwarranted reassurance
Not accepting patient’s feelings
Interrogating
Encouraging dependence
Talking too much
67
OHP # 2 (Could.)
NON-SUPPORT1VE COMMUNICATION
NON-VERBAL
Looking away frequently
Inappropriate distance
Looking bored, irritated
Fidgeting, yawning, looking at the watch
Writing while client is talking
Unpleasant tone of voice
Sneering
68
OHP #3
FACTORS RELATED TO UNSUCCESSFUL COUNSELLING
CLIENT RELATED
Totally unmotivated client
Unrecognized psychiatric illness
Overwhelming crisis situation
Limited personal resources
THERAPIST RELATED
Inexperienced
Excessive therapeutic ambitiousness
Pessimism
Unconscious hostility
Voyeurism
COUNSELLING TECHNIQUES
Setting unrealistic goals
Not setting goals al all
Misplacing locus in therapy
Fostering dependency
Emphasis on insight and neglecting behaviour change
Making premature interpretations
Making destructive interpretations
Communicating beyond clients comprehension
Rigid adherence to specific techniques
THERAPEUTIC RELATIONSHIPS
Negative or positive couiitertranslcrencc
Conh ontive, authoritarian style
69
SECTION 3B
COUNSELLING : BASIC PRINCIPLES AND GOALS
INTRODUCTION
Counselling is a special form of interpersonal communication in which feelings, thoughts
and attitudes are expressed, explored and clarified. Counselling seeks to enhance selfdetermination, boost self confidence, and improve family and community relationships and
quality of life.
An integral part of the counselling relationship is to help people achieve the confidence to
make life-style changes. This involves helping people to define for themselves the nature of the
problems they are facing and then make realistic decisions about what they can do to reduce the
impact of these problems on themselves and their family and friends.
It is important to understand that counselling is about helping people, and that, as people
are different, there can be no universal or predetermined method of counselling. 1 lowcvcr, the
need to be supported and to help people explore and make decisions is present in all cultures and
contexts, and some basic aspects of these functions underlie the most effective counselling
programmes.
In counselling, two people who are in no way related to each other meet to resolve a
crisis, solve a problem, or make decisions involving highly personal and intimate matters and
behaviours. The counsellor’s emotional detachment in assessing the client’s case is extremely
important. There is, however, a continuous gradation between detachment and closeness,
between which the counsellor must find the correct balance; this is important in promoting the
well-being and problem solving skills of the client.
Counselling is both an art and a science, a “science” because of its underlying principles,
an “art” because of the blend of the counsellor’s personality, technique and skill. The ability to
form a helping relationship is paramount in helping another individual to gain confidence and
insight and it comes before techniques or technical information in one’s arena of expertise.
So, in addition to technical knowledge about HIV infection, the counsellor must also
build his/her self-knowledge in understanding counselling principles and values, and information
about formal and informal resources. This involves assessing and knowing one s own strengths,
weaknesses, prejudices and values. Many counsellors have to learn to understand their own
feelings in order to be able to work with other people. Self-knowledge is particularly important
when counselling people of different backgrounds or working with resistant and seemingly
ungrateful clients.
Competent counsellors do not have to like all their clients, but should be keenly aware of
their own reactions, feelings and prejudices and should not allow these to inlluence their
counselling. They will also need to decide how ready they themselves are to discuss sensitive
issues and to what extent their own inhibitions will complicate the counselling process.
70
Counsellors have their own needs and motivations, which they need to examine. I hex
should ask themselves, tor example, whether they can honestly assure other people that they will
keep their secrets and maintain confidcntialit} . Will they be able to continue to counsel someone
liiey dislike or whose behaviour offends them? Will they be able to use confrontation and direct
guidance when necessary? Can they be accepting and keep their own prejudices in check? Will
the} be able to maintain professional detachment with clients who remind them of themselves or
someone significant in their own lives?
These are important questions, for the counsellor's effectiveness depends greatly on selfknowledge, self-discipline and self-restraint, and on achieving a balance between warmth and
acceptance, on the one hand, and objectivity, on the other.
ESSENTIAL PRINCIPLES OF HIV/A1DS COUNSELLING
Counsellors have to pay attention to certain basic principles which keep counselling
focused and directed, fhese are helpful in relation to 1IIVI/A1DS as well where a counsellor
works towards preventing spread of inflection, helps people change their behaviour and supports
people affected by HIV/AIDS
Four important principles are described below:
1.
2.
3.
4.
Unconditional positive regard and non-condemning attitude
Trust and confidentiality
Empathy
Time
PRINCIPLES OF COUNSELLING
71^6
r
TCUST Ahi
Coums ecu
CATION
71
1. Unconditional positive regard and non-condemning attitude
In counselling, clients are viewed as individuals with problems and given respect without
judgements or condemnation of their behaviour. Unconditional positive regard relates to treating
a person as special within the relationship, thus building the clients' self worth and feeling oi
being cared for. Counsellors must be non-condemning in their behaviour. I his implies that the
counsellor must not express disapproval of the person, must not apportion blame related to
causes and effects of the problem of infection, or pass moral judgements that the person deserves
punishment for his/her behaviour. This helps the clients feel free to talk about their problems: to
feel accepted and worthy of attention.
2. Trust and Confidentiality
Trust is the basis of the relationship between the counsellor and the person/s being
counselled. Trust improves the working relationship and increases the likelihood that the
individual (or the group) will feel comfortable in discussing his or her problems and will act on
the information provided. It is extremely important that confidentiality be guaranteed, especially
in H1V/A1DS cases, due to the possibility of discrimination against, and ostracism ol. an
individual diagnosed as having HIV infection. The counselling relationship must be built on the
understanding that whatever is discussed will remain a private issue until the client decides
otherwise. Breach of confidentiality is unethical.
However, there may be some instances where the counsellor or health-care worker feels
that confidentiality may need to be broken, e.g. when a client refuses to inform sexual partners of
his/her infection and refuses to use any preventive methods. In this case, a decision may be made
to notify the sex partners without the client's permission. Here, confidentiality is preventing the
adoption of appropriate measures for avoiding the spread of HIV and so it may be necessary to
reconsider the situation. In such cases, the counsellor will be required to make a decision
consistent with professional ethics and relevant law and consultation with supervisors or other
professional colleagues, (consensus statement from the WI IO consultation on Partner
Notification for Preventing HIV I'ransmission, WHO 1990)*.
3. Empathy and controlled emotional involvement
Empathy is more than sympathy, and it may be expressed as a statement of support (e.g.
“I do understand that you are having to go through this pain”). The most basic and significant
counselling skill is the ability to demonstrate empathy with the client. Empathy is the ability to
understand and relate to another person's feelings and experiences. This entails being sensitive
and responsive to him or her without making assumption about the client based upon what the
counsellor thinks he or she would feel. A counsellor demonstrates empathy by listening
attentively to what the client says, what the client does not say and what feelings the client
expresses verbally or non-verbally.
'In
72
The counsellor then communicates io (he client his/her understanding ol feelings,
thoughts and altitudes regarding a particular problem. Sometimes, a gentle silence can be
enough to convey empathy.- To demonstrate empathy, counsellors must be aculei}- aware of their
own feelings and responses so as to be sensitive to the client. They must be able to use their own
emotional responses as clues to understanding the client while also being able to separate their
emotions from their clients. The quality of empath}- is something that is internalised by
counsellors and then expressed on the client's behalf.
The relationship between the counsellor and the person to be counselled is not devoid ol
emotion and is based on warmth, concern and acceptance. Al the same time, to be able to “ptH
oneself in another persons shoes", the counsellor needs to view the situation objectively and plan
realistically. Hence some level of emotional distancing or detachment is also essential, i.e
controlled involvement.
Some examples of empathy Vs. Sympathy statements.
SYMPATHY
EMPATHY
J) I appreciate what you are going through.
1) Poor you! Its really sad that this
should have happened to you.
2) I understand how you must be feeling.
2) 1 know how you feel, 1 was in the
same situation once.
3) I can understand that you are feeling
3) Your boss is really being mean and
unfair to you - it is very horrible of
him.
angry with your boss.
4) I accept that you are very scared and
unsure if you'll be able to deal with this
situation right now.
4) There, there, don't be scared! You are a
strong, grown-up human being -1 am
behind you and will help you
however I can.
5) Just sitting in silence while the patient
expresses his/her sorrow by crying; it is
alright to let him/ her fully feel whatever
he/she is feeling and just be there with the
person.
5) 1 am feeling very sorry for you please don’t cry - everything will be
alright.
4. Time Management
Providing the client with time and recognizing that change via counselling takes time and
is important from the start. Much of the content of counselling, for e.g. helping clients to absorb
news about the diagnosis of AIDS, cannot be rushed. The concerns that are raised are complex
and sensitive and need time to be considered and dealt with. Time is also necessary to ena e
rapport and trust to develop, both of which are indispensable. Some people may require many
sessions before they start to acknowledge the need for examining their own attitudes/behaviours.
• I-
73
become open io beha\ iour modification and for decision-making on life-style issues. I bus time
should be given at every stage to build rapport, to clarify issues, to externalize feelings, to
internalize implications, to make decisions and to implement behaviour change.
GOALS OF HIV/A1DS COUNSELLING
The overall duration of counselling must be governed by the needs of the individual.
Similarly, while the content of counselling may also vary, there will always be a number of goals
for a counsellor to work towards in preventive and supportive HIV/AIDS counselling :
1.
Forming a helping relationship
People who have just started working as counsellors often anxiously look for techniques
to help them to deal effectively with other people. Techniques are helpful, but they are
secondary to the ability to form a helping relationship. This is established and developed not by
technique, but by the attitudes and qualities of the counsellor.
Counselling skills can be learned and effectively used only by people who are genuinely
concerned about others. Concern or lack of it is conveyed both verbally and non-verbally.
Unless the counsellor can demonstrate to clients a genuine concern about what is happening to
them, counselling will fail.
The helping relationship and the development of counselling skills also depend on a
feeling of commitment to the work to be done. Counselling in relation to HIV infection is both
intensive and difficult. It requires counsellors to face their own mortality every day. to deal
regularly with loss, and sometimes to accept behaviour they may find distasteful. Without
commitment, a counsellor will neither be able to provide the necessary support nor work through
moments of despair and stress.
A helping relationship is in some ways like a friendship, but differs in many other ways,
'fhe communication is focused and directed. There is a built-in power imbalance because the
person with the problem has to ask for help, and the counsellor has the power to provide it. The
counsellor makes controlled use of this power, but keeps it in check by constantly remembering
and trying to imbibe the values and attitudes that are the foundations of good counselling.
As a helping relationship is formed, the counsellor should pay attention to the setting in
which the client or family is interviewed. Is it at home? In a clinic office? In a hospital room?
In a public place? Each of these settings will call for different responses from the counsellor.
Each will influence responses from those being interviewed. A supportive, helpful relationship
cannot develop if the counsellor does not acknowledge both the gravity of the problem and the
context within which discussions about it take place, for example, trying to ask questions about
sensitive personal topics in a crowded clinic waiting-room obviously calls for an approach quite
74
dilleienl horn asking lhe same qncslion in privaie Allcnlion h» ( (mlrxl is impoii.-mi in .mx l<>i111
ol counselling, but is particular!) iinporL it in counselling in relation to HIV infection because ol
the severe stress and stigma associated with the condition.
2. Clarifying and addressing problems
Recognizing and clarifying problems calls for sensitivity during counselling. Counselling
depends on a clear definition of problems, yet counsellors sometimes neglect the client s
definitions and view points. One reason may be that new counsellors feel insecure and
embarrassed about asking the kinds of questions needed to clarify the client's view of the
problem.
In all counselling, and especially in problem-solving counselling, the counsellor must be
able to recognize the real problem. Problem recognition includes:
□ defining the problem as the client sees it;
□ determining why the client is seeking help now;
□ ascertaining the duration and effects of the problem;
□ recognizing what the problem means to, and how it will affect, the client;
□ repeating to the client the counsellor’s interpretation of what has been said;
paraphrasing, i.e., expressing its meaning in different words; checking and clarifying
to ensure that the counsellor is interpreting correctly;
□ summarizing the counsellor’s assessment of the problem and its effects on the client;
□ finding out how the client is coping now and has coped with serious problems in the
past;
□ being aware of the client’s feelings about the problem and about asking for help '
outside or from his/her circle of family and friends or from religious advisers;
□ analyzing the problem in order to reduce it to manageable proportions. To the client it
may appear so complicated as to be insoluble. The counsellor can show that it has a
number of components or sub-problems, which can be handled separately;
□ agreeing as to the problem (or part of a problem) to be tackled. This may be what the
client considers most important or suitable to begin with, or what the counsellor finds
most important or amenable to change.
Accurate and early identification of problems, and also putting them into a realistic time
scale, can promote self-help and coming to terms with fears and concerns about family affairs.
Planning for the family, for example, in the event of chronic illness or death, is important,
especially where children are involved.
75
It is also important to determine whether and how the client will be able to manage new
information in limes oi physical or emotional stress. A periodic, sensitive appraisal of the
person’s ability to cope with the latest diagnosis and prognosis will help. Il is equally important
to regularly review the effect that developing physical illness may have on an individual’s ability
to cope emotionally and intellectually with day-to-day decisions and behaviour.
3. Establishing goals
Counselling always has a purpose. The counsellor’s task is to determine what the
purpose and goals are so that counsellor and client can agree on what is to be achieved, and
check frequently on progress towards achieving them, or whether they need to be changed.
The goals of counselling in relation to HIV infection are necessarily governed by the
chronic nature of the infection and its possibility of ending in an early death. With this
reservation, counselling goals must be set which are related to what the client hopes to
accomplish and what is to be expected of support systems. The goals to be achieved will depend
on the nature of the problem.
Goal-setting includes:
(a) finding out how the client would like the problem Io be solved;
(b) determining what the client thinks should be done to manage the problem;
(c) clarifying what the client expects from counselling;
(d) discussing what goals mean to the client;
(e) describing the help the counsellor can offer, giving realistic hope for change or
assistance, and discussing the reasons for any limits on help;
(I) establishing long-term and short-term goals;
(g) stating the counsellor’s commitment to working with the client.
4. Providing information on alternative resources
Any information provided through counselling (c.g. about HIV infection, risk reduction)
should be consistent both in content and over time. In HIV/AIDS counselling, the counsellor
therefore needs to have a clear understanding of the “facts” about HIV infection and diseases.
Where clients arc being seen over a period of time and as part of an integrated approach to health
care, the counsellor should maintain close and confidential liaison with other health workers
providing health care to that person. All counsellors should have access to updated information
about 1IIV and its management, so that questions from clients can be answered as accurately as
possible. Uncertainties must be acknowledged so that new information can be introduced in a
consistent framework.
76
7
As HIV infection progresses, different medical, psychosocial, and welfare needs emerge.
Information should be provided on the different types of facilities, self-help groups, communit}
resources, and medical support that arc available, as well as new changes in life-style (hat can be
made to accommodate emerging needs. Information on alternative behaviour that includes the
promotion of safer sex or avoidance of pregnancy, for example, should be accompanied by
information on where to obtain condoms and on contraceptive methods.
5. Selection of i cjilislic nllei unlives
Help should be given in bringing about changes in life-styles only after a review of the
family background of the person concerned, including such characteristics as education, culture,
religion and financial situation. Counselling should help people to select alternatives and goals
that are feasible and likely to provide the personal satisfaction and support needed in adopting
particular behaviours. 1 his may involve introducing the person being counselled to groups of
people who have themselves been through similar experiences, (i.e. either they or their partners
are HIV-infected) particularly if they are willing to provide support, such as peer-groups of
homosexual, drug-using, or heterosexual people.
6. Stimulation of motivation and decision-making
When people feel that they have greater personal control over their lives and their
decisions, and when their life-skills, self-respect, and confidence arc increased, their motivation
to make changes will become greater. Positive encouragement of steps taken, attempts made,
and a sympathetic but realistic appraisal of why they arc or are not as successful as expected are
important. Maintaining a respected status within the community is also likely to be a source of
motivation. Explaining to clients that the actions to be taken or already attempted will help loved
ones, may also be a critical source of motivation for them. 1'he counsellor works to increase or
stabilize motivation so that the stress of the discovery of having been at risk of, or of having HIV
infection or AIDS, can be reduced, and a sense of control enhanced.
Supporting a client’s level of motivation is a permanent feature of counselling 1 he
counsellor must explore (and where necessary, attempt to change) attitudes which weaken
motivation in the lollowing areas:
O
o
The client’s self-concept and self-evaluation. Is the “sell-concept” or sense of I
one of strength or weakness? Of worthiness or unworthiness?
Level of self-knowledge. I low conscious arc clients of their own thoughts, feelings,
fears and actions?
o
Self-protection. I low do clients react to seemingly threatening information or
events? Denial is a common reaction.
77
O Isxplanation. I low do clients interpret what is happening. Io them and whv il is
happening? Is the cause seen to be within or outside the sell?
O Anticipation. I low do clients view the future? What cherished hopes or ambitions
must be sacrificed?
7. Helping clients to develop competence
A key counselling skill is to help others to regain a sense of competence and skill. For
example, counselling must include easy “how-to-do-it" instructions (or development of skill) on
prevention of contamination and infection, use of condoms, and maintaining caring relationships
during a crisis.
The counsellor must always focus on the basic behaviours needed to reduce risk of
infection and protect others, and in learning how to persevere in the face of I II V infection or
terminal illness. This last point is very important. It might be asked: why put so much effort into
teaching people how to deal with an incurable illness? Someone who learns the skills of selfcare will more readily sec the need of preventive or safe behaviour and accept treatment as well
as continue an active life.
Many HIV-infected people show signs of psychological distress. They may be unable to
think clearly about their problems or to decide what should be done. They may withdraw
socially, feel helpless and seem completely unable to make decisions or solve problems.
Counsellors working with clients to help them to re-establish their sense of competence
and control must ensure that client’s goals are realistic and feasible. Persons with HIV infection
or AIDS will frequently fall back on a form of denial which convinces them that if they merely
try harder they will recover; they therefore set too high and unattainable goals which, instead of
being powerful motivators, become sources of despair.
8. Recognising and diagnosing signs of psychological distress and providing support
The counsellor must be skilled in recognizing and assessing signs of psychological
distress and incapacity. Distress is a normal reaction to fearing or learning that one is 111Vinfected. It can be alleviated only by expressing and discussing it, and by support. If distress
persists, other, formal psychological interventions may be necessary. At times of extreme
despair and anxiety, providing emotional support anil reassurance should be the main locus.
Helping maximize support for the client and other family members from with the family, friends
and community members wherever possible must also be undertaken by the counsellor.
78
In suinmary, counselling sis si process csin:
(a) ensure passing-on of correct information;
(b) provide support at times of crisis;
(c) encourage change when change is needed;
(d) help clients locus and identify for themselves their immediate and long-term needs;
(e) propose realistic action suitably adapted to different clients and circumstances;
(f) assist clients to accept and act on information on health and well-being and
(g) help clients to be well-informed and to appreciate the technical, social, ethical and
legal implications of HIV testing.
ROLE OF THE COUNSELLOR
In preventive and remedial therapy, in the Held of HIV/A1DS, the counsellor performs
certain activities which comprise of various roles. Each role is designed to achieve a certain
goal. For example, the counsellor as an educator provides opportunities for learning skills and/ or
information for effective role performance. Some of the roles are more directive and prescriptive
(viz. pre-test/post-test and risk reduction counselling) while others, i.c. the clinical role is non
directive, reflective and process oriented, (viz. supportive counselling). IIIV/AIDS counselling
differs from other types of counseling or psychotherapies; in that it is essential that the
counsellor educate and give specific information to the client as well as prescribe pi evention
behaviours.
The IIIV/AIDS counsellor perforins sevcrsil roles depending on (lie nature of counselling
required :
(i) Health Educator and referral - source Role
(ii) Advocacy Role
(iii) Clinical or Therapeutic Role.
The details of each role are, given below.
(i) Health Educator and Refcri al-Sourcc Role:
This is one of the primary roles of the I IIV/AIDS counsellor to help clients function more
effectively by learning new information or acquiring new social skills. I he client may, lor
instance, learn to use the condom and practice safe sex techniques or reduce other risk
behaviours. The counsellor engages in this role with a single client or groups ol clients/
significant others/any other person or persons concerned kvith the problem.
The learning may be organized at the formal level. e.g„ through workshops and training
programs, or at an informal level, at the bedside of the client or with the family members during a
home visit The type of information to be given will depend on the profile of the client,
family and significant others. An illiterate client will need specific concrete mlormation
79
prescnlcd in a simple, visual way (cj’. Hip charts. Hash cards etc.). Social skills max be Icamcd
at an individual or group level. In this role, the counsellor also recognizes the need to refer the
clients to other social sen ice agencies and institutions lor alleviation of distress and achievement
of life tasks. In making referrals, the counsellor provides information and prepares the client to
use the other resources for e.g. refer for. HIV testing to a hospital. In case of an anxious or
fearful person, support by accompanying the client or preparing a family member to accompany
the client becomes necessary. The clients from low economic backgrounds could also be helped
with the costs of transportation.
(ii) Advocacy Role:
This role involves securing or protecting an existing right or entitlement for one or more
clients. Case advocacy is used to secure and protect entitlements of a client. Class advocacy is
used to secure and protect entitlements for a group of clients that share a common status and
problem.
Under the Consumer Protection Act of 1986, once a person with AIDS (PWA)
approaches the hospital or health center, (s)he cannot be refused treatment. The counsellor should
ensure that she/he receives prompt attention and care. Where the goals of the client and the social
system are common and where minimum change is needed, strategies of problem solving,
educating and persuading would be useful. For fundamental change, the counsellor needs to use
negotiating and bargaining strategies as in the case of resistance in accepting seropositive
persons, for care, by nursing staff who are afraid of getting infected.
However, where there is a high level of conflict and risk-taking, for instance, change in a
pending Bill for mandatory testing, pressure tactics would be necessary. The latter would cover
techniques such as, using the media for disclosure of the human rights problem, public and
administrative hearings and, if necessary, legal action. Formation of action or task groups
becomes essential when the right or entitlement affects several people together. A government
ban on homosexuality, for instance, would create tremendous problems for counsellors as such
harmful initiatives would force such persons to remain underground and to not seek help. The
counsellor generally adopts strategies that are collaborative and least confrontational, and Only
later moves onto the more conflictual ones if previous methods fail.
(iii) Therapeutic or Clinical Role :
This is a major role, most often played by the HI V/AIDS counsellor with the objective of
modifying attitudes, feelings, and teaching coping behaviours that affect the clients’ functioning.
This role is performed in agency settings or in private practice.
This role is most effective during supportive counselling for HIV infected individuals,
persons with AIDS and their families. The main focus is on allowing clients to explore and
express their feelings, gain insight into their inner motivations and behaviour patterns and
working towards positive self-growth and effective adjustments in their relationships. The
counsellor is non-directive and more focused on the empowerment of the client to make his/her
own decisions and attitude shifts.
80
A wide varicly ol thcrapculie approaches cxisl which counsellors can use lor supporlivr
counselling, depending on (he specilie needs and issues ol each client. I he main ones aie :
psychoanalysis, cognitive therapy and Rational Emotive Therapy, client-centered and gestalt
approaches, family therapy, transactional analysis and existentialism. No matter which
therapeutic approach a counsellor adopts the essential principles, goals and basic communication
skills outlined in this chapter will remain the same in the context of HIV/A1DS counselling.
STAGES IN COUNSELLING
A counselling relationship with each client has a beginning, a middle and an end, and
when it extends beyond just one session - contact for pre-test and post-test counselling. Even
where the client and counsellor meet for only two sessions, one can structure the sessions so that
there is a logical, natural progress from the beginning to the middle to the end stage. While
counselling cannot be reduced to a formula, since each client is unique, certain components are
universal, depending on the stage. The duration of each stage will depend on the clients’ needs
and readiness to move further in the counselling process.
Beginning Stage : Forming Rapport, gaining trust and defining the needs, roles and
boundaries
At the beginning, clients may react in many different -sometimes contradictory ways.
Although they may feel that they need help, some begin with deep distrust. 1 hey wonder whether
the counsellor will like them, or may even reject them because of their condition or concerns.
Some direct their anger and frustration at having risked infection or having become infected
towards the counsellor, sometimes even questioning the counsellor s competence. I he
counsellor must accept these feelings and encourage their expression, setting limits only on
verbal or physical abuse.
The counsellor should also encourage building ol trust by his/her style ol asking
questions, particularly those about risk practices. The counsellor must explain clearly why it is
necessary to inquire about intimate personal behaviour and, in the case of a reluctant client, probe
the reasons for this reluctance and give realistic reassurance that the information is necessary.
Counsellors in training may find it helpful to consider counselling as story-telling. All
clients have unique stories which they want to tell in their own ways. The counsellor may find
the stories disjointed or rambling but must let them continue, while being objective in the
assessment of the contents.
V
If there is hesitation or fear, gentle prompting by the counsellor is usually enough to
encourage a client to continue (Sec also Communication Skills). Typical “prompts include:
“And then whal happened?”
Whal did you feel when you were told ...?”
81
Such ‘‘prompts" should be used very little at first, and primarily to clarilX the story.
Explaining and making clear to the client the roles and boundaries of the counselling relationship
is an essential part of counselling as this is a relatively new profession in India and many clients
may be experiencing counselling for the first time. By dc-myslifying the counselling process,
counsellors help minimize whatever expectations or anxieties people may have brought with them
about the process? Establishing and clarifying the client's needs and goals, with the most urgent/
important ones being addressed first, followed by the more general and long-term issues, needs to
be done before ongoing counselling can begin.
As the next step in this stage, the counsellor should take a case history, in effect to help
the client tell his/her story in a different, and more orderly way. The history will include basic
personal data as well as information on a client’s beliefs, knowledge and concern about HIV
infection. With a ven- hesitant or anxious client, the counsellor may begin with straightforward
factual questions. With clients who seem at ease or ready to talk, history-taking may begin by
exploring what they know and feel about their problems. By gearing history-taking to clients’
needs and readiness to discuss personal matters, the counsellor begins to establish trust and
rapport with the client. History taking is a process and does not happen in one session.
The personal history obtained by the counsellor could include:
O name and other relevant personal data;
o marital status or involvement in an intimate relationship;
o number of children and where they live;
o state of health of spouse, partner, other intimate friends, children, family;
o occupation and source of income;
o recent health history;
o name of personal or family doctor or medical service;
o educational level/ability to read and write;
o name of person to contact if necessary.
While taking this history, the counsellor should note how the client speaks (shy, hesitant,
direct), relates to the counsellor (looking away, angry, engaged), and whether the client finds it
easy or difficult to communicate. The counsellor should aso remember that confidentiality of
records needs to be maintained. Therefore, all notes and sheets related to clients should be kept
under lock and key or in a sale place.
The other type of information the counsellor needs is the attitudinal and behavioural
history. In this part of history-taking, the counsellor should seek answers to the following
questions:
o What does the client want and expect from the counsellor and the place
where counselling is done?
O What is the basis for the client’s worries?
O Have any signs or symptoms of illness appeared?
82
o
II they have appeared, how long have they been evident?
O
What has the client done so far about seeking help or treatment?
O
What does the client believe caused the illness?
O
What arc the client’s fears?
O
What kinds of risk behaviour, if any, are involved?
O
if there has been risk behaviour, has it been changed?
O
What reactions does the client expect from others?
The counselling approach must be geared to the client’s emotional state and readiness to
face the facts. A factual history is usually less threatening, and a helpful entry point for assessing
the client. In summary, the counsellor should use history-taking as a means of beginning to build
a helpful relationship; the questions being directly related to the client’s concerns and, at the
same time, geared to client’s needs and their ability to use the available resources.
With the information obtained in the beginning phase, the counsellor begins to work with
the client to devise a plan of action. This usually concerns examining current beliefs and highrisk activities, changing behaviour and attitudes, seeking health care and building a support
system.
Middle stage : Ongoing, supportive counselling.
When the client recognizes that the counsellor is available, can be trusted, will provide
information, guidance and support, and will also foster independence, counselling enters the
middle stage. 'This is concerned with refining and implementing a plan of action, which may be
focused on maintaining safe behaviour to prevent infection, or to keep it limited to the client.
I hc focus is on enabling the client to make change and move towards change. In other situations,
where infection is found, discussions with the family, friends and others may be necessary
regarding prevention of further transmission, future care, financial affairs, and the needs of
children and the spouse or partner may be the other issues that require to be discussed.
1 he most difficult and critical task at this stage is often to motivate the client to re
establish contact with the family or explain to them how the infection occurred. I his process of
ongoing counselling consists of supporting and sustaining work on the selected pioblems and
monitoring the progress towards mutually decided goals. Although fear and anger are most
intense in the beginning stage, they will not be fully resolved. I he counsellor should support and
encourage their expression in the middle stage. In case the counscllcr notices their absences
denial and consequent inhibition of independence and decision making is indicated.
83
End staj’c : Closure or ending the counselling relalionsliip.
As plans are developed, and carried out. the counsellor should check regularly to ensure
that the client has actually performed the tasks that need to be done. Kesistance to change is to
be expected, exhibited by a failure to undertake agreed tasks. After the client has shown
willingness to participate in formulating plans and has carried them through, counselling enters
the end stage. This is often very difficult for people who have worked closely with a counsellor
on intense leelings and fears. The relationship between the counsellor and client may then
become correspondingly intense. Despite the need to remain objecti\ e. the counsellor may
experience some feelings of attachment for the client. To the client, tire counsellor may seem to
be the only one who really understands and the thought of ending the counselling relationship
may be painful.
For inis reason, the ending must be carefully planned. The client has often suffered many
losses and. although functioning adequately, he/she may feel unable to carry on without the
counsellor’s help. The counsellor may increase the intervals between visits so as to let the client
try and be independent while knowing that the counsellor is still available. During this stage, the
counsellor also needs to help the client examine the quality and strength of his/her personal
support networks, encourage him/her to build a good support system among family and friends,
as well as provide referrals/linkages with any self-help groups active in the city with whom the
client may be able to identify. The client must be assured of being able to return to
counselling whenever this is necessary.
The counsellor should end the relationship only when it is certain that:
(1) the client is maintaining the necessary changes in behaviour;
(2) can cope and adequately, plan for day-to-day functioning; and
(3) has a support system (family, friends, other intimates, support groups, etc.).
Tasks of the Counsellor at each stage.
In the beginning (or engagement) stage, the counsellor should:
O listen carefully and non-critically;
O respond to signs of crisis and begin helping the person to express feelings an
regain control;
O explain the relevant facts about the prevention of HIV infection, the control of further
transmission of HIV-infection, and AIDS;
o discuss the advantages and disadvantages of antibody testing if this is under
consideration;
84
o whether or not the client is infected, emphasize the absolute need for hehaviouial
change in case of high-risk behaviour;
o identify all the personal, family, social, economic and other problems that may be
associated with the client’s condition;
o assess the client’s capacity for using information and counselling and together select
problems on client and counsellor will work;
o establish sliort-lcnn and long-term goals.
In the middle (or action) stage, the counsellor should:
O clarify whether the client is I HV-positive or negative or whether a diagnosis of AIDS
has been made and discuss related problems;
O continue to provide emotional support and act as a link to resources;
o
support the continuing expression and discussion of feelings;
O help the person to move towards acceptance and control;
O make a plan of action with regard to the selected
problems and goals;
O support and sustain work on the selected problems;
O monitor progress towards goals and modify them as necessary;
O promote the continuation of changes in behaviour.
Finally, in the end stage (contacts may carry on for a longer period, but with greater intervals
between meetings), the counsellor should:
O prepare the client for a change in the counselling relationship;
O support the maintenance of behavioural changes;
o help to handle any continuing problems associated with the client's condition in the
family or work place;
o reassure the client as to continuing interest and availability of the counsellor;
o if AIDS has developed, review plans for the management of illness, care of survivors,
etc.;
o make sure that all needed and available resources (social, tinancial. medical) have
been identified and arc being used, or will be used when needed.
85
ACTIVTY SECTION
ACTIVITY 6: Brainstprniing: What is counselling?
Time: 25 mins
Objective:
Fhe purpose of this activity is to help trainees understand what counselling means.
Procedure:
The trainer starts the session by asking the trainees what they mean by counselling,
keeping a brief note of the responses on the flipchart. Allow 10 minutes for the brainstorming.
Using these descriptions as a base, the trainer evolves an acceptable definition of
counselling and puts up OHP tt 4, to give a general definition of counselling and an introduction
to H1V/A1DS counselling. Hc/she highlights the difference between advice-giving and
counselling.
ACTIVITY 7: Presentation cum Discussion
Time: 1 hour: 30 mins
Materials:
(a)
(b)
OHP, transparencies and coloured markets
Flip charts
Objective:
'Hie Purpose of this activity is to help the trainees understand the principles and goals of
H1V/A1DS counselling, as well as the role of the counsellor. Every counsellor interaction is
based on certain principles of counselling. In HIV/AIDS counselling, the principles of
acceptance, non-condemning attitude and confidentiality arc very essential to the establishment
of a trusting rapport and relationship with the affected person/s/groups. In this activity, we will
learn in detail the principles which are pre-requisite to any counselling process.
Procedure:
The facilitator should discuss the essential principles of I11V/AIDS counselling in detail.
With each principle, give an illustration. For instance, while using OHP # 5 point out that il a
nurse responds to a patient by saying “1 am so sorry that you arc feeling like this but what can I
tell you?” ask the trainees to answer whether this sentence conveys sympathy and empathy.
86
Next, go over the goals ol lllV/AIDS eoonselling and the role ol the counsellor with the
help of OHP ft <>. Lncourage the trainees to ask questions throughout the presentation. I Ise a Hip
chart to maintain a ‘PENDING TRAY’ of issues arising from the questions. Finally present
OHP U 7 to illustrate the three stages in counselling. Conduct a hricl discussion on how the
counselling relationship is initiated between a counsellor and a client, the vat ions stages that
follow and how various communication skills (previously covered in this module) arc important
and useful at each stage. During this discussion, it needs to be emphasized that time and attention
should be given to each stage in the order that it occurs, so that the client understands what the
goals arc at each stage. In the Inst 20 minutes, take up the issues in the ‘pending tray’ Im
discussion. II the trainer is unable to complete, prioritize with the trainees and leave the icsl lor
the next session as there may be similar issues when discussing the process and techniques ol
H1V/A1DS counselling.
S7
OHP #4
COUNSELLING IS A SPECIAL FORM OF
IN TERPERSONAL COMMUNICA HON IN WHICH
FEELINGS, THOUGHTS AND A 1111 UDES ARE EXPRESSED,
EXPLORED AND CLARIFIED.
HIV/AIDS COUNSELLING HAS TWO GENERAL OBJECTIVES:
(1)
Tq prevent HIV infection by advocating and motivating
behaviour changes and lifestyle changes.
(2)
To piovide psychosocial support to those ah eady
infected/affected by HIV/AIDS.
88
/ •
OHP #5
ESSENTIAL PRINCIPLES OF HIV/AIDS
COUNSELLING
1.
Unconditional positive regard and non-condemning attitude
2.
Trust and confidentiality
3.
Empathy and controlled emotional involvement
4.
Time management
I
89
/
OHP #6
GOALS OF HIV/ATDS COUNSELLING
These will vary, but they include:
1.
Forming a helping relationship.
2.
Clarifying and addressing problems.
3.
Establishing goals.
4.
Providing information on alternative resources.
5.
Selection of realistic alternatives.
6.
Stimulation of motivation and decision-making.
7.
Helping clients to develop competence.
8.
Recognizing/diagnosing signs of psychological distress
and providing support.
90
OHP #7
STAGES IN COUNSELLING
1. BEGINNING STAGE - Forming rapport, gaining trust, definition and
understanding of roles, boundaries and needs.
2. MIDDLE STAGE - Ongoing, supportive counselling and goal setting.
3. END STAGE - Closure or ending the counselling relationship.
91
SEC no IN 3C
HIV/A1DS PREVENTIVE AND SUPPORTIVE COUNSELLING :
OBJECTIVES AND METHODOLOGY
PREVENTIVE COUNSELLING : RISK REDUCTION , PRE-TEST AND POST-TEST
COUNSELLING
Introduction:
HIV/AIDS counselling has two general objectives:
to prevent HIV infection and its transmission to other people;
(1)
to provide psychosocial support to those already infected/affected.
(2)
In order to prevent HIV infection, the chief features of counselling that come to the
forefront are risk-assessment, risk-reduction and prc-lcst/post-test counselling. Supportive
counselling and crisis counselling are the main approaches used when providing support to HIV/
AIDS infected persons and their families.
Keeping these two broad categories of HIV/AIDS counselling in mind, one can clearly
see that counselling would be recommended for the following people/cases :
O
O
o
o
Those seeking help because of past or current risk behaviour and have heard about
HIV/AIDS;
Those being tested for HIV (pre-testing and post-testing);
Those not seeking help but practicing high risk behaviour;
Persons already identified/diagnosed as having AIDS or being infected with HIV. and
their families or significant partners.
HIV/AIDS counsellors play a key role in helping individuals assess their risk ol HIV
infection and bring about risk reducing behavioural changes. This should take place across the
country, irrespective of whether facilities for testing exist or not. In a developing country like
India, it will take a long time before opportunities for voluntary testing can be made available. It
will take even longer for the common man to become aware of the need to utilize it even when
available. It is therefore imperative that wherever possible, people with basic counselling skills
are available to counsel and evaluate those at risk and counsel them towards safer behaviour
in order to prevent the rapid spread of the HIV/AIDS epidemic, it is essential that there
be adequate dissemination of information related to HIV/AIDS in the community. However, it is
also seen over and over again that information per se does not lead to behaviour change. Hence
it is important that a large group of workers from varying sections of society (Health personnel,
teachers social workers etc.) use basic counselling skills to help people identify their own risk
and appropriately change behaviour. This should also take place during pre-test and post-test
counselling sessions.
92
The How of behaviour change proceeds like this :
Behaviour change
Attitude change
Inforniation/Education
While doing risk assessment, risk reduction or pre-test/post-test counselling, the counsellor
should keep in mind the natural stages the client’s thinking and reactions will go through before
behaviour is changed. These are :
UNAWARE
I
AWARE
''
I
~~
CONCERNED
r" 1
UNCONCERNED
I .... ~J__
KNOWLEDGEABLE & INFORMED
I
EXPLORE MOTIVATION & ATTITUDE TO
CHANGE
r
—
zi
NOT
MOTIVATED
TO CHANGE
MOTIVATED TO CHANGE
I
- --
----- 1________
NOT READY TO CHANGE
READY TO CHANGE
BI
TRIAL OF NEW BEHAVIOUR
I
REINFORCEMENT & SUCCESS
OF NEW BEHAVIOUR
---
1
DISCOMFORT & BARRIERS
TOWARDS NEW BEHAVIOUR
___________
SUSTAINED BEHAVIOUR CHANGE
Risk assessment and risk-reduction counselling
Risk assessment and risk reduction counselling is an interactive process between
counsellors and clients in which counsellors function more as health educators who provide clear
and simple information, clarify misinformation, and assist in decision-making and
implementation of behavioural changes. Due to the intimate, and often taboo, nature ol nsk
behaviours, counsellors need opportunities to practice asking exphat questions about sexual and
drug use matters while noting their own reactions, values and attitudes, so that they become
comfortable in talking to clients about these issues.
93
'I he process of risk assessment involves bringing u person to the undcrsliindmg llinl I IV
poses a personal threat as a result of his or her behaviour. Education with counse ling can ic p
people break through their denial and come to terms with their potential risk. In this context,
counselling is directive and information-oriented.
The counsellor assists the individual to recognize that, although HIV is a personal threat,
it can be avoided bv adopting safer behaviours. Once this message is internalized, the counsellor
helps the client decide which behavioural changes arc needed and how to implement them.
HIV/AIDS counsellors face considerable challenges in helping people to assess their risk
and reach decisions about the changes they are willing to make to reduce it. Changing sexual
and drug use practices, even in the face of danger, is no easy task.
The goals of a risk assessment counselling session are to help the client,
o
O
Personalize his or her risk of HIV infection by recognizing that it is a personal
threat.
Assess his or her current and past risk of HIV infection.
At the beginning of the counselling session, it is important to discuss the following:
o
o
o
Discuss the importance of assessing the risk of getting HIV so that the disease
can be prevented. Explain that in order to do this, explicit sexual behaviour and
substance use. including behaviours which may be culturally considered subjec s
taboo subjects must be discussed. Explain that the purpose is no o i
assumptions about or judge a person’s behaviour but rather to prevent the person
becoming sick or transmitting HIV to others.
Explain the necessity of reviewing all forms of risk behaviour with each
Exphihi*the specific area for HIV risk assessment (Table 3 below).
BBLEJ
Assessment of Risk
Frequency and type of sexual behaviour and specific practices,
1.
in particular, high-risk practices, such as vaginal and ana.
intercourse without using condoms, unprotected sexua
relations with prostitutes, and drug injecting individuals.
Being part of a group with known HIV prevalence or with
2.
known high-risk life-styles, e.g. injecting drug users, male and
female prostitutes and their clients, prisoners, homosexual and
bisexual men.
3. History of blood transfusion, organ transplant, or
administration of blood or body products.
Exposure to possibly non-sterile invasive procedures, such as
4. !
tattooing and car piercing.
94
Assess lhe client's knowledge oI how IIIV is transmitted and claiily an\
misinformation.
Ask the client to assess his or her current and/or past high risk behaviours.
Ask lhe client to assess his or her risk of IIIV infection. I liscuss any concerns and
o
O
O
clarify misconceptions.
Summarize the discussion about the client’s risk of HIV infection, leading to
o
o
discussion about risk reduction.
Acknowledge the discomfort and embarrassment the client may leel in discussing
explicit sexual behaviour and substance use openly. Reassure them that these are
o
normal reactions.
Explain that the client will be asked to reveal very personal and explicit
information that is not normally discussed with others, and that confidentiality
will be maintained.
It is difficult to clearly separate risk assessment and risk reduction as the first
pontaneously flows into the second. In effect, risk reduction counselling carries forward the
s
process begun by a risk assessment session to lhe next stage.
The chief points to cover while talking about risk reduction:
Recognize that HIV transmission is avoidable.
Identify behaviour changes that will reduce the client ’s level of risk of eontracting
O
o
O
o
Q
or transmitting HIV.
.
r .
Plan behaviour changes. Changing sexual and drug use behaviours is dilficult.
these are slcp-by-step changes which take time, effort and commitment.
Develop strategies to overcome potential obstacles in implementing and sustaining
Evaluate the success and reinforce positive changes. II the client is available lor
follow up, it is worthwhile to see how much change has occurred and encourage
the positive action that has taken place.
PRE-TEST AND POS T-1 ES I' COUNSELLING
and related matters.
|„ some places facilita for testing are not readily
effort should be made to emphasize pieventiye eolinsL
“’.X'Xal
iaintajning of low-risk behaviour where
”* 5l,pp"‘are
vitally important in bringing about and maintaining behaviomal change.
95
Both die pie-test and post-test counselling sessions should accompany testing - or the
decision not to be tested. The information given at these sessions can be reinforced by providing
written material.
However, in reality, no pre-test counselling is usually provided and the first contact
a counsellor has with a client is after the test has been done and the result handed over to
the counsellor. Thus, it becomes necessary for the counsellor to cover the main issues of
pre-test counselling (See Table 2) before disclosing the test result and dealing with the
client’s reactions. The post-test counselling session becomes very crucial and (he counsellor
should do some prior preparation and planning before such a session. Ile/she would also
have to be ready for any strong, emotional reactions (like anger) that the client may have
about the whole testing process or about not having been given support or adequate
information prior to the testing.
Counsellors often have to deal with wrong ideas and even anxieties about HIV antibody
teslintg. The counsellor needs to inquire about the testing procedure followed for each case and
he/she needs to know that a single test or screening does not make a person positive confirmation tests must be done before a diagnosis is made, t he counsellor must ensure that the
client understands what the test implies and what a positive or negative result means. Many
people believe that a positive enzyme-linked immunosorbent assay (ELISA) means that they
have AIDS, and this may cause great distress. 'Hie counsellor must deal with the fear and set out
the facts unambiguously. People whose test is negative may feel relieved and believe that they
can go on living again in the same way as before. Preventive counselling must begin
immediately. 1 hey must be told about the “window period” and what they should do to prevent
acquiring or passing on the infection, and be urged to return for follow-up counselling.
Pre-test counselling
Ideally, rapport and contact should be established between the counsellor and the client
prior to testing and the same counsellor should see the client befoic and alter testing.
Counselling before the test should provide individuals who are considering being or being ,
recommended to be tested with the information on the technical aspects of screening and on the
possible personal, medical, social, psychological, and legal implications of being found cither
HIV-positive or HIV-negative. The information should be given in a manner that is easy to
understand and should be up to date.
A decision to be tested should be an informed decision. Informed consent implies
awareness of the possible implications of a test result. In some countries, the law requires
explicit informed consent before testing can take place; in others, implicit consent is assumed
whenever people seek health care. There must be a clear understanding of the policy on consent
in every instance, and anyone considering being tested should understand the limits and potential
consequences of testing (analysis of legal and ethical issues in the Indian context, is given tn
section 3D of this module).
96
I’csling of IIIV inlcction should he organized in a way (hat minimizes (he possihilily <»l
information disclosure or of discrimination. In screening, the rights ol the individual must also
be recognized and respected. Counselling should actively endorse and encourage those rights,
both for those being tested and those with access to records and results. Confidentiality should
be ensured in every instance.
Issues covered in pre-test counselling
Pretest counselling is done in addition to giving preventive information and is centered on
two main topics: first, the person’s history and risk of being or having been exposed to 111V;
secondly, the client’s understanding of H1V/A1DS and previous experience in dealing with crisis
situations.
The issues and questions involved in such assessments are presented below:
Table 2
Questions on Psychosocial Factors and Knowledge for Pre-test counselling
1. Why is the test being requested?
2. What particular behaviours or symptoms are of concern to the
client?
3. Has the client sought testing before and, if so, when, from
whom, for what reason, and with what result?
4. What does the client know about the test and its uses?
5. What are the client’s beliefs and knowledge about HIV
transmission and its relationship to risk behaviour?
6. Has the client considered what to do or how he/she would react
if the result were positive, or if it were negative?
7. Who could provide (and is currently providing) emotional and
social support (family, friends, others)?
Pre-test counselling should include a careful consideration of the person’s ability to cope
with a diagnosis and the changes that may need to be made in response to it. Ibshould also
encourage the person being counselled to consider why he or she wishes to be tested and w a
purpose the test will serve. When the counsellor enquires about personal history, it is important
to remember that the client:
O
o
o
O
may be too anxious to fully absorb what the counsellor says,
may have unrealistic expectations about the test;
may not realize why questions are being asked about private matters and therefore
be reluctant to answer; and
may not be willing to change behaviour irrespective of the result.
97
The initial assessment should make it possible to discuss and assess the likelihood of the
client understanding the following: (a) the meaning and potential consequences of a positive or
negative results; and (b) how change in behaviour can reduce the risk of infection or transmission
to others.
During pre-test counselling, it is also important that the client be told that current testing
procedures are not infallible. Both false-positive and false-negative results occasionally occur,
although supplemental (confirmatory) tests are very reliable if an initial test is positive. These
facts must be clearly explained, together with information about the “window' period” during
which the test may be unable to assess the true infection status of the person. It should also be
made clear that no test can tell whether someone has, or wall, develop AIDS and the presence ol
HIV antibodies in the blood is proof only of HIV infection.
In summary, pre-test counselling should:
O
O
O
O
O
O
O
O
o
determine what the client understands about 11IV and AIDS;
provide factual information as needed;
discuss potential implication of a positive and negative test result;
explain and obtain informed consent;
review the test procedure;
assess the person’s ability to cope with a positive result, and
establish who else should be informed and is likely to be supportive to the client if
tested positive.
establish a relationship as a basis for post-test counselling.
provide adequate preventive counselling.
Once a decision has been made to take the test for HIV antibody, arrangements should be
made to schedule a post-test counselling session.
Post-test counselling
The post-test counselling session is mainly designed to help the client:
O
O
o
o
Cope with the immediate reactions to the test result (ranging from indifference to
relief to denial and shock)
Integrate and understand the meaning of the test result at all levels (rationally,
emotionally, behaviourally, medically).
Develop a health plan for risk reduction.
Maximize healthy coping skills and strategies.
11IV testing can have three possible outcomes:
(a) a negative result;
(b) a positive result;
' (c) an equivocal result.
98
I’M GOING
TO DIE !
s
“/
o
o
0
'K
WHAT AM I
\
GOING TO DO ?!
'
0
HELP I
(a) Counselling after a negative result
It is very important to carefully discuss the meaning of a negative result (whether this was
expected or not). The news that the result was negative is likely to produce a feeling of relief or
euphoria, but the following points must be emphasized:
1. Following possible exposure to HIV, the “window period” needs to have elapsed
before test results can be considered reliable. This means that, in most cases, a
minimum of at least three months must have elapsed from the time of possible
exposure before a negative test can be considered to mean that infection did not
occur. A negative test result carries greatest certainty if at least six months have
elapsed since the last possible exposure.
2. Further exposure to HIV infection can be prevented only by avoiding high-risk
behaviours. Safer sex and avoidance of needle-sharing must be fully explained in
a way that it is understood and permits appropriate choices to be made. (i.e. risk
reduction counselling)
3. Some clients have a false belief that since high risk behaviour has not led to
infection so far, they have a natural “immunity to HIV”. This should be
addressed or else the motivation to change behaviour will be low. In some cases,
when a client has an infected spousc/scx partner whom he or she identifies
with, a negative result may be seen as a failure and may increase the client s risk
behaviour in an attempt to get infected also. 1 his kind of motivation also has to
be kept in mind..
99
4. Other information on control and avoidance ol HIV infection, including the
development ol positive health behaviours, must be provided. It may be
necessary to repeat such explanations. The counsellor and the person being
counselled may need to practice together methods of negotiating these with others
in order to assist the client in introducing and maintaining the new behaviour.
The procedure for disclosing negative test results is :
(i) Establish rapport with the client.
(ii) Disclose test result.
(iii) Assess :
O the need for a re-test if there have been potential risk factors in the previous six
months;
O the client’s commitment to continue his negative status;
O the client’s alcohol and drug use (which could impair judgement and/or lessen
commitment to safer sex practices).
(iv)
(v)
(vi)
Provide information on risk reduction, viz. non-penetrative sex options, proper
condom use and needle cleaning.
Develop a health plan for risk reduction, setting specific and realistic goals.
Provide resources and referrals as needed or requested.
(b) Counselling after a positive result
People diagnosed as having IIIV infection should be told as soon as possible. 1 he Inst
discussion should be held in private and under conditions of confidentiality, and the client should
be given time to absorb the.news. After a period of preliminary adjustment, the client should bv
given a clear, factual explanation of what this news means. This is not a time for speculation
about prognoses or estimates of time left to live, but for acknowledging the shock of the
diagnosis and for offering and providing emotional support. It is also a time for encouraging
hope - hope that achievable solutions can be found for resulting personal and practical problems.
After a positive result the counselling relationship may enter a new phase. Crisis
counselling will always be necessary as the first step. The pre-test assessment can be reviewed to
determine the best way to tell the client about the test result. How the news is accepted will
depend on the person’s personality, psychosocial circumstances, education level, previous
knowledge of HIV, and cultural attitudes towards AIDS. The client must be told how he/shevcan
contact the counsellor during periods of severe stress. There should be some discussion of what
may happen if employers or others learn that the person is HIV-infected. In India, where societal
approval and other people’s opinions are very important in influencing one’s behaviour, it will be
necessary to focus on and deal with the client’s anxiety and apprehensions about others getting to
know the diagnosis. All the information previously given about safer sex, prevention ol
transmission, and maintaining health must be repeated. Follow-up visits must be arranged, often
on a routine basis.
100
Counsellors must always stress, the indi\ idual's responsibility for chancing
bcha\ iour Io avoid ic-inlcclion. or to limit, il not eliminate, the i isk ol liansimssion io olhvis.
Theymust also emphasise the life-long nature of the infection.
liow the news of HIV infection is accepted or incorporated often depends on the following:
1. The person's physical health at that time. People who are ill may have a dela} ed
reaction. Their true response may appear only when they have grown physical!}
stronger.
2. How well prepared the person was for the news. People who are complete!}
unprepared may react very differently from those who were prepared and perhaps
expecting the result. A previous session of pre-test counselling would increase a
person’s preparedness. However, even those who are well prepared may experience
the reactions described herein.
3
How well supported the person is in the community and how easily he or she can call
on friends. Factors such as education level, employmentjob satisfaction, family life
and cohesion, and opportunities for recreation and sexual contact may all make a
difference in the way a person responds. The reaction to the news of HIV inteclion
may be much worse in people who are socially isolated, have little money, poor work
prospects, little family support, and inadequate housing.
4. The person’s pre-test personality and psychological condition. Where
psychological distress or depression existed before the test result was known, the
reactions may require different case management strategies. Post-result management
should take account of the person’s psychological and/or psychiatric history.
particularly as the stress of living with HIV may act as a catalyst for the reappearance
of earlier disturbances.
In some cases, news of HIV infection can bring out previously unresolved fears and
problems. These can often.complicate the process of acceptance and adjustment and will
need to be handled sensitively, carefully, and as soon as possible.
5. The cultural and spiritual values attached to AIDS, illness, and death, in some
communities with a strong belief in life after death, or with a fatalistic attitude
towards life, personal knowledge of HIV infection may be received more calml} than
in others. However, there may also be a sense of helplessness and hopelessness. On
the other hand, there may be communities in which AIDS is seen as evidence of
antisocial or blasphemous behaviour and is thus associated with feelings of guilt and
rejection.
I
101
Counselling and support an* most needed when leaelion’: Io ihe new*: ol I II V inh < lion
appear. Some reactions may initially be very intense and may even be suicidally oriented. Il is
important to remember that such responses are a normal reaction to life-threatening news and as
such should be anticipated. However, they should be taken seriously and time should be spent in
assessing the gravity of any suicidal impulses or depression in the client. I he client should be
suitably counselled to alleviate such emotions.
The first reaction is likely to be a state of shock or denial, following this, some people
feel emotionally overwhelmed and experience a feeling of loss of control or helplessness: this
may be exhibited as a fiood/outpouring of emotions, thoughts and questions. Other reactions
which may be expressed are : depression, guilt, self-blame, anger, fear and suicidal thinking.
The counsellor should support the client by helping to contain the anxiety and providing
reassurance that his/her feelings, concerns and decisions will be dealt with during the counselling
process.
l lic procedure lor disclosing positive lest results is :
(i)
(ii)
(iii)
(iv)
(v)
Establish rapport with the client.
Ask if there are any questions.
Follow the lead of the client as to when to disclose the results (except where the
client is very impatient and wants to know only the result without understanding
what the test is for or the meaning of I11V/AIDS).
Give the test results in a direct, neutral, non-judgcmental tone.
Wait for client’s responses before answering or continuing with the session.
The following points need to be repeatedly emphasized:
1. HIV infection is not AIDS. Prognoses vary, but every infected person should be
encouraged to live a normal social and economic life unless AIDS-related symptoms
do not permit this. Since normal living requires the support of others, those
concerned may need to be informed and also provided regular counselling to
anticipate and cope with new needs.
2. A person who is HIV positive should take care of his or her general heallh. The
presence of other infections, such as other sexually transmitted diseases will al feel the
immune system's response and may hasten the development of AIDS. 1 he counsellor
must stress the need to avoid exposure to illness as a measure to piolong life. 1 he
counsellor must explain how the infections can be avoided through general home
hygiene. The prevention of other sexually transmitted diseases by the use of condoms
and by reducing the number of sexual partners should also be explained.
3.
Spouses and partners will need support; telling them that the test lor 111V infection
has been found positive is difficult, and considerable support may be needed from the
counsellor. Bringing spouses or partners in for counselling to prevent transmission,
and where indicated, testing, is a frequent counselling goal.
102
4. Spouses and partners must be protected against infection: ( ondoins should be
recommended to prevent infection/ transmission and rc-inicclion o! the patient. I he
counsellor should stress the need for care in ensuring that the condoms are ol good ,
quality. The counsellor should also demonstrate the correct usage ol condoms. ie
use of condoms may not be acceptable in some cultures. Objections to them, an t ie
consequences of not using them, need to be discussed.
In summary, post-test counselling in case of a positive result should:
O ensure that the person understands what a positive HIV test result means;
O discuss how they feel about being infected,
O provide support to help the person deal with these feelings,
O discuss their plans for the immediate future,
CAiiina.
O establish a relationship with the person as a basis for future counsel g
O schedule appointments for medical evaluation and follow-up counsclh g.
(c) Counselling after an equivocal test result
A test result may be equivocal for a number of reasons: for instance, there may have been
rxx'ix— ::±i=:'r==="'-main issues for the counsellors to deal with:
1
The test used to determine whether the person is ioteeted with HIV The Iks.
rests most —, -d ate
or =
103
“window period”. Correspondingly, a positive result suggests the possibility ol HIV
infection. The usual procedure then is to retest, using ELISA or 2 spot tests. If this
test is repeatedly positive, supplemental or confirmatory testing may be required,
using tor instance the Western Blot 'fest. However, a lot of centres today are
diagnosing on the basis of ELISA and spot tests only as these are considered
acceptable by medical experts. The result of such supplemental testing can either be
positive, strongly indicating HIV infection; negative, indicating no infection; or
indeterminate. An “intermediate” result of supplemental testing (and it may be in up
to 10% of samples in some areas), may be for the following reasons:
- the person has developed non-clinical signs of HIV infection
more quickly than might normally be expected;
- a related HIV virus is present;
• a cross-reaction is occurring with a non-viral protein and the
reaction is simulating part of an HIV related protein;
The following options are then available:
- to use alternative methods with the aim of obtaining a reliable result,
e.g. by using combinations of techniques so as to exclude falsepositive results;
- not to carry out further testing. Where the result is indeterminate and
either the results of further testing are being awaited or further testing
is not possible, it is not possible to say with any degree of assurance
that the person is III V-infccted. The counsellor should then advise the
person to present liimself/herself after three months for repeat testing.
It is impoilant to icincmbci (hat, in aieas with low levels ol III V
infection the probability of finding a false positive result is giealcr
than in those where background rate of HIV infection is high. Thus, in
communities where many people suffer from AIDS, it is more likely
that a positive I'LISA result isaccuiale.
2. Prevention counselling and support while waiting for an unequivocal result. I he.
period of uncertainty* following an initial equivocal or indeterminate test results may
be three months or longer after the last instance of potentially high-risk exposure or
the previous test ol HIV infection. It is then important for counsellors to emphasize
essential prevention messages regarding sexual and IV drug-use activity, body fluid
and tissue donation, and breast-feeding. The person will need to undertake the
precautions recommended for 111V positive persons until proven otherwise. I'uilher
the uncertainties associated with this period may lead to acute and severe
psychosocial difficulties, and the counsellor must be prepared to assess and manage
such issues or to make appropriate referrals, if necessary, in every case.
104
CRISIS COUNSELLING
In HIV/AIDS situations multiple crisis could occur. The news that a client is 1 IlV
infected can be a crisis for him her, creating stress, evoking cognitive (thinking), intense
affective (emotional) and behavioural responses.
A crisis exists when a person feels:
o intensely threatened
o completely surprised and caught unawares by whatever is happening
o emotionally disturbed as a result of loss of control
o emotionally paralysed as there does not seem to be any solution to the problem: all efforts
to resolve the crisis seem hopeless, or the results appear to be as harmful as the threat
itself.
The individual usually goes through four stages of the crisis: the blow, the recoil,
withdraw!, and acceptance.
The blow is the shock of fearing or realizing that something is wrong - a symptom
appears, or there is awareness of being at high risk, or a test result is confirmed as
positive.
The recoil occurs as the person struggles emotionally to come to grips with the full
implication of the crisis. In this process, the person may deny and recoil from the news
(the new reality) and demand a battery of tests in another clinic.
Many withdraw in order to be alone with their sorrow or anger, and isolate themselves.
Some people can quickly begin to come to terms with (accept), and adapt themselves
to their predicament.
Reactions to fear of being HIV-infected or confirmation of infection or of AIDS in the crisis
mode may include:
O Denial (This can’t be true)
O Anger (Why me? What did I do to deserve this?)
o Bargaining (God, if you let me off now, 1 will...)
o Resignation (I am helpless...)
o Acceptance (I will do my best as long as I can).
o Fatalism (This was meant to be .... its my destiny..)
Not everyone will display these reactions, but most will to some degree.
105
Once (he crisis stage is over the fact ol being seropositive continues to cicalc slicss in the
individual if not adequately supported. However, all seropositive persons do not respond in the
same way. A person may show greater capacity to adapt and io continue a productive life while
another person may go into depression. The counsellor must be able to recognize the vat lability
across individuals and tolerate uncertainty when making predictions about the possible effects of
stress.
When a client is in a crisis state, a counsellor does not say: “You are over-reacting”, but
instead listens carefully and comments on the strength of the feelings and the fear, or on the
client’s efforts to deal with the problem.
What is important is that the counsellor should respect the client’s perception of crisis,
and go on from there.
Crisis counselling is designed to help the client cope with and resolve the crisis. The
counsellor does not panic, offer false assurance, give advice, or take of fence. I he counsellor
offers:
O Acceptcmce. (Example: “You are angry at yourself at me, and everyone else".)
o Emotional support. (Example: “You are veryfrightened and you may need some extra
time to talk. I shall he here. ")
o Guided (structured) questioning. (Example: “We hath need to know what is going on. so 1
am going to ask you some very direct questions. A fterwards we can move on to anything
else you need to talk about. “)
Sonic basic principles of counselling in crisis are:
Stay in the “here and now”, i.e., focus on the client’s expression of feelings and
anxieties. It is not the time to talk about past history or behaviour, but about
present feelings.
Clarify what the client regards as the crisis.
(ii)
Determine the client’s feelings about the event or information.
(>>>)
Check and attempt to reduce feelings of helplessness, hopelessness, and loss of
(iv)
control by means of questions and observations.
Give a brief assessment of the position and show that the seriousness of the
(v)
crisis is appreciated.
Ascertain what the client regards as the most, as well as the least threatening,
(vi)
aspect of the crisis.
(vii) Select one aspect on which to begin work, preferably involving a task that the
client can accomplish with least support.
(viii) Agree on what is to be done to resolve or ease the crisis.
If the client is using denial as a defence mechanism or is too distressed to
(ix)
understand what is being said give some information repeatedly.
(i)
106
Il would be useful to suggest to the client methods which would enhance his/her coping
skills. Various techniques arc available, and it would be useful for the counsellor to be aware ol
some-of these. One method which could be easily learnt is relaxation. A basic form of the
relaxation method is to close one’s eyes and concentrate on one's breathing, while letting one's
body loose and relaxed. This should be practiced for 15 minutes, twice daily in a quiet place.
Any thought or intruding worries should be removed and not allowed to interrupt the exercise,
i.e. attempt to free the mind of thoughts and messages for those 15 minutes.
SUPPORTIVE COUNSELLING
H1V/A1DS counselling involves, on the one hand, helping persons with 111V/A1DS to
lead active, productive and hopeful lives to the extent possible and. on the other, to cope with the
probability of shortened life expectancy. During periods of relative health, issues involving
activities and personal goals are important. The counsellor helps the client to rpaintain hope and
engage in constructive life patterns. During other periods, coping with the prospect of death is a
more salient issue.
The stress of having HIV infection may precipitate stressors in other aspects ol life viz.
relationships with family members, with friends and in the workplace. Sometimes, having to
hide the knowledge of being infected creates inner tension and isolation. A child may face
rejection in school due to his/her illness or his/her parents HIV-positive status and develop
behavioural problems at home. HIV-infected clients often get minor illnesses (unrelated to HIV/
AIDS). This can induce a crisis particularly if the client takes it to mean that he/she has
developed AIDS. The counsellor thus needs to examine various areas of social functioning to
have a complete picture of the stress effects of HIV/AIDS on the individual, family and related
groups. A proper assessment of the source of the stress will help the counsellor plan realistically
to reduce stress and increase the coping skills of the client(s).
LIVING POSITIVELY WITH AIDS
KrvAND
PQ>xATiO>J
mEIhlAu
■ V,
107
JJie family is a very important social system in the Indian context and performs very
essential functions ranging from socialization to providing the basic means tor survival. Despite
some level of social change in the urban areas, the family continues to be a dependable support
system for a sick person. Hence, the elders, the spouse and ‘significant 'others' need to be
considered as an important resource.
There are practical reasons for informing the family and close associates; they will be
called upon to provide care and support, and their own interests must be considered, especially
when children are involved. The counsellor may need to be present when family members and
others are being informed of the clients HIV status.
Many people will be reluctant to disclose the fact for feelings of shame and guilt, and for
fear of being rejected, or ostracized. The counsellor must accept that such fears are
understandable but, nevertheless, encourage the clients to re-examine their objections to
disclosure. The counsellor must also encourage the client to look to the family or other close
associates for support. One of the most useful questions the counsellor can ask is: “ What will
happen to the people you love if you do not tell them now about what is happening to you?” The
counsellor may help the client to consider how a spouse or partner has reacted in the past to some
wrongdoing, as well as rehearse the process of informing the family.
In the end stages of HIV-related diseases and AIDS, the counsellor’s role is primarily
supportive. The counsellor should be familiar with the common stages of death and dying
(Kubler-Ross, 1969). Disbelief or denial, anger, depression, ‘bargaining’, and acceptance are
common psychological reactions to the threat of death. Some of the useful techniques identified
in helping deal with the diagnosis and 11IV/A1DS infection are as follows:
1. Keep it simple. The counsellor is likely to feel very anxious about dealing with the
terminally ill AIDS clients. This may lead to over talkativeness, use of confusing
language or jargon, jitteriness, stiff body posture, or failure to give the client adequate
opportunity to talk or ask questions. The counsellor must be aware of his/her own
anxiety and handle it by discussing with another colleague and/or adopting relaxation
techniques.
2. Wait for questions. The counsellor can use silence effectively and provide the client
an opportunity to express his/her feelings. 1 he counsellor can wait for questions to
arise. All questions need not be answered. The client may be expressing emotions
through questions (Why is it happening to me?). The underlying emotions can then
be acknowledged and allowed expression.
3. Find out what the diagnosis means to the client. The counsellor needs to understand
how the diagnosis and infection is affecting the client through questioning and
observation of the client’s interpretation and personal meanings attached to the
diagnosis. The counsellor corrects misconceptions and answers questions in a
supportive environment, thus conveying that (s)he is knowledgeable and can help.
108
4. Don 1 feel that you have to answer al one lime every (piesiion lhai eoii/d ariw I he
counsellor musl gtsc (he clienl lime (o nbsoib. think and idled o\ei (he inloiinalion
which should be given in bits and pieces over several visits.
5. Don't argue with denial: II'the client wants dr needs to deny the information offered,
respect his/her right to do so; avoid confrontation. As trust and confidence in the
counsellor grows, openness and communication from the client will also increase. An
initial sense of being accepted is very important to build a strong client-counsellor
relationship.
6. Check for understanding. After you have provided some information, check whether
the client has understood the information.
7. Leave room for hope but do not lie. The counsellor should let hope live without being
untruthful to the client. The counsellor should make himself comfortable about
handling questions like, Ts this AIDS?’,‘Am I going to die?’
8. Support or facilitate discussion on plans for the family. The counsellor should help
the client to organize legal and income matters for ensuring security for the spouse/
family. In case of breadwinners from the poverty groups, the counsellor may have to
assure the client of mobilizing support for his spouse/ family in terms of short-term
relief and long-term alternatives for employment, etc. Such planning will help the
client to reduce his anxiety about his impending death as well as encourage cognitive
coping through a reality orientation approach.
9. Encourage use of rituals and cultural practices to help face the illness and death.
With the help of the'family priest or elders which involves administering of
traditional rites and sacraments of faith or religion, the counsellor can provide support
and counselling and help the client to use spiritual approaches in acknowledging and
facing human mortality and death. For clients who are philosophical, spiritual or
religious, encouraging them to read about or devote some time of their day to their
beliefs or a particular doctrine would lead to a sense of inner peace and tranquility.
Counselling Interventions with People with HIV and AIDS:
The goal of counselling interventions is to help the person with HIV or AIDS live with
the illness in the best possible way. (Specific guidelines for HIV infected persons or persons with
AIDS are given in Appendix 2). Interventions which could be helpful are :
Individual interventions :
O Education
Information about the illness itself, risk reduction, normal emotional responses to the
diagnosis, etc.
109
^*3
hidividual couiiscllin^
Adopting a non-judgeinenial stance, empathizing, normalizing/univcrsalizing responses,
active listening, supporting coping skills.
o Provision of support
Emotional support, support and reinforcement for risk reduction and behaviour change.
o Assistance with disclosure of diagnosis
Offering, when possible, to help the client disclose his/her diagnosis to spouse/partner
and/or family members.
o Grief counselling
Talking directly about reactions to the losses the client has already experienced or
anticipates, talking directly about death and dying, helping the client take care of practical
matters (provision for children, legal matters, finances, etc.), assisting the client in
addressing unresolved emotional and relationship issues.
o Crisis intervention
Identifying and validating client’s ability to cope with past life crisis, assisting with
concrete problem solving, encouraging client’s active and positive participation in current
situation, increasing awareness of options, encouraging expression of feelings within
counselling session, mobilizing support network, providing client with appropriate
referrals.
o Substance abuse treatment
Providing referral for substance abuse treatment if client is experiencing negative
consequences from his or her use of alcohol and/or drugs.
o Encouragement of client’s active participation to increase sense of empowerment
Learning more about the illness, changing health behaviours, helping others, increasing
involvement with spiritual and religious practice.
o Skills training
Problem solving, coping skills, stress management.
o Mobilize social support
Facilitating contact with other people.
o Advocacy
On behalf of client who is unable to do so on his or her own, for example, financial
assistance, basic living concerns, medical and treatment issues.
1 10
i*amih Inlcrvcnlioiis:
I he goal ol counselling interventions for the family iis to help them
'
_ terms with the
come to
impact ol the Hl\ or AIDS diagnosis on their lives. Among interventions which could be
helpful are:
O Education
About the disease, transmission, what to expect in terms of the course of the illness and
emotional responses.
O
Assistance to family
Clarifying conflicting feelings about the disease, stigma, reactions to disclosure of the
diagnosis and risk factor(s). fears of contagion, reactions to anticipated death of the
family member and other losses, shame, impulse to reject; giving everyone opportunity to
share their viewpoint.
o Conflict mediation
Alliance with supportive family member; establishing common ground; mediating
conflicts.
o Modelling positive interaction
Diffusing fear about contagion by acting as a role model for family members when
interacting with the person with AIDS.
o Mobilizing family support
Helping maximize support lor family members within the family and from friends and
community members where possible.
o Encouraging family members to take action
Finding out more about the disease, helping others.
o Supporting the spouse/partner
Validating their concern about their own risk of HIV infection, reinforcement for
behaviour change, exploration of satisfying and safe forms of sexual contact and
intimacy.
o Grief counselling
Talking directly about reactions to the losses already experienced and/or anticipated,
talking directly about death and dying, helping the family take care of practical matters
(prox ision for children, legal matters, finances), assisting the family in addressing
unresolved emotional and relationship issues.
111
Group Interventions :
Any intervention which facilitates interactions among people with HIV or AIDS, or among
iamily members, will help to decrease isolation and stigma while providing education, social
support and role models for coping with the illness. Peer groups can be focussed or targeted to a
specific audience such as people with AIDS, couples, parents, gay and bisexual men, women, etc.
Group inters entions are extremely helpful, but often difficult to assemble. Ways to promote
interaction among people with similar experiences of HIV and AIDS include:
O Peer groups
Education, social support, emotional support, problem-solving.
o One-to-one peer contact
In person or by telephone. Anonymity and confidentiality can be more easily protected.
o Formal or informal groups
Groups of people aflected by AIDS who work towards public education and advocacy.
112
ACTIVITY SECTION
ACTIVITY 8: Group Work : HIV Risk Assessment
Time: 45 mins
Materials: HIV Risk Assessment forms for each participant
Objective:
The purpose of this activity is to become familiar with the information that needs to be
gathered in HIV risk assessment and to understand the client’s experience whep asked very
personal questions that are part of an HIV risk assessment.
Procedure:
Ask participants to fill out the HIV risk assessment (worksheet 2) form about their lives.
Explain that these risk assessment forms will remain in their own hands. They will not be asked
to share their responses with anyone else.
Remind participants that the purpose of the activity is not to evaluate or see results of the
risk assessment form. The form is only a guideline regarding the kind of information to be
gathered in the session, not a recommended tool for using with clients.
After five minutes, divide the large group into small groups of four. Ask them to discuss
the following questions for 10 minutes :
O
O
o
How did you feel as you completed the form?
Were there questions you were unwilling to answer or wanted to avoid?
What did you learn from this experience that may help you when you are
conducting risk assessment interviews with clients?
Next, assign each participant the role or title ol 1 ruck Driver Commercial Sex
„
Worker”, “Intravenous Drug User”, “Pregnant, Married woman”, “Undergraduate hostel student”
and ask them to imagine themselves as that person and think about what their lifestyle and
relationships would be like. Then, instruct the participants to fill our a fresh HIV Risk
Assessment Form as they would if they were the “imagined person” that they have been
designated by you (the facilitator).
113
After 5 minutes, divide them again into small groups of four. Ask them to share their
feelings around the following topics for 10 minutes :
O
O
o
Was it easy or difficult to 1111 in the form as the person you were designated to be?
What was different in the responses you gave in this form Vs. when you 111 led out
the form as youtsell?
Compare your inner feelings while Idling the form now and while filling it earlier.
Bring the small groups back to a large group and discuss the activity with the following
questions while keeping in mind the points for discussion given below :
o
o
o
o
Why might it be difficult for clients to be honest in disclosing information about
their high-risk behaviours?
As a counsellor, what can you do to help clients feel more comfortable in talking
honestly about their HIV risk?
What methods or approaches for assessing risk might be most helpful for the
client?
What has impacted you the most in this exercise?
Points for discussion: Reasons why people will not disclose honest information about
their risk behaviour:
o
o
o
o
o
o
o
fear of recognizing one’s risk.
Denial of risk.
Reluctance to disclose participation in culturally taboo behaviours.
Pear of stigma and discrimination.
Unwillingness to look at one’s past behaviour.
Discomfort in discussing sexual behaviours and substance use openly.
Discomfort in discussing personal matters with a stranger.
Note to trainer: This activity works most effectively as an introductory and sensitizing
activity. The trainer presents the Risk Assessment Counselling Checklist in OHP # 8 to review
the main steps of a risk assessment counselling session.
I 14
WORKSHEET!
HIV Risk Assessment Form (For Activity 8)
Sexual History
1.
Since 1987, have you had sexual intercourse (anal, vaginal or oral) with:
♦
♦
♦
♦
♦
♦
anyone infected with HIV? yes
no
don’t know
anyone who has used intravenous drugs? yes
no
don’t know
anyone who has shared intravenous drugs? yes
no
don’t know
anyone who has gone to hospital for treatment where injection needles were not
changed? yes
no
don’t know
anyone who has ever received blood transfusions or other blood products (for c.g. for
hemophilia or other coagulation disorders)? yes
no
don’t know
any man who had sex with other men? yes
no
don’t know
any man or woman who has had many sexual partners before you? yes
no
don’t know
any man or woman who has had sex with anyone in the above categories?
yes
no
don’t know
2. With these partners, you have engaged most frequently in which of the following sexual
practices'(please tick the relevant ones):
♦
♦
♦
♦
3.
vaginal and/or anal intercourse without a condom
vaginal and/or anal intercourse with a condom
oral intercourse (fellatio, cunnilingus) with a barrier
oral intercourse with a barrier
masturbation, body rubbing, dry kissing
If you used a condom for anal, vaginal or oral intercourse, did you use it (please tick one):
♦
♦
♦
all the time?
sometimes?
once in a while?
115
4.
Hov many sexual pailiiuis (with whom you have not practiced sale sex), have you had in :
♦
♦
the past 10 years?
the past 3 years?
the past year?
Substance Use and/or Needle Sharing
5.
Have you ever used drugs intravenously?
yes
no
if yes, have you ever shared needles or other paraphernalia:
yes
no
6.
Have you ever shared unsterilized needles for other
purposes such as medications, tattoos, acupuncture?
yes
no
7.
Do you drink alcohol or use non-IV drugs?
yes
no
if yes. have you ever had difficulty remembering what
happened while you were using drugs or alcohol?
yes
no.
Blood Transfusion and/or Blood Products
8.
Have you ever received any blood transfusion or blood products (for hemophilia or
other coagulation disorder)
yes
no
if yes, in what year?
116
OHP # 8
RISK ASSESSMENT COUNSELLING CHECKLIST:
i
i.
Explain the purpose of HIV risk assessment
2.
Assess client’s knowledge about modes of HIV
transmission. Clarify any misinformation.
3.
Ask the client to assess his or her current and past high
risk behaviours.
4.
Ask the client to summarize his or her risk of HIV
infection. Discuss any concerns and clarify
misconceptions.
5.
Summarize the discussion about the client’s HIV risk,
leading into a discussion about risk reduction.
I 17
\CriVITY 9: Group Work : hilroduGion io Pi c-icsi mid Posi-icsi counselling.
Tiniex.45 mins
Objective:
The purpose of this activity is to familiarise the trainees with the essential elements and
issues of pre-test and post-test counselling.
Procedure:
Divide trainees into small groups of 4 people. Ask each group to make the following list
and record it on a large paper.
♦
♦
♦
Some of the things a counsellor might do or sax during a pre-test situation.
Some of the things a counsellor might do or say to prepare a client
for a positive result.
Some of the things a client might say or do after hearing the positive result.
Give the group 15 minutes for this listing. Ask all the groups to read out their lists for
each of the three situations. Based on the above sharing, the trainer discusses the essential
elements -related to antibody testing counselling and highlights the main features of pre-test,
post-test counselling sessions.
118
\C 1 I\ I I \ 10: Rok* Plnys : I’rc- l est mid Posi - l est Scenarios
Time: 1 hour
Objective:
1 his activity is designed to help the participants understand that pre-test and post-test
counselling are inter-related activities.
Procedure:
I he trainer asks the participants to form two sub-groups. Each sub-group gets a card with
Kishore s scenario - one as a pre-test and one as a post-test situation.
Two volunteers in each sub-group are recruited to play the roles of counsellor and
counsellee for their card-scenario. The trainer instructs the two groups to prepare and help the
volunteers rehearse their role play for 20 minutes. After this preparation time, the two sets of
volunteers enact their scenarios for the full group for 7-10 minutes each.
After each role play, all the participants discuss the kind of counselling provided and
issues that were important from the clients’ point of view. At the end of the two role-plays and
discussions, the trainer ends the activity, making sure that all trainees recognize the importance
of linking counselling to HIV testing and pre-test and post-test counselling.
Scenarios
#1 Kishore is a 32 year old married man with two children He has been having an affair
with another married woman, Sheela, for the last few years. A friend of Sheela has
recently been diagnosed as infected with HIV. Kishore is worried about his wife and
children. He comes to seek help.
#2 Kishore is a 32 year old married man with two children. He has been having an affair
with another married woman, Sheela. for the last few years. He had gone for testing
because he was worried after hearing about a friend who had been diagnosed as HIV
positive. Kishore had received pre-test counselling from you and has come back to
you after the result. Kishore has tested HIV positive. He disbelieves the test. H° ^Iso
expresses his concern about the future of his family.
'2^
I 19
ACTIVITY I I: (.roup Discussion : C oiinsclhn s I*cars
'rime: 30 mins
Materials: Large paper, 3X5 cards or small sheers of paper, pencils.
Objective:
The purpose of this activity is to discuss counsellors' fears about breaking the news about
lest results. ‘‘Breaking the news” refers to telling a client that he/shc is infected with HI\ . a
difficult and uncomfortable task for most counsellors. There are many reasons for this. Some
are:
♦
♦
♦
♦
The counsellor is inexperienced and not sure what to do or say.
The counsellor does not understand the natural history of HIV and cannot explain
clearly what a positive test result means.
fhe counsellor always feels uncomfortable when people express anger openly.
The counsellor does not know where to send the client for medical care or
legal help.
In this activity, trainees will discuss their fears and concerns about breaking the news.
Procedure:
Ask participants to write on a card or small piece of paper the two things that worry them
the most when they have to break the news of a positive diagnosis to a client. Collect the cards.
Mix up the cards and give one to each participant. (Don’t worry if a participant ends up with his/
her own card). Have each person read what is on his/her card. The trainer should list all the
concerns on a chalkboard or large sheet of paper, eliminating duplications.
Explain that these fears and concerns can result from lack of knowlcd?^ lack of ski lb. or
the counsellor's emotions, attitudes or personal situation. It is important lor participants to
understand the basis of their fears or concerns. Some of these can be avoided if counsellors
acquire more knowledge or learn and practice new skills. When the counsellor s concerns result
from his/her own situations or from personal feelings and attitudes, it is often best to discuss this
with other H1V/AIDS counsellors or with senior counsellors.
On a large paper or a chalkboard, write the following as three separate headings:
♦
♦
♦
Knowledge
Skills
Persona! Issues
120
Now. le-examinc lhe group's lisl and decide (wilh Hie Irainee's inpur.) whedici each
icar or concern can be lessened by increasing knowledge, improving skills, or acknowledging the
personal issues that may arise for the counsellor. The trainer should then rewrite the fear or
concern being discussed under the appropriate heading. Some fears could be best addressed in
more than one category and should be listed in each relevant category. Discuss how these fears or
concerns afiect the counselling session and how counsellors can best respond to their own fears.
Summan' of Major Points:
♦
Fears might include:
The client will commit suicide.
1 he client will walk out of the counselling session.
Clients will not cofnc back for follow-up counselling or medical care.
The client will be angry at the person he she thinks infected him/her and will
try to hurt that person.
The client will knowingly try to infect others.
The client will get angry with the counsellor.
The counsellor will not know how to respond to extreme client reactions
such as anger, depression, uncontrollable crying, or hopelessness.
♦
Breaking the news is a difficult and uncomfortable task for all of us. Sometimes it is
difficult because it is so unfamiliar and the counsellor does not have enough
knowledge or skill to carry out the task. Other times, breaking the news is difficult
because the counsellor gets personally involved with the client or because the
counsellor feels that he/she cannot really help the client.
♦
Frequently, counsellor’s fears lessen after they have had a chance to practice
breaking the news. They gain confidence with experience and begin to develop a
wide range of response to clients.
121
/VCTIVITY 12: Guided Inuigeiy : Supportive Counselling
Time: 1 hour
Objective:
This exercise helps people to explore coping and supportive strategies for managing loss.
They also learn to identify their strengths and weaknesses in helping others cope with loss and
grief. By getting in touch with their own feelings the participants understand the essence of
supportive counselling and can begin to explore their skills in working with HIV-infected people
and/or their families.
Procedure:
Explain to the participants that the guided imagery activity will involve them in recalling
in detail a significant loss in their life. This loss could be:
♦
♦
♦
♦
the death of a person close to them
a separation or divorce
loss of health
change of employmen
If the most significant loss is too recent or too painful, suggest that the participant recall
another loss. Those trainees who find the entire activity too stressful should be allowed to pass
it by. Participants should feel free to reveal only that which they feel comfortable discussing.
Tell participants that they can imagine a loss if they cannot think of one. If they find
constructing mental images difficult, suggest that they recall the situation in whatever way they
wish. Leave a time gap between each set of questions asked so that the participants may
internally feel and think of the situation.
In a calm tone of voice relay the folio wing instructions to the participants:
'2^
"Make sure your are sitting comfortably with your feet flat on the
floor. You may want to close your eyes to help you focus and
relax. Please do not talk to each other or ask me any questions
during this session. As I guide you through this exercise pay
attention to your thoughts and feelings as you become aware of
images and memories. Think of a significant loss you have
experienced in your life. It may be the death of a loved one. If this
is too recent and painful, think of the loss ofsomeone else. It you
have not experienced the death ofsomeone close to you, recall a
loss associated with separation or divorce, loss of health, change
of employment or any other loss that caused you grief Picture this
person or event in your mind. Notice what you are feeling and
thinking.''
122
Now think hack to the events surrounding the loss and what led
up to if. Ids in your mind an image o/ how you first learned oj this
potential loss. If there was no forewarning, concentrate on an
image of when you first learned of me loss, (or diagnosis of a
terminal case). "
What was your initial response?
♦
♦
♦
♦
What were you experiencing?
How did others respond to you?
What helped you most at this point?
What helped you least?
Allow some lime lor trainees to relied internally. I hen continue:
Now make a mental image ofyourselfafter this initial shock but
before the death or change. If there was no time between the two,
imagine this period. Notice your feelings and thoughts. "
Then, ask the following questions to enable participants to explore
internally. Answers should not be called out as this is still in the
guided imagery.
♦
♦
♦
♦
♦
What was this period like for you?
How did you interact with others?
What emotional and behavioural changes occurred?
What helped you survive this period?
What made it difficult?
Now imagine the actual death or loss and the two weeks
following it. Make a picture of that time in your mind. "
♦
♦
♦
♦
What are you feeling and thinking?
Who is around you?
What is most helpful about what they are saying or
doing? If they are not helpful, what would you like
them to do differently?
What helps you most at this moment?
123
"Mnv imagine yourself six months lo/er. "
.♦
♦
♦
♦
♦
Where.are you? What are you doing?
What are you feeling and thinking?
Do you notice any physical or behavioural changes?
What has changed in your life?
What has helped you get through the last six
months?
‘Wow make a picture ofyourself today. Notice what you look like,
what you are wearing. Notice how you feel. Imagine the other
participants in the room. Make a picture of where you are sitting
in the room. Picture the person next to you. Think back to an
earlier session and recall what you were thinking then.
"Bring your attenlion back to yourself, sitting in this room. Notice
your breathing. Feel your feet on the ground. When you feel
ready, open your eyes. Take a moment to readjust to the room. If
you are feeling emotional, take a moment to recompose yourself.
When you feel ready, find a partner and spend 5-10 minutes
discussing what you are feeling as a result of this guided imagery.
Begin to think about and discuss what you learned about yourself
and your experience with loss’.
invite the pairs to join another pair, making groups of four people. Give each group
several large sheets of paper and a pen or marker. Ask the groups to choose a recorder.
Ask the groups to discuss the following questions for the next 20 minutes, recording their
resiponses on the large sheets of papers:
♦
♦
x
What did you learn about yourself and your
experience with loss?
What helped your most:
1. When you first learned about the potential
death or loss?
2. At the time of the death or loss?
3. Up to six months after the loss?
124
i. ■
I
♦
♦
♦
Wluit helped you least during each of these periods?
What does this tell you about helping people with HIV
infection and AID? and about helpign their families to live
with a life threatening illness and/or cope with an actual
death?
What are your personal strengths and weaknesses in
helping others to cope with loss and grief?
Call the groups back into a large group and ask them to tape their sheets of paper to the
wall. Discuss the responses in the large group.
125
ACTIVITY 13: Role Reversal - Empathy (Optional)
Time: 25 mins
Objective:
The purpose of this activity is to practice understanding and empathising with a client's
experience from his or her perspective.
Many times our client’s situations remind us of our own feelings, situations or
experience. Sometimes this makes us react positively to the client; other times we can have
negative emotions such as anger. This is a natural and common human experience. As 111V/
AIDS counsellors, we need to become aware of our tendencies to feel both positive and negative
emotions towards our client and at the same time, develop the ability to feel empathy towards
some aspects of all of our clients. In this activity we will examine our understanding of and our
ability to develop empathy toward others.
Procedure:
Read the following story to the group:
Anil and Aruna have been married for 7 years. They have three
children aged 5, 3 and a newborn. They met in secondary school
and married soon after that. They love each other very much and
have a good marriage. Anil and Aruna were very excited about the
birth of their.third child. Anil works in a textile factory. 1 le has
been quite successful at work and has just been promoted to a
senior managers position. Aruna works as a secretary. Aruna
suspects that Anil has had some extra-marital affairs during the
time they have been married, although they have never discussed
it. Anil is a good father and husband. Anil has been involved with
several women since his marriage. Although Anil knows about
using condoms to prevent AIDS, he didn t think he needed to
worry since the women he had seen were nice, clean women.
Besides he did not see them more than a few times each. Since the
birth of their newborn Aruna has been sick and so has the newborn
child. She was tested for HIV and the results are positive.
Ask the group to think about the position of both husband and wife and the events they
are facing. Ask participants to decide whether they have more empathy for Anil or Aruna in this
situation. Then ask them to write down some possible thoughts and feelings of the person they
have chosen.
126
i
Next, ask all those who have gicater empathy foi Anil Io go Io one side ol Ihu room and
those who have greater empathy for Aruna to go to the other side ol the room. Next, ask
participants to find a partner from, across the room and find a comfortable place to sit down. II
there are an unequal number of people on each side of the room, some groups can have three
people (two from one side of the room and one from the other).
Instruct the pairs (or groups of three) that they are now to change sides i.e. imagine they
are the other person (Anil or Aruna) - not whom they have empathy for. Now ask participants,
in their new roles, to explain (o the other what they arc thinking and feeling. Give participants 5
to 10 minutes for this discussion.
Next, ask participants to step out of these roles and again think of the person for whom
they originally had greater empathy. Using the thoughts and feelings they had written at the
beginning of this experience, (in step 1) ask each group or pair to discuss what they had written
and why they had more empathy for one person than the other. Give the groups 5 minutes for
this discussion. Return to the large group and discuss this exercise. Ask the group:
♦
♦
♦
♦
What did you learn by changing sides?
How did having more empathy for Anil or Aruna influence your empathy lor the
other person in the story?
Would you be able to counsel both persons?
What can help you develop empathy for clients, even when they trigger negative
feelings in you because of your personal experiences or reactions?
Summary of Major Points:
♦
♦
♦
It is natural to feel greater empathy for some people as compared to others.
It is also possible to develop empathy for clients even if you do not feel empathy
for them naturally.
As an 111V/A1DS counsellor, it is very important to develop the skill ol
empathising with individuals whose behaviour and values are diflerent from your
own and to be sensitive to the perspectives and feelings of both the 111V inlectcd
person and his/her family members.
127
SEC11OJN_31>
UNRESOLVED ETHICAL LEGAL ISSUES RELATED TO HIV ANTIBODY TESTINti
HIV testing is a complex subject involving issues related to ethics and human rights.
Some of the critical issues are outlined below.
Why Test?
When someone seekiiig to be tested gives no history of high-risk behaviour, (he
counsellor should enquire into the reasons why testing is sought, and offer preventive and
supportive counselling. Tire counsellor may discourage people who do not want to know the test
result from undergoing the testing, but short! ’ make it quite clear to them that they must behave
as if they were seropositive in order to preve* infection in themselves or transmission to others.
Mandatory Testing
In some places, there is much concern that without compulsory testing, people will not
admit to risk behaviour and infection will not be detected. This risk must be weighed against the
cost and consequences on social order and basic human rights. Counselling should and
encourage voluntary action to bring about behaviour change. Mandatory testing should extend
only to blood and blood fractions, organs or for invitro fertilization or artificial insemination.
Informed Consent
Informed consent is another difficult issue. In places where health care workers usually
behave in an authoritarian manner, it may be tempting to ‘order’ a person to be tested and take it
for granted, that it is alright for one to do so. Counsellors know, however, that people are more
likely to respond positively to information and counselling il they themselves take part in
decision-making. Therfore as s far as possible, counsellors should ensure that each client
understands the procedures, their limits and the positive psychosocial consequences prior to
being tested. This may require orienting and educating colleagues and other health care workers/
professionals in the setting about the importance of informed consent and pretest counselling.
Given our low literacy levels, lack of health awareness and the very complex nature of
HIV infection informed consent as it is understood in the West is very difficult to apply in the
Indian context. Each time a person is treated by a doctor, relevant information is imparted on the
basis of which some form of consent is sought to further the course of treatment. I hough a
patient’s consent is not formally recorded, enough information is imparted to the patient to help
him/her take the required test. Informed consent, integrated counselling service and lacihUes lor
voluntary testing are the ideals we need to work for.
128
Confidentiality
fhe infection may bring into the open many issues which were regarded ‘personal', for
example, ‘sexual orientation. 1 here arises a need to discuss personal issues with apparently
unknown people like doctors, counsellors. It is very important that full confidentiality is assured
in such a situation. Without it, the individual will not be able to share his/her concerns to the
fullest extent. And, if this sharing is not done, effective counselling will not be possible. Another
fallout would be that the individual will not be able to receive any information on primarv or
secondary prevention activities. Awareness of (hi issue of client participation and coopciation is
vital in counselling.
Given the possibilities of discrimination, ostracism and personal self-blame when an
individual is diagnosed as HIV-positive, it is all the more important that confidentiality be
guaranteed. The counselling relationship must be based on the understanding that whatever is
discussed will remain confidential until and unless the client decides to share the information
with someone else.
However, beeause of the very public nature in which our hospitals and clinics function,
some health workers/staff could make disclosures out of carelessness that stems from these
‘public conditions’. Therefore, in evolving the norms of confidentiality for hospitals and other
health settings, regulations for keeping medical records confidential need to be widely
disseminated among all classes of hospital employees. Some sanctions should be set up for
offenders which range from mild to severe (c.g. from warnings to a stricturc/documenlation (o
stronger departmental actions). Counsellors, physicians, other health care staff and the media
also need to be aware that, on the legal side, wilful breach of confidentiality is punishable under
Common Law. Negligence, per se, is a criminal offence and hence, breach of confidentiality of
the identities of those living with 1I1V/A1DS, both wilful and negligent, is punishable under law.
The ethical issues in ‘confidentiality’ revolve around the risk of transmitting infection to
partners by an HIV-positive client. In some circumstances, counsellors many decide to break
confidentiality, for eg., to notify the sex partners, unsuspecting spouse or needle-sharing partner
of an infected person. However, the first step should be to counsel and motivate the client to
share this information with his/her concerned parlncr(s). If the individual refuses to do (his. (he
counsellor/social workcr/physician should make this disclosure to ensure safety altci consulting a
supcrvisor/collcaguc. Another common situation in this arena is that of arranged marriages/
prospective planned marriage. It is incumbent on the counsellor to motivate the client to disclose
his/her HIV status to a prospective partncr/fiance. Since marriage to an infected person could
endanger the life of the unsuspecting prospective partner, the counsellor could carelull v weigh
the option of making the disclosure himsclf/hcrsclf.
The staff of the counselling unit/center need to agree on this issue, and will need inputs
on developing relevant skills, fhe concept of confidentiality can be extended to mean “shared
confidentiality” where a team of health workers in (he health care or counselling setting sharejJ
the confidentiality, but agrees to protect it from anyone outside the team.
129
MAl^EAINXOWElDENJJALILl
E- You Ddht
Iku. Your HqsSaH
rwiLL|l
Partner notification
This issue is linked with confidentiality and has been discussed there too. I here may be
some instances where the counsellor or other health care workers feels that confidentiality needs
to be broken, for example, to notify the sex-partner of an infected person when (he chent has
refused permission to do so. The Consensus Statement from.the WHO Consultation on Partner
Notification for Preventing HIV Transmission specifies that in such situations, the health eaie
provider “will be required to make a decision consistent with medical ethics and relevant
legislation.” In general, where confidentiality is preventing appropriate measures lor avoiding
the spread of HIV, it may be necessary to reconsider the situation in that particular case (W1
AIDS Series 8, WHO, Geneva, 1990).
Equal Opporluiiity
Test results may be lead to discrimination against the infected. This may be in the form ol
social ostracisation. refusal of medical treatment and attention, discrimmation m occupation
employment in social services like housing, education and such others. Some nsk behaviour
groups may be discriminated against, for example, homosexual, hemophiliac, family membu
hrfeJted, some ethnic groups. The right of the patient for equal opportunity must be remembe.
when discrimination occurs.
It is recommended that counsellors should advocate and lobby for no discrimination
against infected persons in terms of employment, health care, educat.on, hie msuranec and
Ration. Heahh care professionals do have an obligation to treat pat.cn s w HIV/AIDS
without discrimination, to counsel them and to update then- own professmnal skills.
130
Other considerations
Though there is no specific legislation in this country, some legal issues to be considered in
the context of the above would be: compulsory testing, isolation, immigration, euthanasia,
protection of health workers against risk of infection, eligibility for medical insurance and life
insurance, pre-cmployment screening, reservations, pre-marriage testing and divorce and such
others. Brain storming needs to be done regarding these issues.
Some legislation, al present, like the Consumer Protection Act, 1986 talk about consumer rights.
Some of the rights of the consumer under the Consumer Protection Act 1986 are:
♦
♦
♦
♦
♦
♦
Right to protection against marketing of hazardous goods.
Kight to information about quality, quantity standard, price, etc. ol'goods.
Right to protection of interest.
Right to access for variety of services.
Right to seek redrcssal and
Right to consumer education
What we need to focus on here is : Can a patient be called a “consumer”? If yes, under
what circumstances? I here is a strong and urgent need for a broad-based law that explains the
transmission modes, protects the dignity and rights of the patients and addresses key questions
like non-discrimination, testing, confidentiality, screening of blood and the role ol the health
services. But, until that happens, it is the responsibility of the health and counselling
professionals to address these issues in their own settings and establish some guidelines lor (heir
services and activities.
Suggested Readings
Gautam, S.( 1989): The AIDS Prevention Bill, 1989; Protection or Prosecution? The I?awyers,
October, p. 7-10.
Grover, A. (1990): AIDS victims- Isolated by the law The Layers October, p- 4-7
Grover, A. (1992): AIDS act now! ... Before it’s too late, fhy Lawyers, May, p. 4-1 1
Ivey & Glucksten : Basic Attending Skills
Kubler - Ross. E. (1969): On Death and dying, Macmillan
McGoldrick, M., Pearce, J., & Giordano, .1. (1984) : ElbijRi!y_iiudTiiuuly^lJieiapy
The Guilford Press.
Panos Dossier (1990) : The Third Epidemic, Ch. 9 : AIDS, the law and human rights. London :
Panos Publications
Satir, V., (1988): The New Peoplemaking. Science and Behaviour Books Inc
131
ACTIVITY SECHON
Acnvn Y 14: Case Studies:.Ethical A Legal Issues
Time: 45 mins
Objective:
The objective ol this activity is to provide the trainees with an opportunity to examine,
understand and work through some olThc difficult, sometimes controversial, ethical and legal
issues that are related to H1V/A1DS.
Procedure:
Present OHP #9 at the start of this activity to outline the main ethical and legal issues
linked with H1V/A1DS. Briefly describe the implications and meaning of each term on the OHP.
Then, display Case study //I on OHP #10 and ask each participant to write on a piece of paper:
(a)
(b)
What issues docs this case study presenl/indicatc?
What are various options or alternatives for action in this situation? (cncouiJgc
them to generate as wide a variety of alternatives as possible).
Allow 5 minutes for this step. Invite 3-4 participants to share their responses and
thoughts. Note these on a flipchart and make concluding remarks about the general pattern ol
thinking or action that emerges from the responses. Allow It) minutes lor this discussion.
Repeat this process for Case study 112 (Olli’ #11) and Case Study //3 (OHI’ /M2) separately. I ry
to involve as many participants as possible by asking different people to share their responses,
for each case study.
Summarize the activity by underlining that these are dillicull areas and lot some issues
there may be no clcarcut answers. Emphasize that each pmticipant should examine lus/hei own
work situation and come up with options that would be suitable lor that environment.
ACTIVITY 15 : Review Questions
Time: 20 mins
Procedure*
answers should be corrected. Treat the other three questions as personal opinions and genet
discussion points.
-_____________ —-----------------
_____
132
1
OHP//9
ETHICAL AND LEGAL ISSUES
RELATED TO HIV-TESTING AND COUNSELLING
1. Mandatory Testing
2. Informed Consent
3. Confidentiality
4. Partner Notification
5. Equal Opportunity and non-discrimination
133
Olli’// 10
CASE STUDY // I
Ilarish, a 22-ycar old waiter in ai restaurant, went to a nearby
general practitioner looking tor a; cure for discharge from his
penis. Hie general pi actilionei prescribed some antibiotics
and also sent him to the municipal hospital for an HIV test by
just handing him a written note for the pathologist.
I liirisli
came to the hospital and got himself tested, after which he was
asked to go sec the hospital social worker, The test results
would be passed onto the social worker alter analysis. Harish
does not know what he has been tested for and has come to the
social worker to fix an appointment, as instructed by the
pathology department. This general practitioner has been
refei ring other cases also in the same fashion for the past 5-6
months. What are the issues to be examined in this case?
134
OHP# 11
9
CASE STUDY#2
A large pharmaceutical company has heard of III V/AIDS and
its rapid spread in all parts of India, especially t|ic metros. 1 he
company has a total strength of 10,000 employees with about
5% falling in the top management cadre/level. There is a
physician doctor appointed as Chief Medical Officer with the
company, along with 3-4 consultant/spccialists who come in
twice a week. The managing committee feels it would be a
good idea to test all the blue collar workers, to start with, so as
to detect HIV infection prevalence in the company workforce.
It has put this recommendation to the Chief Medical Officer to
give his comments and decision.
What are the implications or possible effects of such a
measure? What would be the reactions of people in dilfcrent
positions or at different levels, fin the company?
135
OHP// 12
CASES 111 DY //3
Ashish is 25 years old and w
<s as a junior executive in a
ks
bank. During his college days, be used to go out a lot with his
friends for drinks, movies, parties, etc. Once, the full group
had gone to a small, two-star hotel where they had
experimented with sex with a couple of commercial sex
workers (organised by the staff of the hotel). Early this yeai,
Ashish had seen 3-4 girls for marriage as he and his parents felt
it was time for him to settle down and get married. He liked
one of them. The girl’s family also liked the match and the two
had gotten engaged three months back. I he marriage was
scheduled in three month’s time.
Ashish had read about 1IIV/A1DS and got slightly worried
about one month before his engagement. He had gone to an
HIV -anonymous testing and counselling centre. After some
counselling, he had agreed to be tested and the results came out
positive. He lias met witli the counsellor lour - live times but
has been refusing to inform anyone in his family (or his fiance
and her family) of his status. He is worried about their
reactions and the consequences and refuses to take the risk. He
has discussed children with his Fiance and both he and his
fiance are looking forward to having children in the near
future.
What are the dilemmas facing the counseHoi !
I3(>
L
WORKSHEET:3
Review Questions
1. Which two communication skills would you rate as the most essential
in HIV/AIDS counselling? Why?
2. Identify three kinds of supportive behaviour and three kinds of non supportive behaviour in the counselling process that are relevant in the
Indian context.
3. List the principles of H1V/A1DS counselling.
4. How do you perceive the role of the counsellor?
5. What are the chief characteristics of:
a. Pre lest counselling
b. Terminal care counselling
6. Please list two ethical/lcgal isues that you feel are very crucial to your
city or state vis -a- vis 11IV/A1DS counselling services. Give reasons
for your choices.
137
MODULE 4
I’SYCllOLOGK AL ISSUES AND SEXUALITY
EXPECTED OUTCOME:
The trainees will gain an understanding of sexuality in terms of sexual orientations and practices
in relation to HIV/AIDS. Trainees will also be sensitized to the skills in discussing sexual
practices, sensitive issues and will be made aware of the psychological issues in relation to 1IIV/
AIDS.
MODULE AT A (JLANCE
TOTAL TIME - 4 I IRS 55 MINS.
CONTENT SECTION
PSYCHOLOGICAL ISSUES
SEXUALITY
SEXUALITY IN INDIA
GUIDELINES ON TALKING ABOUT INTIMATE TABOO TOPICS
ACTIVITY SECTION
30 mins
1 hour
1 hour
EXERCISE: WHERE DO 1 STAND
CONTENT PRESENTATION
EXERCISE ON ST1GMA
GROUP WORK
PAIRED EXERCISE
BRAINSTORMING
GAME AND DEMONSTRATIONS
REVIEW QUESTIONS
30 mins
30 mins
30 mins
45 mins
10 mins
a,
138
OVl R\ IEW
Psychosocial counselling is particularly important in dealing with lll]/AHW and
rerpdres an understanding of the ways in which people react to fear of infi'ction or a threat lo\
life. Some of the emotions (which are normal and common) people experience and express in
testing and diagnosis situations are : shock, disbelieft bargaining, denial, guilt. Jear. anger,
suicidal thinking and depression. Human sexuality is a very important aspect of people's lives
and needs to he well understood by counsellors when doing HIV prevention and supportive
counselling. It refers not only to sexual intercourse/activities but also to feelings, attitudes and
values. One's emotions andfeelings of love also play a large role in shaping one's sexual
behaviour. What is considered as normal by one person in one society may he considered as
abnormal by someone else in another social environment, h is important for counsellors to he
non-judgmenlal about client's sexual preferences and orientation and keep their focus on
exploring safer sex options. Some of the sexual behaviours that need special attention in
connection with STDs and HIV in India are abstinence, masturbation, nocturnal emissions, oial
sex and homosexuality.
To obtain an understanding of the client s behaviour which has led to or places them al
risk of HIV infection, the counsellor must be able to obtain information on sensitive topics such
as sex practices and drug injecting. This can be done only through informed questioning.
Questions must also be used to verify that all clients understand the basic information on HIV
infection and its prevention. Clients must be given advice on safer sexual practices, but told (hat
(he only completely safe behaviour is sexual abstinence or a monogamous long-lasting
relationship. The latter is particularly important in cultures in which advice on sa/cr sexual
practices is not well received, in discussing levels of risk, counsellors will have to talk to clients
about sensitive topics, and will need to decide how ready they are to talk about them. I he
consistent use of condoms must be emphasised and instructions given on how they should be
used.
139
PSYCHOLOGIC AL ISSULS
As AIDS has no cure, the threat of HIV infection is a threat to an individual’s very
existence. People faced with this very stressful event respond in a variety of ways I he news of
having HIV infection may produce some very distinct psychological effects. It is important Ito
recognise the impact o I (he news of 111V infection on the
t infected in<li\ tdiinl in (he linnm ini. Icpnl.
» ■
«
•
•
4•
*
‘
'
•••••■••.11*
*1
familial and occupational aspects of his or her life.
The implications may need to be identified and managed by referral & other appropriate
mechanisms. A variety of emotions have been recorded vis-a-vis people’s reactions to HIV testing
and to the diagnosis of a positive result. It is important for a counsellor and other health care
providers to understand these reactions and support the clients experiences while they work
through these emotions. The major emotions are enummerated below.
Shock and disbelief
1 he news of HIV infection causes intense emotional shock. Il disrupts the
patients usual coping strategies, d otal loss of control, break down or emotional
withdrawal are a few of the reactions.
Bargaining
“I cute them il they slop basing
Some people try to bargain. They think God‘ will
sex. Some people think they wiill get cured if they have sex with a virgin or a
child.
Denial
Some people may respond to the inews of their infection or disease by denying
it. For some people, initial denialI can be a constructive way of handling the
shock of diagnosis. However, if it persists, denial can become counter
productive, since people may refuse to accept the social responsibilities that go
along with being 111V positive.
Guilt
A diagnosis of HIV infection often provokes a feeling of guilt over the
possibility of having infected others that, or over the behaviour that may have
resulted in the infection. The patient may also feel guilty about the sadness te
illness will cause loved ones and families, especially children. Previous events
that may have caused pain or sadness to others and remain unresolved will often
be remembered at such times and may cause even greater feelmgs ol gmlt.
140
i
I’ciir
People with 1II V'infection or disease have many feais. I he leai ol dr mi' and
particularly, of dying alone and in pain is often very evident, lear may be baser
on the experiences of loved ones, friends or colleagues who have been dl with
or died of AIDS. It may also be due to not knowing enough about what is
involved and how the problems can be handled, fears should be openly
discussed in the context of managing the difficulties, and with the help ol Inends
and family or with the counsellor.
Loss
iF?
£.
People with HIV related diseases experience feelings of loss about then lives
•and ambitions, their physical attractiveness and potency, sexua! rekrt.onships
status in the community, financial stability and independence. 1 erhaps the
common loss that is felt is the loss of confidence.
Anger
Some people become outwardly angry because they feel that they have been
unlucky in contracting the infection. They often fee that they have bu.
information about them has been badly or insensitively managed. Ange c
sometimes be directed inwardly in the form of self blame lor acquiring I II V,
in the form of self destructive behaviour.
Suicidal activity or thinking
People who are HIV infected have significantly increased risk of suicide.
Suicide may be seen as a way of avoiding pain and discomf ort or of lessening
SwXnw L grief of loved ones. Suicide
Suicide may
may be
be active
(-.e. del,berate selfactive (i.
injury resulting in death) or passive (i.e concealing or disregarding the onset ol
fatal complication of HIV infection or disease).
Anxiety
Anxiety often becomes a fixture in the life of the person with 1IIV
rellecting the chronic uncertainly associated with the inleclmn. Some ol the
reasons for anxiety are given below:
O progress of health in the short and long term
O ability of loved ones and family to cope
XXXSS’-—. ...... ..
O abandonment, isolation and physical pain
O fear of dying in pain or without dignity
O loss of privacy and concern over confidentiality
conlidcntiahty
141
Dcpi cNsioii
Depression may arise lor a number of reasons. I he absence ol a cine and the
resulting feeling of powerlessness, loss of self esteem, the loss of personal
control that may be associated with frequent medical examinations, and the
knowledge that a virus has taken over one’s body are all important factors.
Similarly, knowing others or about others who died or are ill with 1II V-relaled
disease and experiencing such things as the loss of potential for procreating and
for long term planning may contribute to depression.
142
SICXIIALI TV
Sexual behaviour change of a client is an important component of S 11) and HIV
counselling. Unfortunately, many counsellors find it difficult to gel over being shy, embarrassed
and put off dealing with the sexual issue; at other times, they are judgmental and label a sexual
behaviour as not normal. Counsellors will essentialy the need 4 C’s - Compassion, ( arc.
Communication and Counselling, in order to achieve success in this arena. It is also important to
have a basic knowledge of sexuality and the range of sexual behaviours.
What is Sexuality?
Sexuality is a complex phenomenon which is difficult to define but pci haps easy to
understand. Sexuality refers to the total sexual makeup of an individual. It is cxpicsscd in many
physical ways. It is not confined to sexual intercourse but includes touching, talking, cmbiacing,
fantasizing, kissing, caressing or just holding hands. In addition to covering the physical aspects,
sexuality also encompasses feelings, attitudes, values and preferences. It involves a lot of caring
and sharing. Understanding sexuality is important for safer sex behaviour.
What Exactly is Normal? ,
foday it is recognised that there arc many variations of sexual behaviour. No two people
have the same sexual behaviour. On the other hand, we all like to think that our thoughts and
actions regarding sex are “normal”. In reality, our thinking has been conditioned by culture,
tradition, society and our own emotions and experiences. An appropriate example is ol
homosexuality. A range of responses are expressed by different people about this: I hey are
unnatural”; “Should not be tolerated”; “It is abnormal”; “If found in a work place, they should be
ostracised or sacked”; “It is an alternative sexual behaviour and homosexuals are as good as
heterosexuals”. Whatever may be the beliefs or personal views, counsellors must be nonjudgmental in viewing the client as a person requiring compassion, care and help to practice sater
sex rather than concentrating on changing the sexual orientation.
Sexual Preferences/Oriciitatioiis
One of the sexual characteristics of humans is the preference for certain kinds ol partners
or sexual activities. Although there are common patterns which we share with each other, each
individual is probably unique in his/her pattern of preferences. Fundamental to oui sexual lives
is the gender and type of person we are attracted to because this plays a large pait m determining
our intimate relationships, i.e. arc we attracted to someone of the same or opposite sex. (are pin
preferences predominantly homosexual, heterosexual or bisexual)?
(i,) l,C Persons'^ate atliactcd to and choose to share (heir bodies sexually vvilh persons ol the
opposite gender only, are called hetereosexuals (i.e. man-woman lehtmnsh.ps) octa y
speaking these male-female relationships are more common among people^ In the
contcxltflUV/AIDS, the spread ol'IIIV infection is highest among the heleioscxr.
group
143
Ihmiosexunlily :
(l>)
Persons who feel attracted to or choose to share their bodies sexually with persons ol the
same gender are called homosexuals. In a male-male relationship, the pe.son mas be
termed “homo-phile” or "gay”. In a lemale-letnalc telalionship the petson r; mown as a
“lesbian” The reason why homosexual behaviour is preferred by some Is still dr bate <
The term “alternative sexuality” is becoming a more acceptable term to refer to
preference of one’s own gender group in intimate relationships. Attitudes towards
homosexuality arc changing although there is still a great deal of antagonism, contempt,
anger and misunderstanding among people. 1 lealth professionals are now conung to
accept homosexuality more as a sexual variation than as an illness. Sometimes,
homosexual experiences may be situational as occurs in prisons, some boarding schools
and colleges. The person may participate voluntarily or be forced even when he/she
usually prefers heterosexual intercourse. Studies also suggest that m India homosexuals
sometimes maintain a bisexual cxistence.ln order to ensure soc.al acceptance, people
project a heterosexual nature while carrying on homosexual activity away from the public
eye. .
(c) B,s™^ls are pclsolls W|,(, frequently indulge in both homosexual and heterosexual
experiences namely they are persons who are sexually attracted to or have mteicomsc
with both males and lemalcs. A number of homosexuals are unable to stand upto soc.e a
disapproval or family pressure for marraige and may gel marr.ed, thus enle. mg a b sexual
role Studies also suggest that homosexuals in India sometimes mamtam a btsexua
existence in llial the heterosexual side being (heir public side so as to ensure socta
acceptance. This group is very important and needs attention' keeping in view the It cue
of III V transmission in India which is moving from heterosexuals to homosexuals.
Role of Love and Emotions in Sexuality
Different people have different motivations for wanting and engaging m sexual
.
H n nortant to view sex as an activity that human beings choose m order to fulhll
erC?(could be physical emotional, romantic, economic). Emotions, m particular, play a veiy
a need (conic
I
inve” or “fcclitm attracted" to someone increases
.ole ll'^eni* |ogica| and rational though* « oven cultural
?K
IUc conteX5. i< * e—Ual to oxa,nine n,caning and value that sex
. <
“X
- one one. sugges.ioos or give guidance thui »ouid he
realistic in and respectful of the individual s hie.
advoca^g
’
age, gender, societal nones and cdueanonal levels. I
IO ogc g . |
.........
144
There (ire some dilTerenees between men and women loo. Most women waul lhe sexii il
experience Io be an emotional as well as a physical bond Women lend Io pi-iccive sex nol nicicl\
ns briel genihil conlacl, pleasniablc though il may he. hul also ns shaiinp. an emolionnl inlimah’
part ol each oilier.
I hey engage in sex to gain happiness ol shilling rxpriieiices. lhe Inn ol doing
lhings(sexual and oilier) together. They believe that pleasme is obtained by giving pleasnie to
another.
A couple’s perception sexual pleasure depends on their knowledge of the role ol sex in
intimacy, and the fact that pleasure can be increased by communicating their needs to each other.
Some people obtain great sexual satisfaction from “pure sex ", that is a sexual encounter between
two people who are strongly attracted to each other physically but who have no deep emotional
bond. Others reject Ibis form of sexual pleasure, claiming that unless emotions are involved,
sexual pleasure is inevitably diminished and “pure sex” can never equal “love-sex .
In “love-sex”, the focus is on all kinds of erotic activities from kissing, hugging to mutual
masturbation as an expression of the emotional caring and love between two people. < )ne s
attitude towards the meaning of intercourse also influences (he kinds ol sexual activities. II the
belief is that sexual pleasure can be derived only through intercourse(coitus). it would lead to
deriving pleasure from quick penetrative sex without any emotional involvement. II such a belie!
exists, individuals may seek sexual intercourse from CSWS quite frequently.
Counsellors need to explore with clients their I'eelings and needs about sex. so as a
develop plans of action that are realistic and successful in terms of safer sexual beha < iour.
Counsellors should emphasise that sexuality is not just sexual intercourse but also i.ivtuu.s
touching, talking, embracing, fantasising, kissing, caressing or just holding hands. Counsel.c;..
could also encourage clients to strengthen their emotional bonds with their partners and nr. :
focus on “coitus” or “pure sex”.
145
SEXUALITY IN INDIA: SOME ISSUES
The spectrum of sexual behaviours is wide and should be viewed in the context of
culture. Some sexual behaviours in the context of STDs and H1V/AIDS are mentioned below.
Abstinence
This refers to the act of keeping away from sex. Culturally, in India, a number of young
people believe that sexual intercourse should only be done after marriage. Virginity is till prized.
While recommending safe sex, those wishing to practice abstinence should be encouraged. In
India it is also seen that the sex life of the married couple is often controlled by several outside
forces.
Ideas of auspicious and inauspicious days, and long periods of abstinence after child
birth etc. minimizes the number of days when the husband and wife can be sexually active.
Other periods when sexual abstinence is considered essential, or is inevitable arc during
menstruation and mourning. These long periods of abstinence can lead to men indulging in sex
outside marriage for e.g. going to commercial sex workers (CSWs). Thus the Counsellor must
motivate the client to experiment within the marital relationship as a means of being sexually
satisfied.
Masturbation
This refers to stimulating one’s own genitals to reach orgasm. Most males masturbate
with their hands, while some rub their penis against the surface of the bed or use some object.
Females masturbate by stimulating their clitoris or vagina with their lingers. Masturbation is stil
taboo in India due to a majority of the beliefs related to semen and masturbation. One traditional
belief propounds that one drop of semen is equal to 40 drops of blood and the loss ol semen is
believeo to disturb the powers of concentration, leading to weakening of eyes and moral and
physical power. Masturbation is reported to cause severe anxiety among men as many believe
that long term masturbatory habits lead to insanity, I B, exhaustion, back aches, sunken eyes,
deformity of penis and eventual impotence. It is important for the counsellor to assess and
remove misconceptions and guilt regarding masturbation so that the client can see the value of
masturbation as a safer sex practice.
Nocturnal Emission
Involuntary ejaculation during sleep is called Nocturnal Emission If a male does not
have any other method of sexual release, he will experience “wet dreams’ or nocturnal
emissions. The person will have a dream with erotic content during which ejaculation will
occur He may suffer from guilt or shame or unknown fears when such dreams occur.
Misconceptions regarding nocturnal emission arc similar to masturbatmn. Counsellor must help
their male clients understand that nocturnal emissions are perfectly normal.
146
Oral Sex
Using the mouth in any way on portions of the body is referred to as oral sex. I lowever,
most people believe it is specifically using the mouth on the partner’s genitals. “Fellatio” refers
to the female using her mouth on the partner’s genitals. Cunnilingus is when the male uses his
mouth to stimulate the female’s vagina. Oral sex should be avoided in cases where HIV
infection is a possiblity or other infections/ulcers are present in the mouth. The male should
wear a condom while engaging in fellatio. Studies show that some men like to experiment with
different postures for intercourse or different types of sex including oral sex. I lowever they may
refuse this form of sex with their wives. Such men may therefore, look to relationships outside
marriage for sexual variation, and may even approach CSWs. I his behaviour will have
implications on H1V/AIDS transmission.
Anal Sex
In anal sex/intercourse, the male inserts his penis into the anal canal (rectum) ol his
female/male sexual partner. The female may at times insert a finger or a similar object into the
rectum of her partner. During anal intercourse the woman docs not usually reach orgasm but the
man usually climaxes. Anal intercourse is considered a very risky behaviour, in the context ol
HIV/A1DS. This is because the rectum is small and not as elastic as the vagina; and there is no
natural lubrication or secretion. The lining of the anal canal can easily rupture/crack during
penetration leading to bleeding. Similarly the skin of the penis can get affected/torn. I his can
result in intermixing of semen/seminal fluids and blood (exchange of body fluids) and it leads to
an increased risk of HIV transmission if one of the partners is infected. 1 he risk is usually more
for the receptive (whose anus is involved) partner than for the partner doing the penetration.
While it was earlier thought that only homosexual couples indulge in anal sex, incidences
of anal sex have also been reported among heterosexual couples.
On Counsellors and sexuality:
A few words for counsellors on sexuality
O they should be comfortable and familiar with the terminology of human anatomy,
physiology and sexual behaviour;
they should understand the basic underlying processes of reproductive and sexual
O
they need to appreciate the range and variety of sexual expression in the human culture;
O
O they must recognize the social implications of human sexual behaviour an t ic ic a i\e
nature of these implications in different societies.
they have to work at being able to deal candidly with their own sexuahty in relatmn to
O
oneself and others, and reflect on the related moral and ethical dilemmas.
147
I
TALKING ABOUT THE USE OF CONDOMS
7
The counsellor must emphasise to clients of both sexes the importance of consistent use -A " >
of condoms. Even in the case of strong resistance to the use of condoms, clients must be helped
to assess realistically the risks to themselves and others of not using condoms.
The counsellor should be forthright in telling clients that condoms need getting used to,,
and that they will need to practice putting them on. Clients also need to be told that condoms are
not foolproof against tearing or leakage, and must be used carefully and properly.
Instructions for condom users:
i
I
L
For maximum protection against HIV infection, condoms must be used correctly. Make
sure that you understand and follow these instructions :
o
o
o
o
o
o
o
L.
o
o
.o
't
o
Use a new condom every time you have intercourse. Check the expiry date before use.
Always put the condom on the erect penis before intercourse begins.
In putting on the condom, squeeze the nipple or empty space at the end of the condom
in order to remove the air. Do not pull the condom tightly against the lip ol the penis,
leave the small empty space (one or two centimeters) at the end of the condom to hold
the semen.
Unroll the condom all the way to the base of the penis. .
If the condom tears during intercourse, withdraw the penis immediately and use a new
condom.
After ejaculation, withdraw the penis while it is still erect. Hold the rim ol the condom
as you withdraw, so that the condom does not slip off.
Remove the condom carefully so that seminal fluid does not spill out. Dispose used .
condoms in a closed receptacle.
If a lubricant is desired, use a water-based one, since petroleum jelly may damage
condoms.
Do not use saliva as a lubricant - it is ineffective and may lead to breaking ol the
condom.
Store condoms away from excessive heat, light, and moisture, as these cause them to
deteriorate and perhaps break. Do not keep them in the glove compartment of cars or a
wallet for long periods of time.
Condoms that are sticky or brittle or otherwise damaged should not be used.
Even the well educated may find these instructions may prove difficult to follow. It ispreferable that counsellors become conversant with them and then explain them in simple
language. Use of simple graphic material(adapted to the culture) is recommended. Consider
adapting the culturally appropriate graphics already in use by family planning associations in
I '
your area.
I
148
1
I
THE CONDOM
STRONG....
....SENSITIVE
SAFE....
..AND SIMPLE
GUIDELINES ON TALKING ABOUT SENSITIVE TOPICS
It is necessary for counsellors to obtain an understanding, or history of the behaviour
which may have exposed the client to IIIV infection or AIDS. I his means that counsellois must
be able to gather and interpret information about very private - and sometimes illegal 01 socially
condemned - behaviour. There is no simple formula for getting people to talk about topics such
as their own sexual activities, drug injecting or responses to infection from blood transfusion.
Effective discussion of sensitive topics will depend in large part upon the ability of the
counsellor to:
O Gear his/her communication to the emotional and intellectual level ol the client
O Make the client feel safe and secure by establishing a supportive relationship; and
O Demonstrate his/her own ease in talking about topics usually avoided in ordinary
social life or in medical consultations.
Whatever approach a counsellor uses, it will require skill, tact and sensitivity towards the
client. With some clients, counselling can be a process which develops gradually and may need
to be eased into slowly. A rapport will need to be established, early on together with an overall
atmosphere that helps the client to develop a feeling of safety and trust. Without this, the
counselling process will not be completely successful. The counsellor’s style must therefore be
reassuring, confident and direct, but considerate of the client’s feelings and fears and should
acknowledge the client’s dilficulty.
149
'Phc following guidelines on talking about sensitive topics may be useful for counsrllois.
1.
Ask direct questions so as to be clear about what is worrying the client, and w hat
lie or she wants and expects front the counsellor.
Example : What do you want from me (this clinic, hospital, etc.) right now? What
made you decide to come her now?
2.
Establish the reasons for the client’s concern or belief that he or she is infected or
at risk of infection.
Example: You tell me that you are afraid you have AIDS. Tell me what you know about
the ways in which people become infected. In which of these ways are you most at
risk?
3.
Anticipate a certain degree of embarrassment discussing sex; point out that you
realize that people do not usually discuss it in such depth.
Example: We do not usually talk very openly about sex in our country. But now, since
you believe you may have been at risk of infection, you and I must determine the
degree of risk. To do that, I have to ask some very specific questions. Most people feel
a bit embarrassed by these questions, and you may too. For example, 1 need to know
how many sexual partners have you had over the past six months.
4.
Explain clearly why you must enquire into sexual practices and drug in jecting habits that it is in order to determine precisely w hat the client needs to do to
prevent becoming infected or passing the inlcctipn on to another person.
Example: 111V is transmitted' in a nutTibcr of quite specific ways. You know (hat
sharing needles is dangerous for you and for others. What can ;you do Io keep
. ,youisell'
free of infection, or to protect other people?
5.
Explain the reason why you are asking questions about all forms of transmission.
Example'. Sometimes people are offended when I ask about practices that seems strange
or even repulsive because they are not common in this area. But, people travel, and
sometimes experiment, so we must make sure that al the possible risks aic coveicd.
In such interviewing, the counsellor should use the formal expression first (c.g. vaginal
intercourse). If it,is not understood, the slang expression should be used and the client
asked which one is preferred. The client must not feel that the counsellor is making any
moral judgement on any sexual behaviour or other risk behaviour.
6.
Be very explicit in getting information about sexual practices
Question : What do you think people find most difficult to give up (whatever the risk
behaviour is?) What do you think might be hardest for you? When you say you do
some risky things, what do you mean?
150
Question : Do you think it is possible lot yon nml yotu spouse/pnilnei Io nbslinn honi
sex? Have you tried condoms? When you and your spouse/paitnei talk about
condoms, how comfortable are each of you? This information must be communicated
in language and terms that the client understands. Thecounsellor will need to try
different versions and will have to vary them lor individual cases.
The counsellor should anticipate that some of this information may be met with
embarrassment laughter, turning away, or even anger, depending on the cultural context, l or
example, a person might become angry with counsellor who mentions masturbation, on mhgious
IZs As always, the counsellor should respect the clients beliefs. However the counselb.
should point out that everyone is entitled to complete information, whether or not a decision
made to act on it.
it is imperative that the counsellor acknowledge that changing sexua
patterns or behaviour, and maintaining that change, is very diflicull.
Cultural expectations about sex roles and sexuality, and about
childbearing, must be discussed. A suggestion about condom use w nc i
makes good sense to the counsellor may be perceived by a client as an
assault on his masculinity or as a threat to the relationship with the spouse.
Suggested Readings :
Gordon, S. & Snyder, (1989):
health. Boston : Allyn and Bacon.
I„mn.. .ln..mnl of Social Work. Special Issue : Sexual behaviour and AIDS io India. Vol LV,
No. 4. Bombay: 'fata Institute ot Social Sciences.
Kakkar Sudhir, (1989): bmm.atH(daUi>ih : ExpknilJJKbanSfiXliahlX* Ncw Dclhl ' 1
Books.
Kothari P. (1987): Common Sexual Probiotic Bomba? : V.R.P. Publishers
t»i$ - 3^
151
Acrivn y srxnoN
ACTIVITY 1 : Where do you stand?
Time : 30 mins
Objective :
The purpose of this activity is to make the trainees identify personal values about sex and
to be able to discuss these values with others. It also gives them a chance to listen to different
opinions and values from their colleagues. There are no right or wrong answers. The purpose
is not to convince others of your values but for everyone to listen to new or different ideas.
Procedure :
Prepare two signs which say “AGREE” and “DISAGREE”. Tape them on the walls on
opposite sides of the room. There might not be enough time to work with all the statements listed
below, so the trainer can choose those statements from Worksheet 1 that arc most relevant and/
or controversial for the group. The trainer should read each statement and ask the trainees to
decide whether they agree or disagree with statements and accordingly stand near the AGRIT7
DISAGREE signs. Trainees can go to the middle of the room if they are undecided. Encourage
them to choose an opinion.
After you have read (he (list statement and the participants have moved Io opposite sides
of the room, ask each participant to lind a partner in their side of the room. Each person explains
to his/her partner why he/she agrees or disagrees with the statement. This should take about 2
minutes. There should be no discussion. The trainee should only listen to what the other person
has to say. Next, ask every person to find another partner, this time from the opposite side ol the
room. Repeat the same procedure of sharing.
Read the next statement and repeat this procedure. You can vary the ways in which
participants discuss their opinions/values with each other. For some statements, you may ask
them to discuss only their values with someone or several people from the opposite sides of the
room. For other statements you might ask people from both side of the room to share their
views. Continue this activity till time permits. At the end, spend 5-10 minutes asking the
following questions to facilitate an exploration of the impact of this activity.
Questions for Discussion
♦
What surprised you?
♦
Mow did you feel exposing your values to each other?
♦
What was it like to see that others disagree with you? How did you feel?
♦
How did it feel to listen to different views, without trying to change other s opinions?
♦
Did you change any of your views after listening to different ideas?
♦
How might your values and attitudes bias HIV/A1DS counselling? What can you do to
keep your values from influencing HIV/A1DS counselling in a negative way?
152
WOW SHEET 1
Statements about sex
A)
Parents should not allow their daughters as much sexual freedom as they allow their
sons.
B)
Children should be taught about sexually transmitted diseases (S I Ds) and AIDS at
school.
C)
It is alright to have sex just for pleasure.
D)
It is okay for a man to have extra marital sex.
E)
It is acceptable for a woman to have premarital sex.
F)
People who have HIV infection should not have sex.
G)
It is more important lor a man to be sexually satisfied than a woman.
II)
Parents should discuss safe sexual practices with their teenage children.
1)
If a wife wants to use a condom for HIV prevention, but her husband does not, then the
wife has a right to refuse sex with her husband.
J)
It is alright for men to have sex with other men.
K)
Talking to teenagers about sex encourages them to practice sex.
L)
It is alright for parents to allow their sons to practice sex before they get married.
I
153
<
ACTIVI TY 2 : CoiHcnt I’tcsciiliilion
Time: 60 mins
Objective :
The purpose of this activity is to gain an understanding of sexuality and the psychological
issues in relation to HIV/AIDS.
Procedure :
The trainer highlights the issues brought out in the content section of this module.so.that
trainees have a better idea of sexuality and the psychological issues in relation to HIV/AIDS.
ACTIVITY 3 : Fear, Stigma and Stress
Time : 60 mins
Ma“riais;
i,;3
Objective:
The purpose of this activity is to let the participants experience the fear, stigma and stress
associated with HIV/AIDS.
Procedure :
Divide participants into pairs with each person in the pair designated “A” and “B".A’
explains to “B” that the results of a recent blood test reveal that “B” is 111V posit, ve. B
>cn
“S words all hi. or her leers eboor .bis news. A sbooid—•
‘I”'*,,..
“B”“ P “•inios
Moon - -esui.s » “A"
for 10 minutes again.
Bring the full group together and ask group members to call out the feelings that \\cic
expressed. Write the results shared by the participants under the headings tear, stigma and stres
on the flip charts for people to see.
In pairs again, “A” who is a boss, says to “B” an employee :: “ There are rumours going
should be instructed to be persistent
.............
154
Discuss this second role playing scenario with the lull group in lerins ol:
♦
♦
What fears emerged?
How would you feel to hear that your colleagues and
friends were talking about you in that way?
Next, ask the group to call out things that are said about people with H1V/AIDS. Write
the responses up on the prepared flipchart, under WORDS. I hen ask how people with I If V/
AIDS feel when they read or hear these things. Write the responses on the flipchart under
FEELINGS. Encourage feelings to emerge. Finally ask participants how people act oul these
feelings. Write up the actions called out by participants on the flipchart under AC 1 IONS.
Trainer must discuss that, following these actions, newspapers make their reports sensational and
scandalous. Thus we have the vicious cycle of STIGMATIZATION.
ACTIVITY 4 : Small Group Work: Sexual terminology
'rime : 30 mins
Objective :
This session is designed to help the counsellor - liiiinccs practice talking aboutI sex and
referring to sexual activities.
sexual terminology, and to have trainees feel more comfortable
c--------
Procedure:
Divide trainees into small groups of 4-6 people. Distribute Worksheet 2 Ask each group
to come up with acceptable and slang terms for each of the given terms m English and/o. them
local language. After 15-20, minutes have the trainees rc-assemblc as a lull gioup. Ask iacl
group member to read out one word from their group's list for the large group to hcai. V
practicing this skill of using acceptable sexual terms, they will reduce possible future d.dculUcs
in talking to clients about sexual behaviours. Wrap up this session by stating that a good ■
counsellor should be able to select the “acceptable category” words to reler to any of these sexual
terms without offending the clients, and without feeling too uncomlorta lie.
155
WORK SIIl'.IC rZ
J
Sexual Terminology
Technical English
1.
Sexual intercourse r
2.
Semen
3.
Ejaculation
4.
Penis
5.
Vagina
6.
Masturbation
7.
Orgasm
8.
Breasts
9.
Anal intercourse
10.
Kissing
11.
Oral sex
12.
Erection
13.
Buttocks
14.
Condom
15.
Homosexual
Acceptable terms
English/Local language
156
Slang/
Colloquial words
ACTIVITY 5 :
Paired Exercise: Developing Communication Skills to Discuss
Sensitive Issues Related ( Sexuality
Time : 30 mins
Objective :
This activity builds skills among trainees for discussing sensitive issues and increases
their awareness of the associated discomforts.
Procedure :
The trainer starts by asking the group for examples of sensitive issues. I hen he/she
divides the group into pairs and explains the activity:
“One of the pair will act as counsellor and the other as client. 'Chits’ or small pieces ol
paper will be passed to the 'client’ in each pair containing the description of a sensitive
counselling scenario. The counsellor should try to help the client with his/her concern or
dilemma”.
Use one of the scenarios listed below and begin the activity. Alter 10 minutes, the lull
group re-assembles and each of the counsellors and then the clients, share their experience
(feelings and thoughts) with the group. The trainer concludes the session by using OH I /H and
going over the five guidelines listed.
COUNSELLING SCENARIOS :
□
1 suspect my girl friend also has other boy friends but I love her. I am ahaid ol AIDS
and when I ask her abourt other boys she gets very angry and tells me I do not trust her.
What can I say the next time 1 see her?
□
Besides my wife, 1 have a regular girl friend. 1 always use a condom to avoid a
pregnancy but she insists 1 should not use a condom during her mensli nation peiiod as
it is a sale period. What shall 1 do?
□
I think that my son is using drugs, but he has not talked to me about it yet. Should I
bring it up?
I
□
My wife and 1 have occasional anal sex and have been doing this for years. I was .
recently told that 1 can get AIDS -1 am now afraid and have come to you tor adv.u .
□
I am afraid of oral sex. Is it bad? Am 1 in danger of infection, particularly AIDS?
□
1 have a boy friend with whom I regularly have anal sex. 1 do
I am 17-year old boy.
not want to stop but 1 am worried it may not be healthy lor me.
157
OHP # 1
GUIDELINES ON TALKING ABOU T SENSITIVE TOI’K'S
Ask direct questions so as to be clear about what is
1.
worrying the client and what he/she wants and expects
from the counsellor.
2.
Establish the reasons for the client’s concern or belief that
he/she is infected or at risk of infection.
3.
Anticipate a certain degree of embarrassment at
discussing sex; point out that you realize that people do
not usually discuss it in such depth.
4.
Explain clearly why you must enquire into sexual practices
and drug injecting - that it is in order to detei mine
precisely what the client needs to do to prevent becoming
infected or passing the infection on to others.
5.
Explain why you arc asking questions about all the forms
of transmission (viz. you are making sure that all possible
risks are covered).
L
ACTIVITY 6 : Brainstorming : Safer sex
Time : 30 mins
Objective:
This activity shows trainees how to identify behaviours with clients that will reduce their
exposure to risk of HIV transmission.
Procedure:
The trainer draws a line down the middle of a large sheet of paper or board and heads one
.side as “Good things” and the other side as “Bad things” as shown below:
GOOD THINGS
BAD THINGS
The group offer their ideas about good things one enjoys/likes and bad things or the
negatives about sex. Once the paper or board is full, the trainer brings the group around to
considering ways/behaviours by which the good things of sex can be kept and the bad things
(risks) avoided or reduced.
The trainer also encourages the group to focus on the trainee’s perception about emotions
(love, desire etc) being the good/bad parts of intercourse. He/she asks trainees to summarize the
major points that have been shared. OHP # 2 is shown to highlight safer sex options as the
conclusion of the activity.
ACTIVITY 7 : Game and Demonstration : Correct Condom Use
Time : 45 mins
Materials : Comdoms, penis models/bananas/bottles and tissue paper.
Objective :
This activity aims to make all trainees more experienced at discussing and demonstrating
condom use.
Procedure :
Each trainee needs a condom for this next part of the activity. Ask all trainees to open the
condom packet and handle the condom. Some trainees can try to inflate the condom. They
should all stretch the condom to see how strong the condom is. Make copies of the condom cards
for each group and mix them up. Handout a set of the condom cards to the subgroups of 3
trainees. Ask the group to put the cards in order.
159
V>
After 5-10 minutes, the trainer demonstrates how to use a condom using a penis model,
bottle or banana. State the steps as you carry out the demonstration. The trainees should correct
any mistakes in the order/sequencing of their cards. Then distribute condoms, models and tissue
paper (for wiping lubricant off fingers) to all the trainees. Each trainee should act out teaching
one of the group members how to use the condom while the other monitors (by silently leading
the cards) in pairs. Each should take a turn.,Then discuss how they feci about teaching condom
use. In what situations might they/might they not be comfortable teaching how to use a condom?
What prevents or makes people reluctant to use condoms?
ACTIVITY 8: REVIEW QUESTIONS
Time : 10 mins
Trainees Illi up Worksheet-3 within 10 minutes. Trainees can discuss their answers with
a partner or with the trainer.
160
' V f
WORK SHEET 3
Condom use cards
Carefully open the package
so that the condom docs not
tear. Do not tinioll the
condom before putting it on.
If not circumcised, pull the
foreskin back. Squeeze the tip
of the condom and put it on
the end of the erect penis.
161
Continue squeezing (lie tip oi
the condom while unrolling,
until it covers the entire penis.
Always put on a condom
before entering your partner.
162
i
After cjacuhition, hold i'ioi ol
the condom and pull penis opt
with condom before looping
erection.
Slide condom off without
spilling the semen inside.
163
c
'l ie and wrap the condom (in
paper), then throw in a dust
bin. Wash hands.
a
Bui n or bury the condom
with other trash. Wash
hands.
164
OHP # 2
SAFER SEXUAL ACTIVITIES
Talking, writing or reading about sex
Watching sexy films and live shows
Individual masturbation
Deep kissing
Mutual masturbation
Sex with underclothes on
Sex with other parts of the body (e.g., thighs, breasts)
Penetrative, orah vaginal and ana! sex using condoms
V
165
L
WORK S5SRE'!' 4
J
Review Questions
1.
In your own work place or community, which of the high risk practices would be most
difficult to talk about?
2.
Explain the following terms:
Bisexual
C
Masturbation
Non-judgmental attitude
3.
How comfortable will you feel discussing the sexual behaviour of your client if hc/she
is of the same sex? (please circle one)
Comfortable
Very uncomfortable
Very comfortable
Uncomfortable
4.
How comfortable will you feel discussing sexual behaviour it your client is ol the
opposite sex? (please circle one)
Comfortable
Very uncomfortable
Very comfortable
Uncomfortable
166
MODULE 5
SPECIAL ISSUES
EXPECTED OUTCOME
Trainees will become aware of the special counselling needs of substance users, women,
children and individuals involved in non-heterosexual relationships.
MODULE AT A GLANCE
TOTAL TIME - 3 HRS 35 MINS
CONTENT SECTION
SUBSTANCE ABUSE IN INDIA
WOMEN
CHILDREN
NON-HETEROSEXUAL RELATIONSHIPS
ACTIVITY SECHQN
GROUP DISCUSSION
DEMONSTRATION
ROLE PLAY
ROLE PLAY
QUESTIONNAIRE
REVIEW QUESTIONS
40 mins
15 mins
45 mins
45 mins
50 mins
20 mins
l
167
I OVERVIEW
In most countries substance abuse plays a major role in the spread of HIV. Prevention
efforts must target not only people who use intravenous drugs and their sexual partners, but also
people who abuse other substances including alcohol. The use ofsubstances by any individual,
must be reviewed in the context of HIV/AIDS prevention. The importance of avoiding sharing
needles, syringes and other injecting equipment should be emphasised. The use of bleach to
sterilise injecting equipment should also be explained.
Women with HIV-infection are at particular risk of social isolation in their families and
communities. The sitpport and assistance needed by these women in re-establishing social
networks wherever possible is very important. The decision to undergo HIV testing is quite often
in relation to a woman's desire for, or in response to, pregnancy. Decision making about
pregnancy will be an important part of counselling women, as they re-consider their lives in
terms of HIV-infection.
The counsellor must ensure that, the woman being counselled understands what specific
factors within her own life constitute a risk for HIV infection or re-infection. She must
understand that seronegative women, like seronegative men, should be assisted to understand
what choices they have in behaving responsibily to protect their own and others ’ health.
HIV infection in infants and children requires a great deal of knowledge, stamina, and
sensitivity on the part of the counsellor. Parents and those taking care have to be given
consistent emotional support and information to enable them to provide adequate care.
Counsellors should be sensitive to the fact that infected children and their families may
experience discrimination. This means that the counsellors must provide strong emotional
support to children and their families and try to educate teachers, other parents and other health
workers.
Counsellors need to be aware ofspecial counselling needs of individuals in non
heterosexuals relationships. Sexual preferences ofsome people which may be socially
unacceptable at present in India need to be considered; Eunuchs, Homosexuals and Eisexuals.
168
SUBSTANCK ABUSl, AND AIDS IN INDIA
The problem of Intravenous Drug Users (IVDlJs) was not considered seriously one in
India, except in certain pocket's. It is reported that in the North-Eastern states like Manipur,
Nagaland, Mizoram and Assam where the percentage of drug users itself is high, intravenous drug
use is wide spread. In most cases needles are shared and are seldom washed prior to sharing or
are washed using plain water.
Studies indicate that 1VDU is more common than believed in metropolitan regions and
smaller towns. Thus, prevention efforts are a must in view of the sharp increase in the proportion
of IVDUs among those infected. Since transmission rate after exposure to infected blood is very
high (90% or higher) and since there is multiplicity of high risk behaviour namely, Imultiple sexual
partners and alcohol abuse, this adds to the vulnerability of the IDVUs to infection. It is estimated
that this group is the most vulnerable to infection in India. Currently only 13.45% of those who
are HIV positive in the country (statistics upto 31st March 1994) are IVDUs. In terms ol sheer
numbers, the figure is staggering, and is poised to rise steeply.
Prevention efforts must target not only people who use intravenous drugs, and then sexual
partners, but also people who abuse other substances such as alcohol. The use oi substances by
any individual, must be reviewed in the context of HIV prevention. Some examples of substances
that are abused are alcohol, marijuana, smack, heroin, opium etc. HIV infection can be
transmitted in substance abusers in the following ways:
O Direct ti ansniission : sharing of hypodermic needles, syringes and other equipment.
o Sexual transmission : intravenous drug users can transmit HIV to sexual partners.
o Perinatal transmission : women who are intravenous drug users or are sexual paUners of
nlravcnous drug users and are infected with HIV can transmit the virus to the child.
o Suppression of the immune system : drug and alcohol use compromises the immune
system and increases a person’s susceptibility to HIV inlection. I his may also
increase the speed of disease progression once a person is infected with HIV.
judgement : use of alcohol and drugs reduces inhibitions and decreases the
o Impaired
likelihood of a person practicing safer sex and/or using condoms ellectivcly.
169
Definition of Substance Abuse ,
Substance abuse includes both alcohol and drug abuse. Substance abuse is the use of
substances where by the method,.quantity and frequency in which it is taken leads to physical,
emotional and sociological problems. Substances use becomes problematic because it interferes
with a person’s physical, psychological or social functioning. This might include:
O Medical problems directly related to substance use.
O Relationship and family problems.
O Depression.
O Inability to hold a job.
O Legal problems.
In general, the use of some substances like tobacco and alcohol is sanctioned in all
cultures. The standards by which these substances arc judged to be problematic usually dillcr
from those used to assess substances which do not receive cultural sanctioning, for c.g. like
opium, crack, coke, brownsugar etc.
Thus people using substances that do not have cultural sanction experience guilt and
shame may hide their activities from family members and other people and may associate only
with peers who are also addicted to these substances. Reaching out and counselling these people
becomes a challenge as one has to break through a lot of secrecy and barriers.
Common Myths and Prejudices About Substance Use
O Substance users are immoral or bad people.
O Substance users cannot change their behaviour.
O There is no point in treating substance abuse for a person with AIDS.
Counsellors need to examine these myths and see if they also hold these views. I his
would seriously hamper reaching out and providing HIV/AIDS prevention information to clients.
uy
INTRAVENOUS DRUG USE1
SHARING NEEDLES
<
170
RISK REDUCTION FOR IVDU’S
'I he counsellor must emphasise the importance of avoiding the use of drugs. I he
counsellor must also emphasise that if drug use cannot be avoided, then it is important lo avoid
injecting drugs. If the person cannot avoid the use of injecting drugs then, hc/she needs to be told
to avoid sharing needles, and syringes and other injecting equipment. Explain the risk of 1IIV
transmission through sharing needles and syringes and other skin piercing instruments.
Instructions on maintaining clean injecting equipment can be given as follows:
The first step is to flush the equipment several limes with clean waler lo gel rid of (he
blood or other debris stuck inside the equipment.
Then either:
sterilise by boiling the injecting equipment for 20 minutes
OR
use bleach in the following manner:
or
A teaspoon of household bleach should be mixed with a litre of water
Put the solution into a bowl and flush the syringe and needle with the solution twice.
The syringe and needle should be Hushed twice with water.
171
WOMEN
In the world, the number of women infected with HIV is growing luster than Hie mtmbei
of men This is due lack of education, cultural beliefs regarding the role of women wHhm the
lamily and society, and lack of economic power. All of the above factors influence the 'clative
vulnerability of women and their access to means of prevention and support in the lace of AIDS.
Issues which are of special concern to Indian women are discussed in this section. Women
can be infected with, as welfas can transmit HIV. In either case, the counsellor must clearly
understand certain psychosocial and cultural issues as they have important unpheatmns lor women
and related issues such as childbearing.
Contraception and sexual behaviour
The counsellor should be comfortable talking frankly about contraception and HIV
SSSEiSSSSiS
he left in doubt about how HIV is transmitted. The need to use condoms should be s icssed in
s«x“ “iXships which ..cou.sidc.mblc, mutually r.iU.lul and monogmous rdahoosh.p.
Sometimes the ptessu.e on women 10 bear cl.ild.cn and .heir desire ... do so. may make a
deei JXoid pregnancy very dinieuh. A decision shmid «I.
X
be .old eery clearly about the risks k»M^invdnlec.ed wo.nen have access
.......
and follow-up with regard to their choice and use of contraceptives.
f are sale
employed
(*
...
=i==i,
...................
I==“=!S='==‘-'--........ ......
infection.
Usually, Indian women are uncomfortable or
1‘
use condoms. There is also an implied lack of rust^t
slll,port her
the use of a condom. The counsellor must explore tm. pi
tliat coik1o111s ale
motivation for condom use to avoid mlectton ^^Xeption, women have to take
used and used properly. As in family planning
womaiVs job lo encourage the use of the
Xo ooX “Js S«eslid .ha. e.Ja„sell.,.s h.fonn . ......... .»■!! .
men about the effective use and disposal oi condoms.
I
172
(
^hlpVf^cHher starls/rcquests
L
'I'lansinission ol'I IIV cnn be i'acililatcd by the presence ol gcnilal lesions, inllaininalions.
secretions, and scarification. ThelUD has been implicated by some researchers as possibly
increasing transmission. In India women often avoid seeking treatment for S I Ds due to the
shame, stigma, fear and guilt associated with these illnesses. In regard to these conditions, women
should be encouraged to provide themselves a measure of protection through seeking treatment
for genital conditions, choosing appropriate birth control and avoiding sexual intercourse when
genital lesions of any type are present.
otswvjtaiawMv* awrarMva
!
L
wwaarrn
It is important that society as a whole recognize that the spread of
HIV infection results from both male and female sexual behaviour.
In most cases, women are infected due to their partners behaviour. I listoi ically, the focus
t
has been on prostitution and its relationship to HIV infection. Focusing on prostitution and its
relationship to HIV infection has the detrimental effect of implying that women are responsible for
the spread of HIV. In addition, it draws away attention from male heterosexual behaviour.
Therefore it is essential that counsellors carefully examine the sexual history ol the woman-client
and her partner to reduce the possibility of assuming that the fault lies with the woman.
Nevertheless, prostitution is on the list of behaviours which can lead to HIV infection. It is
not prostitution per se that puts a woman at risk of HIV infection, but rather the number and
types of sexual contacts as well as the risk, behaviours of the partners. It is important that you as
the counsellor remain non-judgmenlal in dealing with these women, and advocate the use ol a
condom for both HIV and SID prevention.
Women bear an undue burden
of negative factors which
increase their risk to HIV/AIDs.
/ffOiKiOrAiC. At
7
LA’
j
Z '"A
V'?/*40 'x
L
r
A
.MV
; &
i
. /j
l
173
I
Counselling women in pi e-testing silmitions
Early counselling contacts, ideally in pre-testing, should especially locus on helping the
woman feel safe in the counselling setting. As 111V counselling inevitably leads to discussion bl
sexuality, many women will prefer a female counsellor, at least for the discussion of mtnnate
matters.
Information about reproduction will be part of any pre-test counselling with women, and
counsellors must be clear about the facts. Testing may be a determining factor m decismns about
reproduction. The counsellor must reassure a woman that it is her choice to undei go testing, n
Indian woman may refuse to be tested, either because of her own or her partner s wishes, as she is
viewed as the potential bearer of a son. Expectant mothers who are HIV positive or spouses ol
infected persons may value the pregnancy/ma ernity to such an extent that they insist on
continuing pregnancy inspite of die HIV positive status ol one of the spouses. Whatevei he.
decision, the counsellor must try to ensure that the woman receives the best possdile mcdiUl care
and provide her with supportive counselling Uiroughout.
The counsellor must provide guidance about HIV testing. Due to of the “window Jriod”,
IIIV antibodies may not be detectable until some months after exposure. I he counscllm should
take into account the “window period” and the degree of the woman s contmumg exposum m
considering the need for, and frequency of, repeal leslfing.
Counselling women about a negative test result
The counsellor should ensure that seronegative women understand that, like stioneg
men they should always act in ways to protect their own health and that ol their spouse.
Uninfected women, whose sexual partners are known to be infected, or at nsk of bttommg
infected should clearly understand hew unprotected Sexual intercourse with such paHnus puls
to?options for negpiiafn.s safer sex. ...eluding regntar use o! c.ndu.us. ,.»y
be rehearsed in such circumstances. As Indian women often do not have a choice o
contraception, this may be a di fFicult situation and so she may need the counsellor s gun a cc
addressing her spouse.
The positive 11IV test result : Psychosocial Issues for women.
Counselllors counselling women who have already tested positive for 111V or who have
bec„ 4 d.... T=i «
ZX XXX p^, or Child is
syw—JXSX-XXXX «actual
... -illness
... ..olh"her‘"child
iij “ra"as
own illness.
174
Indian women are ol'len either unaware ol their positive status or they may be the las!
ones in their family to know their diagnosis due 'he power hierarchy in the family structuie.
Disclosing her infection to Iter sexual partner ano .amily can be very distressing, and is likely to be
an important issue in an ongoing counselling relationship.
For women, the concerns regarding HIV infection are not merely medical but also threaten
her social and cultural identity. It is an unfortunate reality that when the iirst case is identihcd
within the family, the blame is most often attributed to the woman, even if the evidence
contradicts this. The counsellor must provide emotional support in such circumstances and also
acknowledge the woman’s fear that her family and ’fiends will abandon her because ol her actual
or perceived past behaviour.
A single woman’s seropositive state, may be the First indication which reveals to her Ihmily
or intimate friends a secret life that involves activ ties which she has engaged in and winch would
be condemned by others. For a married worn-- her partner’s inhdehty may, lor the hmt time, be
made undeniable. The confrontation of these
is within the family unit may be veiy desti active.
lllV-infcctcd women often feel extremely lonely and isolated. Fear ol social stigma
compels them'to keep the condition secret. Their main fear is that of being abandoned, thereby
depriving them of the support from family, friends, and community orgamzalmns Jfe-estabhshmg
connections with the family and other social groups, Fmding substitute sources ol suppoit and
examining the basis of her fears is often a major task for the counsellor.
The counsellor may help an infected woman acknowledge and talk about her leclmgs
Very common emotional reactions include; anger towards the person, usually the sexual pa tne
who ini'''-led her- grief at her loss of health and status, al a changed body image and sexuahty. at
the possibility of living to give up concieving children and the possibility of dying and leaving her
SE aline and guill relating !o how she may have been the cause of illness m her own famdy.
particularly her children.
arc used with infected or ill women. Decision-making
Various forms of counselling
counselling may be a major focus for infected women who have children or am pmgnaiit, as they
will have to deal with cultural and religious beliefs and medical realities.
Counsellors should help women ideulify Iheirexislms ^'““X^omrXrsshouU
XkCSl’eml7L^en»ine^
families and commuoiliesismetreolive way of Mdmg individual clieu .
Women’s peer-6OTps may be Imoiher effectivo means of
are eslmnged from family and friends.
benefit from meeting other women who arc Hi V-positive. A counseuo
175
g(J
y
Position to arrange such meetings. There arc many advantages ol contact with other Ills -in cctcd
women. In cultures where support groups are r e or non-existent, the counsellor may be able to
create situations which teach women to help eac. > ether through difficult times. I. his, m turn,
couid provide the basis for the fonnatiou ol a gio ip.
Seif-help projects on HIV/AIDS education and support.can be doubly helpful lor women.
It not only helps them speak publicly abut their i’lness and find direct avenues of support, but also
helps them gain skills and confidence that come from being a recognized teacher mid helpe.
Involvement In education and support projects ah o' gives Union a new family lor suppoi . 11 !S
important for HIV-positive people as well as tluri • commumty to see that HIV positive people can
be contributing members of the community.
Women of childbearing age who are HI V infecU should receive post-test ccunseilmg m
order to enable them to make an informed deci^on about whether or not to avotd pregnancy, k >s
inwortard for the counsellor to explain that HIV can be Ulansmttled from an infected women to
Soetus during pregnancy or to the infant ch ring birth or through breast-ftedmg. The pregnant
woman should be ptenared for the possibility that the child will be born with HIV imection.
However, there is at least a 70% cb. nee of having an umiifected mlant.
Currently the risk of transmission ton the mother to the infant is estimated to be between
20% and 45% The prognosis for the pregnant woman with HIV infection, in terms of disease
nropression is uncertain. It is believed that in the early s ages of HIV infection, piegnancy has
lirtle if any effect on the complications and outcomes o| pregnancy. 1 his may not be the case in
XsZ's of HIV infection, especially when the womak has AIDS. Ihe pregnancies m women
with AIDS are more often complicated, especially by eariy (premature) labour, as might s
expected in seriously ill or debilitated women.
When HIV infection occurs during pregnancy or when an HIV-infected womair becomes
t counselling on possible courses of action during piegnancy is generally hmiteu to
StXte support and careful discussion of possible outcomes. Infected pregnant women
rrv r-uire more frequent medical and psychosocial support, services. A high ievc! of
psychosocial support may be necessary in cases where to are difficulties with the family dun g
and after pregnancy.
Wian women rerely take pre-natal care. In a study conducted in 1988 by Professor
Stol^TSrZZ^^^
of the child. The pounsellor should (liercforp insist on icgutar medical check-v ps.
«A pregnant woman is view
.^ves «...« ha,f.a son. Ife Ghor's e^ib^n in
- - «s
determining Hie sex of the child is down played u-d Hie woman’s leitilily is evaliiaicil nrraliv<lv il
the couple do not have a son. The counsellor mu I keep in mind the above prevalent cultural
attitude while counselling pregnant HIV positive women.
While the tragedy of a child born with HIV is compelling, women’s decisions must be
placed in the larger context. Studies and interviews show that many women, will often choose the
risk of bearing an HIV-positive child. Even where women first learned of their sero-status during
pregnancy and aborted, many chose to carry subsequent pregnancies to term. While it is
extremely important for counsellors to help women and their male partners assess the risks of
giving birth to an infected child, it is equally important to help the woman or the couple to find
other means of feeling socially valuable or productive and improving their sense of selfworth and
purpose in life.
Another problem that exists in India is that of illegal abortions. These arc still practised in
the case of unwed mothers and those women who are unaware/embarrassed to use proper
medical facilities. It is possible that HIV positive expectant mothers may avail of these facihlies to
abort the foetus, but hide their own HIV status. Other complications may set in if HIV positive
mothers resort to illegal abortions, as such abortions are not likely to take infection control into
consideration. The counsellor must help, encourage women to avail of medical facilities.
Given that many women will chose to bear children and that this will be seen as a positive
contribution to her family and community, counsellors should help the woman develop a plan ol
how she will care for her child, how she will cope with the possible illness of the child how her
family and community will help her, and how she expects to support and care for her child if she
becomes sick.
The husbands or partners of HIV-infected women should be included in counselling
sessions Whenever decisions about avoiding or terminating a pregnancy or about preparing lor a
possibly infected infant need to be made, they should involve both the potential parents. I he
social and psychological support the woman will need is likely to be best assured if she gets h
cooperation of her partner. Thus, counsellors should make serious and active efforts to involve
and reach out to the woman’s partner/spouse.
Breast-feeding
Most cases of the motber-to-infant transmission occur during pregnancy and delivery,
although recent data confirms that some of them occur through breast-feedmg also 1-ortuna c y,
the
majority of babies breast-fed by HIV infected mothers do not become inlcctcd through
Xt milk Recent evidence suggests that the risk of HIV transmission through breast- ceding;
is
"Z '"2
risk factors in both these circumstances.
\T!
Brcastbccding is a crucial element <>l child
survival. A baby’s risk ol dying ol AIDS
through breast-feeding must be balanced against
its risk of dying of other causes if not bi east-led.
Breast milk provides an infant with essential
ingredient that build up his/her immunity
against future diseases. It is recommended that
in countries or areas where infectious diseases
and malnutrition are the main cause of infant
deaths and the infant mortality rate is high,
breast-feeding should be encouraged among
pregnant women, including those who are HIVinfected. This is because their baby's risk ol
getting 111V infection through breast milk is
likely to be lower than its risk of death limn
other causes, if it is not breast-fed. Women
Lo know they are HIV-infected and for whom aiternativi feeding (formula milk.) might be an
affordable option, should seek advice of their health care providers in
m deciding
deeding how to
lo feed
Iced their
r>M
infants.
On the other hand, in settings where the main cattde of death during inlancy is not
infectious diseases and the infant mortality rate is low, tire general consensus is (hat the advice to
safe leedmg
feeding alternative lor
pregnant women known to be infected with HIV should l|e.lo use a sale
Im
their baby rather than breast-feed.
Women and Risk Reduction
The issue for women, as for men, is clearly a survival issue. In order to survive, ,
individuals will need lo know lhat they are al risk and Hurl lhey have a choice. I he hrsl cho.cd ,s
being able lo say “no" (o high risk behaviours. To make ids possible, .1 ,s essonbol lo empowi
the women.
===“==^1;
pSS S sexuali; active individuals. However, in the case of women, tins mvolves
promoting protection messages that are not under the woman s condol.
The most important point about risk for all women (and men) is the fact (hat a wom4
fact majority ol me mt-ciec
.
are blamed for being the source ol Iransmtssiott. 1 he st.g.<m< and
with this disease often rests with women.
disci nnmation
.om Ucd
In India, us in other coimtries, Commcrciid Sex Workers (CSWs) arc olii-tt singled on! lor
special attention in lhe’conlext of AIDS due to Um multiplicity of their sexual contacts and high
STD rates. Unfortunately this has lead to a siti lion where they are viewed as transmitters of
HIV rather than recipients of the virus. Studies indicate that CSWs in India avoid using the
existing heal th structures for meeting their health needs due to the harsh and inhuman treatment
they receive at the hands of medical and para-medical staff. Studies also show that CSWs are
unaware family planning services (except abortion). CSWs may seek treatment from quacks so as
to avoid facing ridicule from medical staff. Front a. public health point ofview, it is very difficult
to discover, educate and counsel the large number of women who are al risk of acquiring
infection through heterosexual intercourse. Thus, it becomes the goal of AIDS programmes to
educate all women about their risk of sexually asquired AIDS, and to encourage adoption of risk
reducing sexual behaviour.
CHILDREN
HIV infection in infants and children requires a great deal of knowledge, stamina and
sensitivity on the part of the counsellor. Parents and caregivers have to be given consistent
emotional support and information to enable them to provide adequate care.
The counselling activities and issues include :
O Assisting parents to'talk about distress and guilt at having infected their child.
O Helping parents to cope with criticism from others especially from family members.
o Repeating information about transmission, prevention and the risks of any future
pregnancy.
Managing
the illness of an infant or child.
o
o Supporting the child so as to enable it to develop physically and socially as much as
possible, given the clinical condition.
Explaining
to the parents, family, school personnel and others the minimal risk the child
O
presents to other children and adults (i.e. reducing the possibility of the trauma of
discrimination).
Supporting
parents in facing the many uncertainties about the future health and well being
O
of their child.
There are four groups which have to be considered. There are specific counselling issues
pertaining to each group.
I. Children most at risk of getting HIV infection.
Children in need of blood transfusions or blood products e,g,
(a)
(i)
hemophiliacs, thalassemia, leukaemia, and
Children vulnerable to sexual abuse especially within the family
(b)
unit (in such cases special needs to be addressed by counselloi)
Children in legal custody
(ii)
Street children
(iii)
(iv) Children in various institutions
179
f
!l, Children whn are HIV inlcclcd.
(0
(ii)
.J
Children infected intra-utcrine
Children who are infected by shared needle use, by transfussion of blood or blood
products.
III. Children whose parents, siblings are infected.
IV. Children who are orphans (due to parents death via AIDS).
The counsellor must explain and re-explain as necessary the risks, the limitations oi testing
and the need for parental caution with respect to transmission. The counsellor must also stress the need to treat
the potentially or actually infected infant in the same way as a normal child would be tieated.
Infants with suspected HIV infection should receive as much affection and care as possible
and be treated like normal infants except for being kept under medical observation. Just as with
the infected adult, psycho-social support, emotional stimulation and adequate nutrition must he
assured to the child This will require the counselling of parents and siblings as the inlant is
dependent on the adults around him/her. The counsellor may need to help parents to keep
appointments at clinics and elsewhere as it is necessary to monitor and protect the child s health.
The baseline emotional and economic stability of the family, life have an impact on the
care the infected child receives. The family and home life may be in deep disordered as a result of
parental activities such as drug injecting or because of the illness. 'I he counsellor must be
prepared to assist the family in finding ways to ensure that the child receives proper and timely
care within the extended family network or outside the family. If parents cannot provide tne caie
required the counsellor may then need to find substitute care. Whenever there is doubt about
parental competence,
the counsellor
counsellor must
must watch
over the
ipetence, the
watch over
the health of both the infant and his/her
parents.
STKEET CHILDREN
hgjVSTALL]
o
180
!
I'he counsellor should discuss with (he lutnily members and other caregivers their concern
about the risks that the infected child presents'. • them. In the group of “Children at risk” street
children emerge as a group especially vulnerable to AIDS owing to their special characteristics.
They are forced to seek survival on the street, which is often difficult in terms of their needs
related to food/clothing, shelter, protection and social security. Some of them are engaged in
economically gainful activities like working as hotel boys, coolies at the railway station, guarding
and cleaning cars, selling flowers and other trivia at traffic signals, shining shoes, working in
gambling dens, “wadi” work and often as ragpickers too. These activities often expose them to
several health and occupational hazards for which they rarely seek care. This is partly due to
ignorance and partly due to the fact that they receive indifferent attention from large public health
facilities.
Sexual exploitation by older boys, men and women, in exchange for money or favours is
also common. Several street children are initiated into drug and alcohol abuse at an cai ly age and .
visit CSWs or take up commercial sex themselves. Street children are also known to be engaged
in selling blood and organs in their struggle for survival. In the light of H1V/A1DS prevention and
control, this group assumes significant importance. Fighting for survival on a day-to-day basis,
they themselves are not likely to be concerned about becoming infected “sometime” in the future.
This in turn may render them indifferent to preventing infection and thus be more vulnerable to
HIV infection.
' .
*
..
In some instances HIV has been transmitted to chiWien through sexual molestation by
infected adults. In cases where sexual molestation is suspected, interventions should be
aggressive and investigations must be thorough. Such children of older age, must be taught
assertiveness skills, concepts of privacy and the right to self determination about their bodies.
They will also need help in understanding what has happened to them and coping with the
subsequent fears and insecurity.
There is also special concern for children living with addicted parent(s). A parent who is
an active addict has few resources available to allow effective protection or advocacy for a child.
In addition io the usual issues raised when working with children having life threatening or .
terminal illness, many providers experience fear of contagion and may experience resentment
directed at the parents for causing this suffering to their child.
Practical information about hygiene
The counsellor should discuss with family members and other caregivers their concerij
about the risks that the infected child presents to them. I he risk is low, but care should
nevertheless be taken to avoid contact with the body fluids. Caregivers should protect and cover
breaks in the skin and other abrasions. Brothers and sisters and other children must be taught to
avoid contact with the body fluids of the infected child/infant. Families will require practical
information about hygiene. The counsellor may need to provide disinfectants and other materials
or give advise on where to obtain them. The mpre a,counselor understands the practical
problems faced by a family, the more useful and empathetic practical solutions will be ottered.
181
A whirlpool ciTcct is created among families as a result of IIIV/AIDS whereby ramilicalions arc
dramatic. Some of the effects are :
o
o
o
o
o
o
Siblings affected by the trauma of an ill or dying sibling. 111V negative children
affected by ill or dying parents/siblings.
Healthy children dealing with premature loss ot parents to AIDS or coming to
terms with parental HIV.
Children dealing with illness (such as hemophilia, thalassemia, malaria) who have
to take on the additional burden of AIDS/HIV.
Economic hardship or deprivation as a result ol economic strains brought about by
caring for infected infant/parent.
Economic hardship or deprivation due to the loss of the breadwinner.
Economic hardship as a result of reduced income shared among greater number ol
family members.
Care of the HIV/AIDS diagnosed child
Psychological care of children with AIDS is of great importance. These children are
suffering from a terminal illness, compounded by the fact that they may have a mother, or a lather
(or both) who are similarly infected. In some families, infection may extend to siblings and thus
multiple problems are possible. The treatment of the child may involve repeated or constant
hospitalizations, painful medical procedures and the added assaults of opportunistic infections.
When faced with an unfamiliar or potentially threatening environment, many children may react
adversely. Reactions differ widely and can be seen as manifestations ol anxiety or fcai. ie
anxiety has to be reduced, so that the child can be encouraged to cooperate in the treatment and
medical procedures. Using approaches like play therapy or art therapy would help m .educing the
fear and anviPtv
anxiety in
in children.
children. Spending
Spending a lot of time with children is an essential element ol
successful counselling of children.
Younger children arc particularly distressed by highly visual, short-term painful
oroccdurcs - they arc also more likely to see illness or surgery as punishment, furthermore
inaccurate or incomplete understanding of bodily functions, structure and purpose may p.ed.spo. c
children to unpleasant misconceptions about medical procedures.
Irrespective of the age of the child, the level of care offered is crucial in determining the
I . alral and life adjustment of the bereaved children.'! here is a dilemma about mloiming is a
psyc ro Ofa
parent who needs understanding and help may need to inform the educational
tX iS Th X ..g approach to this problem most be moltl-prottget). If the d.agnos.s ot
MDs ls Sowm the stigma ma/tesuh in a ehiid being isolated. Children of mfeeted patents ma,
have to drop out of school if a parent is too ill or has died
ssesfesr-.
School children who have been told or already know that one of their family members is
182
infected child should be treated in the same way as any other child at the school. Childien ollcn
respond to reactions ofthe adults around them. So it is important tor the connse loi to ensme th.it
the children’s parents and teachers are well informed. Problems arising m the school setting
should be dealt with as quickly as possible to ensure that they do not gam a momentum ot then
own.
Stressors which arc dominant ir. the minds of parents who have IIIV/A1DS mlecled children in
hospital are as follows :
Fear of progressive illness.
O
Fear ofthe child dying.
O
Worry about the child experiencing pain and suffering.
O
Loss of normality.
O
o Negative reactions of others.
o
o
o
Guilt.
Loss of control
Changes in family structure
the deam
death ox
of a pm
parent
The child’s reaction to (he
cm may include
Shock -
it can be short lived, transitory or long lasting.
Denial -
the reality of a loss may be overwhelming and a child may need to deny it. Such a
child will need gentle help to grasp the reality and the permanence ol the loss.
Guilt -
it is not uncommon for people to experience guilt feelings after a loss. I hese may
be rationally or irrationally based. Children may feel that they were somehow
responsible for a death. They may blame others such as a surviving parent or
sibling.
Anger -
they cannot express their feelings.
Physical
extreme grief may bring about physical symptoms such as pains, breathlessness etc.
symptoms -
n
-on this is no’ common but children tend to cope with grief by exhibiting mood swings.
DepreS™.. - **««« childre„ fceli„g
of control. Facing death, they .no, heeonte
farfnl for their lives. Ihe, .W feel that their world has become nopredtcuWs.
183
Counse 11 ing Cli i 1 d rc11
The counsellor must not separate the child from (he parent and must ensure that,
whenever possible, the child is accompanied by someone close. 1 he counselling sessions must be
frequent and short. The counsellor should make it clear to parents that it is their responsibility to
inform a child who can understand information about a particular condition and what it means
(e.g. why the child is coming for counselling). The child should be included in intei views with the
parents and where appropriate, with grandparents or siblings. 1 he counsellor can then observe the
reactions of both the child and the family.
The counsellor should not discuss issues such as sexuality and 111 V inlection without
parental permission as parents may object to their children learning information reganling
sexuality Older children can be seen alone or with the family. 1 he older the child is, the closci
are the reactions and management strategies used with adults. When family membets hear one
another’s views, they may find it easier to make the necessary adjustments lor supporting the child
and at the same time protect themselves from infection.
Counselling extends to answering the multiple questions a child may have: .lai gon lice,
simplistic explanations go a long way. At the same time, the counsellor must ensure that the child
has a clear understanding of the explanations by paraphrasing and checking with the child, hank
and open discussions may bring relief to them. They need to be treated in an environment that
allows them to ask their questions freely and allows them to trust that the response is honest.
Their fears can often be enhanced if they are excluded from the discussion.
The counsellor can help the parents in their explanations to the child or the adolescent.
Information and knowledge may be the only prolection against discrimination such as teasing at
school. Role reversal techniques can be useful with both children and parents to enable them to
identify and ask the questions that they consider important, e.g. a parent can play the role ol a
teacher who wants to know about a child in the school with HIV infection.
It is also important to promote the child’s self image and self-esteem and emphasize how
well he/she is coping. In order to understand how one should talk to children about death, be it
their own from illness, or that of a sibling or a parent, it is a prerequisite to have some
understanding of children’s concepts of death and how they accommodate these. 1 he cluld s age
and the support sunounding the child are two key elements in pacing the information ielated to
death.
The child’s sense of time should not be thought of in relation to an adult s. 1 Ins means
that a child is able to easily deal with events in the more immediate future and may Imd events m
the distant future harder to grasp. The child must be given as much as hc/she can take and should
be provided the space for ongoing open dialogue.
184
When a child is dying,, silence, denial and pretence are Ihiee laclois that aic often picscnl.
in a child, when a child is dying. Such defenses may be props that are keeping the child together,
and it is important not to destroy these without careful thought and the provision of alternatives.
Counselling is not only linked to informing a child about death. The illness brings with it many
fearful and perhaps painful procedures. If these procedures cannot be avoided then, the child
should be prepared for them. The child may need a lot of encouragement to face up to his/her
remaining life with enthusiasm. 1 he terminal period marks the time when the death is imminent
and seen as inevitable. A child may have a need to say farewell, either overtly or symbolically and
this can be easily facilitated by the counsellor. This can also to apply to a child whose IIIV
infected parent is dying.
People long for the birth of a healthy child. When HI V infection is present at birth, parents
must begin to anticipate the possible loss of the child. Grief is an expected and necessary reaction
and counsellors must accept and support it. However they should also watch for a parent’s
withdrawal into chronic grief or seeming indifference and neglect of the child or other children in
the family. Counsellors should encourage parents to deal with and work through their grief by
talking openly about their feelings of self-blame or guilt because of their past/current risk
behaviours.
NON-I1ETEROSEXUAL IUCLAHOWSHIPS
It is important to note that heterosexuality is not the only accepted norm of sexuality in
India. Many other variations exist and are accepted in a far better manner than in most Western
societies. This may be partly due to the evidence of homosexuality, bisexuality, transvestism and
hermaphroditism found in the Indian epics and ancient literature. Eunuchs and homosexuals
formed part of the royal courts of many Indian kings and bisexuality was known to be common
among persons of royal lineage. Folklore, myths and traditions thus encourage the acceptance of
alternative forms of sexuality. In modern India, this acknowledgement however docs not imply an
overt acceptance of the desirability of alternative forms of sexuality.
In the context of IIIV/AIDS, it is important to address the needs of people which may be
socially unacceptable at present in India: for e.g. in the case of Eunuchs, Homosexuals and
Bisexuals.
Ilijias/Eiiiiuclis
Eunuchs encounter more ridicule than compassionate tolerance. I he term “hijra” or
“chhakka” which implies incomplete sexual identity is often used derogatorily as the lowest fpim
of abuse. Undoubtedly the world of the eunuch is private and this community strives to retain its
privacy. According to studies, the eunuch is basically a castrated male. He may also be someone
who feels trapped in a male body with a female sexual identity. In such an event, castration may
be voluntary. At times, male homosexuals involved in passive anal sex aie known to turn to this
way of life due to inability to find a social position that accommodates (heir behaviour. At other
times a child may be given away in icturn for a divine favoui. A child with sexual 01 other
deformities may also be given away by parents. It is not known how many children are abducted
by the cult, but there is evidence to indicate that abduction is prevalent.
185
What is known about the practices related to castration and the healing of the wound
suggests a lack, of care and indifference to hygiene. In fact their health is likely to he hiiddy
neglected. Health facilities available to the general public are socially out-of-bounds for them
since their image either evokes fear or contempt from people. Their sexual hygiene, practiced?
related to castration, post castration care and sexual activity (often anal sex) are likely to make
them specifically vulnerable to S I'D and IIIV infection.
Eunuchs indulge in commercial sex as a way of earning some income. 1 hey at e
frequented for oral and anal sex by homosexuals or bisexuals. '1 he clientele that approaches this
group is unique as they are generally said to be middle aged men who arc travelling away from
home. Their clients don’t want to be seen with this group and thus sex is quick and penetrative
and mostly in deserted public places. As eunuchs are not the preferred choice, this group fears
losing clients and thus does not insist on condoms. Eunuchs are harassed by the police and thus
have to change their pick up points and therefore are difficult to track. The counsellor must
understand his/her own limitations in working with this group before getting into a lheiapeuiic
relationship. 1 his group needs non formal education, health education, empowcunent as a gloup
and information regarding legal issues. The counsellor must encourage assertiveness in the use of
condoms. As eunuchs often identify with the female sex, a female counsellor may be much mote
effective.
Homosexuality
Homosexuality has been a taboo subject, its existence not being recognised. Till the panic
about the AIDS epidemic hit India, its existence was known but not discussed. I lomosexuals arc
a minority group who are sexually attracted to members of their own sex. A common myth
prevalent in India is that homosexuality in an abnormal condition and people who are practicing it
should be treated and cured of it.
In (he metropolitan cities, especially Bombay and Delhi, several prominent personalities
openly acknowledge their gay identity. 1 he majority continue to hide their (me sexual pu lerence,
by adopting bisexuality and even marrying under high parental pressure or to ensure social
conformity. There is an added risk of HIV infection to the male paitners and spouses ol mamed
homosexual/bisexual men.
The vulncrabilily'of this segment to HIV infection is high due to lack ol inlormatioii and
due to denial of the risk when information exists. Sexual practices among homosexuals pieclude
the use of condoms as condoms are associated with birth control. Sexual contacts aie often short
lived and anonymous, though long-term relationships which under-emphasisc the sexual aspect < o
exist High sexual activity and multiplicity of sexual paitners also characterise homosexual
relationships. The possibility of negotiating condom usage or actually using (he condom are (Ims
low. Distrust towards the heterosexual community, is partly due to fear of their icaclmn to
homosexuality. The homosexuals are thus often suspicious and unwilling to listen, a al . it
would be to members of their own community. The counsellor has to be sensiUve to the leais o
this community and should have a non-judgmental attitude towards (hem. C ounsellmg must cover
issues related to health information, counselling on AIDS and condom usage.
186
I his group identities with men. I hey would thus be more comfortable with a counsellor of
similar sexual preference. The counsellor needs to be empathetic and understanding towards the
needs of this group. Counsellor must also emphasize the need for negotiating long term
emotionally stable relationships among this group. Usually members of this group get involved
with a mate for sexual purposes before getting into an emotionally satisfying relationship.
('ounsellor must also cover issues regarding health and hygiene, STD control and the importance
of a homosexual being comfortable with his own sexuality.
Bisexuals
These individuals are heterosexuals by nature but adopt occasional, homosexual liaisons
due to non-availability of alternatives or as a convenience, for e.g. prisoners, young men in
hostels or male dormitories and men who live away from their wives in collectivity. Others may
adopt the bisexual way of life since it camouflages their true preference for homosexuality. Others
may be coerced into homosexuality, for e.g. young boys in hostels, prisoners or truck cleaners.
T his group is likely to be more deprived of information and may actively avoid any exposure to
information as it implies an acknowledgement of their sexual activity. Lack of education and
other features of socio-economic marginalisation may act as further disadvantages for this group.
In India this group is very important in the context of HIV transmission as the trend is
from heterosexuals to homosexuals. There is a risk HIV transmission to the male partners and
spouses of married bisexual men. The counsellor needs to deal with denial which is greatest in this
group. Phis group is difficult to detect as they cling to their denial and as a result, deny high risk
behaviour. Another feature that may be seen in this group is lack of long term relationships with
their sexual partners. The sexual encounters are often sudden and not planned for and this leads to
low condom usage. The counsellor needs to address issues regarding Health education and
condom usage.
Suggested Readings :
Mane P. & Maitra. S. (1992): AIDS Prevention, Bombay : Tata Institue of Social Sciences.
Plant M.A. editor, (1990): AIDS. Drugs and Prostitution
Rainchandran P. (1992) : Women's Vulnerability. Seminar 396 p. 21-25.
Selwyn A.P. : Injecting Drug use and 1IIV infection, Geneva: WHO
UNDP 1IIV and Development Programme Publication: Young women : Silence, susceptibility and
the HIV epidemic.
187
Acnvi rv seci ion
i
ACTIVITY 1: Group Discussion : What do I believe and feel about Substance abuse?
Time: 40 mins.
Materials: Large sheets of paper, pens, markers or coloured chalk.
Objective:
The purpose of this activity is to understand and discuss personal attitudes and cultural
beliefs and attitudes about substance abuse.
3
*
*
Procedure:
Divide the large group into small groups of six people each. On three large sheets of
paper, write the following headings?
75
ALCOHOL
INTRAVENOUS DRUGS
NON-INTRAVENOUS DRUGS
' they
’ ' can think of which describe, people who
Ask the groups to brainstorm all the words
drugs. The
list should include common names or
use or abuse alcohol, intravenous drugs or other
c
-------------slang terms, beliefs and attitudes. Within each category, ask trainees to discuss specific drugs or
^,’r,tpiv After
After 1155 minutes,
liquors separately.
minutes, ask
ask the
the groups
groups to
to move on to the following questions:
What does the list suggest about general cultural responses to:
1.
2.
3.
♦
alcohol use and abuse?
intravenous drugs and abuse?
non-inlravenous drugs and abuse?
What are your personal responses to the above?
In nrocessing the responses, trainees should be asked to consider how cultural attitudes
P ’ '
. users might effect AIDS prevention efforts and how their persona
and values toward substance
ight
affect their work as prevention counsellors.
views migl
--------
L
188
ACTIVITY 2: DEMONSTRATION OF THE USE Ob BLEACH
Time: 15-mins
Material: A packet of bleach, one litre container, a teaspoon, a syringe and needle, a bowl ol
water.
Objective:
This activity aims to teach all the trainees the correct use ol bleach to disinlect needles and
syringes and other injecting equipment.
Procedure:
The trainer demonstrates the preparation of the solution of bleach and demonstrates how
to flush the syringe and needle first with the bleach solution and then with water. 1 he first step is
to flush the equipment several times with clean water so as to demonstratew to the trainees the
way to get rid of blood or any other debris stuck inside the equipment.
Then take a teaspoon of bleach and mix it with a litre water, put the solution into the
container and flush the syringe and needle with the solution twice. The syringe and needle should
be flushed then twice with water.The trainer also explains the option of sterilisation of syringes by
boiling them for 20 minutes.
ACTIVITY 3: Role Play - HIV infected single mother with small child.
Time: 45 mins.
Objective:
The purpose of this activity is to address some of the counselling issues that arise while
counselling women and children.
Procedure:
Read through the following scenario:
Mrs Lal comes for counselling and mentions that her seven-year old
son Ramcsh has been difficult lately; in particular, he will not stay in
school but wanders back home. She andRamesh now live on their own.
Mrs Lal is a single parent who separated from her husband two years
ago after he told her he was HIV positive, the result of an affair with
another man. She was then tested and found to be HIV positive. She
has recently been diagnosed as having AIDS Related Complex.
Ramesh has been told nothing about his parents’ HIV status.
189
Condict a rd
as^o^nZw ^\ninutes fmXml^lay, 10 minutes
f"dbN tedines riven below Next focus the several group discussion on how Mrs. Lal can help
Er^XZSroX » weH as plan for future possibilities for lite child. Ke.ne.nber to
put the volunteers through a de-role after the role play.
Points for discussion after role play:
Mother’s anger as a result of:
1.
2.
3.
4.
Husband’s unfaithfulness
HIV infection through husband
Unfairness of lile
Ramesh misbehaving
Mother worries that:
1. The neighbours might find out she has HIV
2. Ramesh is going to get into trouble with school
i 1
Mother’s fear of:
1.
2.
3.
4.
5.
Her death
Her illness, which cannot be hidden Irom Ramesh
What will happen to Ramesh if she dies
Ramesh becoming HIV infected
Ramesh growing up to be like his father.
Kamesh’s anger as a result ol:
z S^cXSg wrong with his mother and him not knowing about it.
L
Ramesh’s fears:
1. Mother may die t
2. What might happen to him
I
I
l_
i
190
ACTlVri Y 4: Role Play
Time: 45 mins.
Objective:
The purpose of this activity is to identify the range of special issues that arise out ol
situations related to children.
Satinder, 26, and Meena 20 are a couple who live in a slum area in
Bombay. They bring their 2 year old daughter to the hospital for an
HIV test on the request of the doctor. Their daughter Manisha is Ill V
positive. Thereafter the couple finds out that they both aie HIV
positive. Satinder used to visit CSWs before his marriage. Also,
Meena is 2 months pregnant.
#1
#2
Lakshmi, 6, was born with a blood disorder. Subbu,28 and Janaki, 24
are her parents. Lakshmi is thalassemic and needs regular blood
transfusions. During one of the transfusions she has contracted 111V
virus.
#3
Mrs Roberts, 41, a school teacher has found that Viren, 10, from her
V standard class was declared HIV positive after a surgery where he
received blood.
Procedure:
Participants can break into three small groups. Each group discusses the scenarios,
considering the discussion points. After 30 minutes, they come to the bigger group where each
group shams their scenario and findings. Allow 7-10 minutes for group lor presentation. The
trainer sums up the issues identified by the groups.
Points of Discussion:
♦
♦
♦
♦
What are some of the special groups that exist in these situations?
■
What are the special issues in relation to the special group in each situations.
What would the fears of individuals in these scenarios be?
What are some counselling issues that would ar ise?
191
C
ACTIVITY 5: Self Awareness Questionnaire
Time: 50 mins.
Objective:
This activity is designed to allow all participants to explore some of their own attitudes
and become aware of their level of comfort towards certain groups that are at risk of ge mg
infected with HIV.
Procedure:
tntrodnee Ibis activity by telling the participants that this activity is designed,to hove then,
^d^S each question & as a result he gets 4 different responses for each question.
Remind the participants that there are no right or wrong answeis.
The trainer then discusses with the participants how their responses to the statements on
th “Self Awareness Questionnaire” relate to counselling and education. Some pcop.e may icsis
lorce those opinions on others.
Xc”= aXScteir feelings and then continue. Relax »d have some fun with tins
exercise.
The facilitator should discuss whether the trainees learnt something new about themselves
by filling the questionaire. If so, what did they learn?
ACTIVITY 6: Review Questions
Time: 20 minutes
Aita 10 minutes to the trainees to fill Worksheet 2. Trainer to discuss the likely «»« ™lh
____
the trainees.
192
jj
tT . WORKSHEET 1
—w
....
Self Awareness Questionnaire
Consider each sentence as carefully as you can, then place the number indicating your feeling next
to each one.
SECTION 1
Strongly Agree
1
Agree
2
Disagree
4
No Opinion
3
Strongly Disagree
5
1. I would feel comfortable working with a gay man.
2. I would enjoy attending social functions where lesbians and gay men are present.
3. If a member of my gender made a sexual advance towards me I would feel angry.
4. 1 would feel uncomfortable if 1 learned that my boss was homosexual.
5. I would feel nervous being in a group of homosexual people.
6. If I saw two men holding hands in public, I would feel disgusted.
7. I would feel comfortable if I learned my daughter’s teacher was lesbian.
8. It would disturb me to find out that my doctor was homosexual.
SECTION 2
Answer the following questions:
1. Do you know someone who is a commercial sex worker? What do you think of her?
1
I
2. If your brother/son came up to you and said that he was in love with a man? How would you
react?
V
3. Did any of your friends earn money or get expensive gifts by being call girls? What did you
I
thik of them
193
4. Do you have any friends who had sex before marriage? How do you feel about them >
could that person have said or done to make you feel better?
6,
2 groups of dionU youwould have moral and elhleai ddommas in working »i.h7
194
WORKSHEET 2
. Review Questions
1.
Why is it necessary to discuss about substance abuse?
2. What are the additional factors to be considered in HIV and drug abuse?
3. What are some of the issues related to pregnancy which a counsellor should discuss
with a woman who believes that she lias been at risk?
4. What would a counsellor need to say to a woman who believes that an IUD
(for e.g. Copper T )will protect her from HIVinfection?
V
195
5.
What arc sonic of the major counselling issues for parents ol IHV inlcclccl children?
6. What are some of the major counselling issues for infected children?
7. What are some of the major counselling issues for infected individuals involved in non
heterosexual relationships.
196
MODULE 6
STAFF SUPPORT, NETWORKING AND DOCUMENTATION
ia^nw.samcKsanaajia>i J«LW»irs
EXPECTED OUTCOME
Trainees will become aware of the importance of staff support, networking and
documentation They will be sensitised to the importance, the skills and the need for staff support
XXX and its slrategids. They will become aware of .he need and .he difleren. me.hoda
of documentation.
MODULE AT A GLANCE
TOTAL TIME 2 HRS 35 MINS
CONTENT SECT1QH
STAFF SUPPORT
NETWORK
DOCUMENTATION
ACTIVITY SECWH.
45 mins
i hour
30 mins
20 mins
BRAINSTORMING
GROUP WORK
GROUP DISCUSSION
REVIEW QUESTIONS
197
OVERVUM
from work hazards. Health wo
.
M
^.nnnrt network Documentation is also an
b>
systematic manner, and is a tool for professional learning.
198
mMfaM “‘ “
CHALLENGES AND PROBLEMS IN IIIV/AIDS COUNSELLING
“Any category of health worker may be called to examine, treat, perform some procedure
on, or counsel an HIV infected person or AIDS patient” (WHO Counselling Manual). Besides
these tasks, the health worker may be called upon to counsel, or otherwise support the infected
and/or their families or intimate friends. These tasks bring with them certain problems with them
that the health workers engaged in HIV infection related work have to face. 1 hese problems are.
o
Many a times the health workers bring a certain set of values, biases and prejudices
with them. These biases may prove a hindrance in the acceptance of the clients as
persons, and can thus affect the service. For example, the worker may not be able
to accept a client whose life-style or circumstances may lead to his/her being
infected.
o
Health workers may be overwhelmed by the social and emotional issues
confronted by them during their work. Breaking the news, talking about death,
facing the grief of family members and discussion sensitive topics like sexual
orientation can produce emotional stress which needs to be recognised and
handled. Such emotional stress, if persistent, can have effects like
reduced productivity and problems in team work.
o
The burden of caring for patients who have a virtually hopeless prognosis can
affect the staff causing frustration, depression and a sense of despair.
o
Health care workers may be torn by conflict between their professional duty
to care for infected patients, and their fear for their own safety. Their anxiety about
infection may cause them to exaggerate precautions to the extent of withholding or
seriously reducing the quality of care or of the service they are expected to give.
o
Lack of understanding or support from other levels of staff in the health care
facility or lack of cooperation or appreciation.
All these circumstances lead to a phenomenon called burn out. It refers to a progressive
loss of idealism, energy, and purpose and is experienced by people in the helping prolessmns as a
result of the conditions of their work. Being faced with young, seriously ill, dying people,
,
inadequate facilities, understaffed health care institutions, insufficient training and client overload
are some such conditions which may foster burn-out and subsequent alienation towards wqrk.
Over time the burn-out effect may be expressed in emotional withdrawal, Hostility towards
persons with AIDS and the staff-members, depression and cynicism. Physical symptoms of
burnout include ulcers, headaches, backaches, and other such problems.
199
tu organisational terms, burn-out is expiessed by.
a)
Absenteeism
O repeated short term absences.
b)
Accident prone behaviour
O prolonged absences due to illness or injury
O repeated minor accidents
O more than one major accident
1
c)
Unrest
O interpersonal friction
O occupational stress
d)
Transference and Counter 1 ransfercnce
O expectations of clients’ from counsellor increase
O counsellors becomes emotionally involved with their clients
Once .he counsellor Eeu en.olion.lly involved with his/her elien. he/she finds himself/
herself unable to work objectively with their client.
The cost in terms of reduced productivity, reduced quality of care and excessive use of
benefits is high for the health care system. When employees leave then jobs out of frustrate ,
there is loss of trained and experienced personnel.
The healll. cam slad; taefore, need support programs for avoiding •humour start™,
and for improving their involvement in their work.
BURN OU L
Staff Support
'v7<
Staff support is expressed through
programmes which:
0)
/' / y '</ , ,
\7'^\
(ii)
(iii)
(iv)
recognise the vulnerability oflhe staff
and
enhance efficiency/productivity,
reduce effects of work stress,
protect from work hazards.
200
I
J
'W'’
Essential steps to provide staff support are listed below:
a) Enhancement programmes .
These include arrangement for training and other staff development programmes, Some of
these are:
O Formal discussion groups like an inhouse staff clinical society where
problems/ issues regarding work can be discussed and dealt with.
O Provision of library for the use of staff.
o Nomination of staff to conferences, workshops, etc.
Q Refresher courses.
Some informal programmes can be instituted by the staff themselves. Examples of these
are Journal club, Study Group, etc.
b) Stress Management Programmes
The staff can be encouraged to keep mentally and physically lit by providing programmes
to help recognise and manage stress. However, difficulties like lack of space, shift duties, lack ol
funds, and difficulty in convincing the staff themselves, hamper such programmes in hospital
settings.
There are several approaches to reducing stress at work:
O
Modification of work practices or organisational characteristics to
diminish the causes of stress.
Assistance in development of personal coping mechanisms.
O
c) Organisational approaches and supervision
O
o
o
o
o
o
o
O
Regular staff meetings to allow venting of feelings,
provide support to encourage innovation.
Flexibility injob arrangements.
Adequate work load/staffmg.
Early recognition of complaints and early redressal
(specially interpersonal problems).
Fostering team-work.
Encouraging staff participation in planning and -not only in implementation.
Frequent inservice education sessions and other opportunities
to improve skills and confidence.
Monthly staff meetings where each counsellor gets to present a case study
and there is a group discussion on the issues presented in the case.
201
Supervision mainly consists of holding ongoing weekly supervision meetings to discuss
issues and feelings being aroused within the workers. Usually, a senior staff worker serves as the
supervisor for the team and mentors/guides the work and professional growth of the staff
members. Supervision is more effective when done on a one to one basis (supervisor with one
staf member at a time).
This process should include an update on the progress made in each case by the counsellor
as well as his/her own feelings aroused by the process and the intended plan of action for the next
few sessions with the clients. It’s important for the supervisor to watch out for issues that may be
personally intense or difficult for the counsellor, expecially where there is a clouding ofjudgement
and ambiguity in the worker. The supervisor needs to point these out to the concerned in a
supportive, nonjudgemental and direct manner. Suggestions on how to take care of oneself and
enhance one’s professional growth also form an essential part of effective supervision.
d) Counselling
Sometimes j ust being able to talk about the stresses - frustrations fear, guilt, anger,
inadequacy with others who share the same job stresses is therapeutic. Encouraging formal and
informal counselling and peer-support groups would help. These are not therapy groups but have
characteristics of self-help groups. The discussions in these groups may lead to constructive
group strategies for coping as workers are encouraged to share not only the problems but even
the successes, for e.g. techniques developed and tried out by them.
While group sessions may help the majority, some workers may need individual
counselling. There may also be a need of psychiatric/psychotherapeutic consultation.
202
c:) Personal Coping Mechanisms
■5»
Staff can be helped to develop better coping mechanisms so as to avoid or reduce job
stress. Training sessions should include identification of causes and symptoms of stress/burn out
and help them develop coping plans. Some of the strategies could be lifestyle education, exercise,
biofeedback, progressive muscle relaxation, cognitive restructuring meditation, yoga and others.
SOME PERSONAL COPIIWJylJS.CHANISMS
f
L
!
The staff could also be encouraged to form their own groups. Expert help can be given by
inviting visiting faculty. There are of several studies showing that simple meditation like relaxation
techniques can have a dramatic effect. In a study at a large Cincinnati Hospital, nurses received
training in bio-fccdback, muscle relaxation in daily, one hour sessions, over a two week perm .
After three months, both the biofeedback and muscle-relaxation groups showed significant
improvement in the ability to cope with stress, increased job satisfaction and energy levels at
work, and fewer sleep disturbances.
Staff who turn to substance abuse as a maladaptive coping mechanism also need help,
i
L
I
I
secondary prevention programmes (Employee Assistance Programmes) and rehabihtation.
Protection from work hazards
Health care workers, particularly those who have frequent contact with blood, are at a risk
of acquiring blood-borne diseases, including HIV. This emphasises the need to develop a
practical approach towards the prevention of these infections in the health care setting.
L
As blood borne diseases are frequently carried by asymptomatic patients it is not always
praaX
.» cxpee. „ know .he blood dleeeee sMus of each pane,... Therefore,
universal precautions are absolutely essential.
203
Occupationally. HIV infection among health care workers due to work-related causes >. a
rare event. 1 lowcvcr, in circumstances when testing is indicated, the worker must .ccewc o
benefit of pretest and post-test counselling service. It must be seen that.
O Testing is voluntary '
O Informed consent is obtained prior to testing
o Confidentiality of tests is assured
o Laboratory testing is done if needed
o Confirmatory testing is done if needed
o Worker is protected against discrimination
Education is at present, the most effective defense against the spread of HIV *nfection. ,
The employees’ heaith service must assume a leadership role in educating patients and staff about
ways to prevent the spread of HIV.
networking
..........
as informal channels.
Frequent contact
tealth workers
80Ver“"Tf °XZ‘”rvi»S .'nd they :»Ae the general public aware of available services. S wortaslaid also ..reel reguiarly so as to discuss difficult and debatable tssuea.
Corarsciionsnsediobees^
counselling center/hospital for refer . -Intemational Planned Parenthood
specific support or help, networking is of great assistance.
documentation and MONITORING
It also helps to keep information in a systematic manner.
Types of records
O
o
o
o
Reports/Assessments
Graphic presentations/Genograms
Registers
Case notes
204
' ’ \ The clients' ease rceoid should inelude
Records should be maintained regularly
an assessment done at the beginning stage of treatment,
(1)
regular case notes maintained for each session with the client,
(2) any other interactions with the client on phone should also be noted, and
(3)
in case the counsellor involves other professionals/resource persons, the recor s o
(4)
these interactions should also be kept.
What to record
The organisation, format and content of case or client records will vary from agency to
agency. However, most records need to contain two types of information .
(1) the raw data and
.
(2) the worker’s (counsellor’s) thoughts about the meaning of that data.
The raw data is the basic facts about the clients and his or her situation. An assessment
summarising the worker’s impressions and hypothesis gives added meaning to the data and shoul
also be included.
A good report is characterised by
Brevity: The report should say no more than needs to be said.
Simplicity: Select the least complicated words and phrases. Avoid jargon, ike
psychiatric labels, describe and give examples of the behaviours you want the rea er
1.
2.
3.
4.j
to know about.
. P.
Usefulness: Keep the report’s purpose in mind. Do not include information
merely because it is sensational or interesting. Ask yourself why you want to
write this report and what those who read it need to know.
Organisation: Plan and outline the information you need to include. Use headu gs
to break information into topical parts.
■ ■ * are; often used in social history assessments.
The following arc the headings which
Identification data (name, age, sex).
O
o Reason for coming to the clinic/center
of problem
o Statement
Family constellation, significant others and interpersonal relationships.
o Physical functioning, health practices and health problems.
o
practices, sexual health and problems.
o Sexual
Intellectual functioning and educational backgrounds.
o Emotional functioning and problem-solving capacity
o
o Employment and economic situation
o Housing
o
5.
Confidentiality- It is very important to respect the client’s right to confidentiality.
«hid. neeJs to be protected sitodd be included oiler coreiul
thought. Access to the record should be restricted to staff.
205
6.
7.
8.
Objectivity: Select words that express your observations and thoughts in an
accurate and non-judgmental manner. Avoid value-laden phrases and words which
give connotative meanings. Some examples> are:
O Client has some sexual practices like homosexuality.
O The client claims to have taken drugs.
o The client is a prostitute.
Though you will need to give your impressions and opinions, examine them
carefully to see whether they contain subjective judgments. It would be best to
give this under a separate heading “Health worker’s or Counsellor s opinion,
observation and assessment”.
Reievance: The information included in the record should have a clear connection
with the client’s problems to avoid cluttering.
Focus on client strengths: Emphasis can be given on what the chent/family can do,
not on what they cannot do. Successful intervention is based on client strength.
Monitoring focuses on implementation and ongoing activities rather than outcomes or the
impact of a programme. The purpose of monitoring is to anticipate, prevent and safeguard^
problems in implementation thereby preserving or protecting the quality ot any programme.
Monitoring begins with the development of a systematic awareness of the progress of aclivit ,
This can be done by carefully developing and selecting Some key indicators which would
give information and insight about how an organisation or programme is progressing towards ts
goals Thus timely and regular reporting of information about these selected indicators helps thp
programme managers identify any bottlenecks or barriers which may be affecting the pmgrammp
The n“ep ■would be to collectively with counsellors, nurU chief medical officers, project
managers/directors and brainstorm on a possible solution or constructive steps to eliminate the c
barriers Monitoring should be more “proactive” rather than “reactive”, evaluative to the problems
and maintain a certain level of performance as well as move the project or activities forwar .
Finally monitoring is an ongoing activity which guides and helps shape the programme
rate ([“S« outeomc/ovaluafian of lae impact of.il the aeuvt.es that have eompnsed
the programme.
Suggested Readings :
AMA Management Briefing (1985): AIDS.: Mhirkpl^d™
^delwich J. with Brodsky A(1980): Bunumt New York : ^uman Sciences Press
Lyons J.V. & Moritev K. Y. (editors): Regional counsullation Partnerships for AIDS prevention.
UNDP publication.
Mckay M. & Fanning. P (1985):
Celestial Arts (publishers)
•
206
ACTIVITY SECTION
ACTIVITY 1 - Brainstorming - The Challenges Faced in II1V/A1DS Counselling
Time: 45 mins
.
Materials: Chart paper and markers
Objectivefl he purpose of this activity is to discuss the challenges faced in H1V/A1DS
counselling.
Procedure:
As a large group, brainstorm responses to the following question: Which major
challenges or difficulties do you face while doing HIV/AIDS counselling?
Review the list which comes out of this exercise, and tell the group which major
challenges will be discussed in the lecture session. If needed, discuss some of the points raised by
the group but not covered in the lecture.
Points of discussion
Recommendations for the better counselling might include:
Acknowledge that HIV/AIDS counselling is exhausting work.
❖
Acknowledge that we all have limitations as counsellors because
♦
❖
♦
❖
4
♦
♦
❖
♦
❖
♦
❖
we are only human.
Become aware of our prejudices, biases and assumptions so that they
do not interfere with the counselling process.
bind support from colleagues who arc also working as 111V/A1DS counsellors.
Plan ahead and make alternate arrangements whenever possible.
Ask a colleague to conduct a counselling session tor you if necessary.
Postpone the counselling session when appropriate.
Develop skills in organising your schedule better.
Learn to accept that you cannot change the client’s life or behaviour for him/her.
Peel good about your work as counsellors even when limitations prevent
you from doing all that you would like to do for your clients.
Learn additional information or skills necessary to improve
your abilities as a counsellor.
Be aware of your personal limits.
Learn how to treat a client with acceptance and respect even if
you do not like him/her or agree with his/her lite choices.
207
❖
Consult with other counsellors to get feedback about your reactions
and to get support. Ask them to help you understand your reactions belter.
Refer the client to another counsellor if it is necessary and if one is available.
Find creative ways to support each other. For example, form counsellor support groups
in your area.
♦
❖
ACTIVITY 2: Group Work: Planning for our own Limitations
Time: 1 hour
Materials: Large paper, markers, tape, paper, pencils
Objective:
The purpose of this activity is to discuss the limitations counsellors experience on the job
and ways to cope with them.
Procedure:
It is important to acknowledge that I11V/A1DS counselling is very demanding and that as
counsellors, we all have personal limitations. Since our first obligation is to our clients, we must
identify our limitations and find ways to help ourselves and each other cope with these limitations
so that they do not interfere with counselling. In this activity we will be sharing our experiences
and ideas about coping with personal limitations. Ask participants to think ot a real or imagined
counselling situation when they were aware of their limitations as counsellors or when they felt
their personal lives affected their counselling (i.e. issues of counter transference). Ask each
person to write answers to the following questions:
♦
♦
❖
♦
Describe the situation
In what ways did you feel limited?
What did you do or say?
How did you feel about yourself and your counselling skills?
Could you have handled the situation any better? What might you have done
differently?
Divide the group into small groups of 4 to 5 people. Ask each person to share what hd/she
has written with his/her small group. Ask each group to discuss the common ideas and situations
in the stories of the group members. Ask each group to complete the following task: Based on
their discussion, each group is to write on a large sheet of paper “10 ways to cope with P^na
limitations.” When each group is finished, their sheet of paper should be taped on the wall. Invite
participants to walk around the room and read each group’s list. Return to the large group and
discuss the ideas. Make one large list of ideas for coping with personal limitations, elumnating
duplicate answers. Discuss how this list can be useful. Consider ways to make it available to
other counsellors.
208
ACTIVITY 3: Group Discussion : (.'oping with the Stress o! IHV/AIDS (.oiiiisclling
Time: 30 mins
Materials: Large paper, markers, tape
Objective:
fhe purpose of this discussion is to identi^ effective ways to cope with the personal and
work-related stress of HIV/AIDS counselling.
Most trainers have, or will, experience stress as HIV/AIDS counsellors. 1 hey can support
each other by sharing the ways they have found to cope with this stress.
Procedure:
Ask participants to share one way they deal with the stress of working as an HIV/AIDS
counsellor. As each person states his/her idea, record it on a large sheet of paper at the front of
the room. Review the following the points of discussion.
Points of Discussion
Ways to cope with stress might include:
❖
recreation
discussing certain problems with senior counsellors or fellow counsellors
♦
♦
♦
❖
❖
♦
♦
♦
finding a quiet place to think
meditation
spending time alone
relaxing
joking, using humour
prayer
group meeting^ with other counsellors
eiWWSW’-MWM
ACTIVITY 4 : Review Questions
Time: 20 mins
G
Allow 10 minutes for trainees to complete Worksheet 1. Trainer should discuss the most
appropriate answers (Allow 10 mins).
209
•I
•
[
WORK SHEE1 1
>
Review Questions
;
... ... z.. .
.... ... z
■ '/<;
"r
■'
• . ... ...
v
.
‘
. ..
..... . ; .
'
.' /.■■
....
r ' ■ .f..'. What is “buril-out”?
*
2.
What emotional reactions are cause for concern in health workers who arc
suffering burn-out?
Vhat types of interventions or activities might a programme manager undertake
n order to prevent or deal with burnout in the workplace?
i
----------------------------------- ;—
■I
<3
I
i
■
■
I
APPENDIX I
PRAC PICAL JNJ ORMAnON FOR PEOPLE WITH
HIV INFECTION OR DISEASE
Counselling for both support and prevention is needed in the post-test or post-diagnosis
phase. In addition, to acknowledging and working with the psychological issues that appear at
this time, in clients who are HIV-infected, the counsellor should emphasise information that
provides the framework for living with HIV. Similarly, as part of the process, the following
points should be covered repeatedly in all counselling sessions, for both HIV-positive and HIV
negative people:
1.
HIV infection is not the same as AIDS. People with AIDS have HIV infection, but
only a proportion of those with HIV have AIDS.
2.
Sexual intercourse, whether heterosexual or homosexual, is the major route of
transmission of HIV. The virus can be transmitted by any penetrative sexual act in
which HIV-infected semen, vaginal/cervical secretions, or blood is exchanged. HIV
infection can be prevented. During each act of sexual intercourse, men should always
use a condom. Women should make sure that their partners use a new condom for
each act of sexual intercourse. Instructions of the use of condoms are given in
section 2, and guidelines for sexual practices are presented in section 3.
3.
Condoms, when carefully and consistently used, provide effective protection against
HIV transmission. Latex condoms lubricated with silicone or water-based lubricant
are recommended. When additional lubrication is desired to reduce the risk of
condom breakage, only water-based, (not oil-based) lubricants should be used.
Animal membrane (e.g., lambskin) condoms are not believed to be as effective as
latex condoms as a barrier against HIV and are therefore not recommended.
4.
Non-barricr contraceptives such as intrauterine devices (IUDs) have no protective
effect against HIV transmission. It is not clear whether oral and injectable
contraceptives affect the risk of HIV transmission. Coordination between AIDS
control and family planning services is clearly essential.
5.
Certain health conditions, especially other sexually transmitted diseases may
accelerate the progression of IIIV infection to AIDS. Guidelines for avoiding sexually v
transmitted diseases should be followed by people with as well as those without HIV
infection. Section 3 contains excerpts from the WHO publication, Prevention of
Sexual Transmission of Human Immunodeficiency Virus (HIV). This type of
information must be clearly explained to the client and. with the explicit agreement of
the client, to his or her sex partners, if that person is known and accessible.
I
it is iu>l vel clear whether pregnancy accelerates the progression of IIIV infection to
AIDS. The uncertainties about this must be carJfully explained to mlectcd women ol
childbearing age. The risk of transmission to the foetus is 20-45%, If a woman has
AIDS she is more likely to have problems with the pregnancy. 11 HI V-inlected
women want to avoid pregnancy, advice about contraceptives should be given to them
and their sex partners. Access to safe and reliable contraceptive methods must e
().
ensured.
7.
8.
With regard to immunization, studies have demonstrated that the use: of the^ following
vaccines is safe in children suspected of being mlected with HI V-1, BCG. DI . Ol .
IPV measles vaccine and tetanus toxoid (all the standard vaccines recommended or
children). However, BCG should not be used if a child has symptoms of HIV-related
disease The safety of other live vaccines, such as yellow fever vaccine, has not cen
evaluated. In general, where there is a high prevalence of HIV mfection
asymptomatic persons should continue to be immunized m accordance with the
standard schedules recommended by the WHO Expanded Programme on
Immunization (EPl), further experience continues to support these
recommendations, highlighting the benefits of immumzaUon m protecting Hl V-1 infected children, particularly against measles and the complications of tuberculos .
Persons with HIV infection should never donate body fluids, such as blood, semen,
and breast milk, or body organs.
9.
If blood from a person infected with HIV is spilt in the home or workplace, it should
be cleaned up with an absorbent material (such as cloth, rag, paper towel, oi
sawdust) while avoiding direct skin contact with K. 1 he blood-soaked absoi be
material should then be disposed off either in a plastic bag, burned in an incineraloi
or buried The area that was contaminated with the blood should then be washed with
a disinfectant (preferably sodium hypochlorite, or household bleach^di uted 1. wit
water) to clean up any excess blood spills. If gloves arc not available anolhci
"m-Xch as i plasflc bag. a huge wad of paper, towels or cotton should be used to
protect against direct skin contact. I lands should always be washed with soap and
water after cleaning up blood or other body fluids.
“lothcs or cloths that arc visibly contaminated with blood should be handled as little
possible. Household (rubber) gloves should be worn, if available, and the clothes or
’i.-Pces of cloth placed and transported in leak-proof bags. Such items should be
washed Hh detergent and hot water [al least 71 C (160 f)l for 25 m mutes or Um v
merelrual blood, these should be wrapped in Jlasuc or paper unu aun etc .
11
10. People with IIIV infection should not share syringes, needles, or other.skin-piercing
instruments, as this adds the risk of transmission of HIV and other pathogens to the
existing risk of such practices. People with HIV should avoid being tattooed or
having any other invasive procedure unless sterilization of the instruments can be
ensured before and after the procedure.
11. People with HIV infection should not share tooth brushes, blades, razors or other
instruments that could become contaminated with blood (even though the risk of HIV
transmission from these devices is extremely low).
12. People with HIV infection or disease usually seek or request information about
treatment and possible cures. It is therefore important for counsellors to receive
regular and reliable updates as to the progress of research, together with information
about the availability and effectiveness of specific drugs or therapies for HI V-rclatcd
conditions. While there is as yet no cure for HfV infection or for AIDS, some
therapies have been found to be cllcctivc in treating opportunistic diseases aiising
from immunodeficiency. At least one drug, zidovudine (also known as AZT), has
proved effective in extending survival time and relieving symptoms in some patients.
More than 40 different drugs (antivirals and immunomodulators) are currently being
tested separately or in combination in more than 100 clinical trials, mainly in
industrialized countries.
13. It is also important to recognize that many people may mistake expensive treatment or
care for good treatment. Counsellors should be aware of this and help patients make
decisions on the advantages and disadvantages of different therapies and interventions.
Counselling should also emphasize socially constructive behaviours and activities that
do not involve a risk of HIV transmission. Casual social contact, sharing crockery and
cutlery, being in the same room, sharing swimming pools and lavatories do not pose a
risk to anyone and help to maintain a feeling of social cohesion.
Drug injectors who are unable to stop using drugs should be told where they can
obtain sterile needles and syringes (if this is possible) or how to disinfect, injecting
equipment using bleach. Some countries or cities have needle and syringe
exchange facilities. Drug use is always expensive, and some drug injectors may
engage in prostitution to obtain the money they need lor drugs. Combining drug use
with prostitution is particularly dangerous for both the prostitutes and the client.
Special care is needed in counselling those thought to be doing this, by regularly
providing condoms, and by encouraging them to insist on their use.
Sex partners of drug injectors may be at risk of acquiring HIV infection and other
diseases if sexual intercourse occurs without the use of condoms. Counselling and
information should always be provided for the sex partners of drug injectors on how to
avoid possible 111V infection by the adoption of safer sexual practices.
Ill
4
witive health behaviours need to be actively encouraged. The specific behaviours to
' be encouraged will vary frorii one social groups to another. The counsellor wdl need
to be specific to meet the needs of individuals and special situations. It is important to
stress to HIV-infected people how they can live with AIDS. In the following section
are some general guidelines for living with AIDS.
Section 1 : Living Positively with AIDS
A person with AIDS should try to keep the body strong. This means they should
□
□
□
□
□
□
□
□
□
□
Eat a balanced diet whenever possible including food which is rich in proteins,
vitamins and carbohydrates. Nutritional deficiencies may adversely influence
immune system.
,
Slay as active as possible to keep fit and get regular sleep. Exercise helps prevent
depression and anxiety and can add to a general feeling of well-being and
contribute to general health and stamina.
Continue to work, if possible.
Occupy oneself with meaningful or at least distracting activities.
Give both physical and emotional affection.
Socialize with friends and family.
Talk to someone about the diagnosis and illness.
Use a condom during sexual intercourse.
Seek medical attention for health problems and follow advise lor care
including counselling and social services. This includes preventive services such as
immunization for children and infants with 1 11 V/A1DS.
Reduce stress by identifying potential and actual stiess lactois.
They should avoid:
□
□
□
□
□
alcohol and cigarettes.
other inl'cctions-inchiding further doses of IIIV.
pregnancy because it lowers the body’s immunity in some eases hastens the
onset of AIDS in 111V positive women.
Using unprescribed drugs.
Isolating themselves.
Section 2 : Instructions for condom users
for maximum protection, condoms must be used correctly. The following instructions should be
given to condom users:
□
□
□
Use a new condom each lime you have inlcrcouisc,
‘ i on the penis before inlcrcouisc begins;
always pul (he condom
pul the condom on 1when the penis is erect;
IV
□
□
□
□
□
□
□
□
□
in putting on the condom, squeeze the nipple or empty space al the end o( the
condom to remove the air from end of the condom. Do not pull the condom
tightly against the tip of the penis; leave the small empty space (1 to 2 centimeters) at
the end of the condom to hold the semen.
unroll the condom, all the way to the base of the penis,
if the condom tears during intercourse, withdraw the penis immediately
and use a new condom;
.
after ejaculation, withdraw the penis while it is still erect. 1 lold on to the urn ol
c
condom as you withdraw, so that the condom does not slip oil;
remove the condom carefully so that semen does not escape. Dispose off used
condoms by flushing, burying, burning;
if a lubricant is desired, use a water-based one-petroleum jelly may damage condoms,
do not use saliva as a lubricant - it is ineffective and may cause the condom to break,
store condoms away from excessive heat, light, and moisture - these cause them to
deteriorate and perhaps break;
condoms that are sticky or brittle or otherwise damaged should not be used.
iiiu vuuuoviiMi
The
counsellor must make sure that condom users understand and follow these
instructio^s.^f ihcVprovc difficulUo follow, the counsellor must explain them in a simple
language and with the aid of graphic material. The counsellor should consider adapting the
culturally appropriate graphic material already used by the local family planning serv.ces.
Section 3 : Guidelines on preventions of sexual transmission of HIV
The following general guidelines
adapted to different local situations.
1.
arc aimed at individuals or groups. They may need to be
Recommendations io all persons to prevent sexual transmission of IIIV
Be aware that, if you have a mutually faithful relationship with your sexual
(a)
partners, if you are both 111V seronegative, and if neither of you is exposed
to contaminated blood e.g., by intravenous drugs or sharing needles, you
are not at any risk of a sexually transmitted HIV infection.
If you intend to have sexual intercourse and are not m a mutually lait i u
(b)
sexual relationship, be aware that your chance of acquiring HIV infection i
influenced by the following three, main factors.
l.The choice of your sexual partncr(s)
The risk of infection is directly related to the likelihood
that your partner may be infected; for both heterosexual
and homosexual partners. I lowcver. there is no way to
know whether someone is infected by looking at him/
her. Therefore, the use of condoms is the only way to
avoid exposing oneself to the risk of infection.
V
2. The number of sexual partners
The greater the number of partners with whom you have
sexual intercourse, the greater the likelihood that you
will encounter a partner with HIV infection. Therefore
reduce the number of sexual partners to the greatest
extent possible.
3.The type of sexual behaviour practiced
Abstinence is the best way of preventing sexual
transmission of HIV infection. However, lor many
people this is not acceptable or realistic. The use of
condoms and other safer sexual practices are the only
ways of decreasing the risk of becoming infected with
HIV or transmitting HIV to a sexual partner.
Restriction of sexual contact to activities that do not
involve the sharing of semen, vaginal and cervical
secretions, of blood (e.g., hugging, caressing) will
eliminate the risk of acquiring HIV infection. Other
“safer sex” practices include masturbation, massage,
kissing and hugging. Oral sex should be avoided if theie
are sores present in the mouth or on the genitals. 1 hese
precautions are also advised for men having sex with
men, or women having sex with women.
11. Recommendations to HIV-infected peisons
(a)
(b)
Inform potential sexual partners of your HIV infection and decide either to avoid
sexual intercourse, or rigorously restrict sexual contact to activities (c.g., hugging,
caressing) that do not involve sharing of semen, vaginal and cervical secretions, or
blood. Discuss the precautions that need to be taken to minimize the risk of HIV
transmission from sexual activity (c.g., the use of condom).
If you both decide to engage in penetrative sexual intercourse, learn how to use
condoms correctly as consistent, correct use will reduce the risk of
HIV transmission.
(c)
Strictly avoid sexual intercourse when youi or your sexual partner has an infection
during menstruation.
or lesion in the genital, anal, or oial area Jnd
<
VI
M)
Avoid pregnancy. I llV-infecled women who are pregnant should know about the
health risk to their unborn children and the potential health hazard to themselves, and
should be provided with counselling services. 111 V-infected men should discuss the
hazard of pregnancy with their partners.
(e)
Do not donate blood, plasma, semen, breast, milk, body organs, or other tissues.
(9
Mothers should continue to breastfeed.
(g) Inform former and current sexual partners about your HIV infection and
recommend that they visit a testing centre or health-care provider for counselling
and evaluation (including, if available, serological testing). 11 you are unable or
unwilling to notify formerand current sexual partners personally, request health
workers or public health agencies to notify or help with notifying such partners.
(h)
Do not share syringes, needles or other skin piercing instruments.
HL Recommendations to sexual partners of HIV-infected persons
(a)
Contact a health-care provider for counselling and evaluation (including, if available,
serological testing). If the HIV serological test is negative and you arc clinically
healthy, and if die last unprotected sexual contact or needle-sharing exposure with
your infected partner was six or more months ago, it can generally be assumed that
you have not acquired HIV inlection from that exposure. 11 youi last exposuie was
less than six months ago, or if you continue to have sexual intcicouisc with your
infected partner, repeat tests will be necessary to determine whether iniection has
occurred. If you were negative on initial serological testing, see the
reco m m end a t i o n s be 1 o w.
(b)
Be aware that avoiding sexual intercourse with an HIV-infected peison or rigorously
restricting sexual contact to activities that do not involve sharing ol semen, vaginal
and cervical secretions, or blood (c.g., hugging, caressing) is the only way of
eliminating the risk of acquiring HIV infection from the person. If this is not
acceptable, the use of condom is an alternative, but it is not without risk. Although
the precise effectiveness of condoms in preventing 111V infection is unknown their
correct and consistent use will significantly reduce the risk of transmission.
(c)
(d)
Avoid all sexual intercourse when cither you or your sexual partner has an infection
or lesion in the genital, anal, or oral area and during menstruation.
If you are pregnant, find out and seek counselling about HIV-antibody testing. If
you arc tested and found to be seropositive, find out and seek counselling about the
significant health risk to your unborn child and the potential risk to yourself.
VII
I
(c)
Dot not donate blood, plasma, semen, breast milk, body organs, or other tissues.
(f)
Offer HIV testing information and counselling to people at increased risk of
infection.
IV. Recommendations to health-care providers
Doctors, nurses and other staff who are handling HIV infected patients, their blood
products or their lab specimens are also likely to be worried about their risk of infection. The
counsellor has to be aware of such risks. The risks in reality are very low and to date there are
only a few people known to be infected, from the hospital through looking after HI V/A1DS
patients. However, there is a potential risk and care must be taken whenever blood and such
samples are handled, so that it does not come into contact with broken skin. WHO estimates that
the risk of infection through a needle slick injury (needle having been used on an IIIV infected
person) is lower than 1 in 200. The counsellor who is involved in counselling health care
providers can get more details from the NACO and WHO Manuals for Health Care Workers.
VIII
APrENDLX 2
UNIVERSAL HEALTH PRECAUTIONS
THE PRINCIPLE OF UNIVERSAL INFECTION CONTROL:
Health care workers must strictly follow infection control precautions at all times and for
all patients irrespective of HIV status. At the outset, the following points are very important for
all personnel in healthcare settings :
□
□
□
The risk of HIV transmission from patient to health-care worker (or vice-versa),
is minimal i.e. 0.01% (there being no intimate contact involved).
However, the lethal nature of HIV makes precaution essential.
Besides, the nature of precautions to be taken for HIV prevention are extremely
simple and basic. They also help to minimize the risk of many other infections.
Transmission of HIV occurs in a pattern similar to that of Hepatitis
B - the precautions appropriate for Hepatitis B are therefore
si mi liar to those against HIV
PRECAUTIONS TO BE TAKEN FOR INFECTION CONTROL
Given below are the precautions to be observed while dealing with all infectious cases,
including HIV.
A. When you arc likely to conic into contact with BLOOD or any other BODY-FLUID:
□
□
□
□
Always use barrier protection
Always wash your hands thoroughly after taking off the glovesplain soap and water will do
Be very careful while handling specimens of body-fluids. They must be kept in
good containers, scaled and put into waterproof bags and labelled
‘BIO-HAZARDOUS’.
if any body-fluid is spilled either by the patient or by you,
(a) Use fresh chlorine over it,
(b) Swab with cotton,
(c) Pour chemical disinfectant,
(d) Wipe,using disposable gloves
(e) Dispose cotton, swab, gloves etc. in incinerator.
IX
BARRIERS 8 0 BIC USED WHILE HANDLING BLOOD AND BODY FLUIDS
GLOVES protect you
when you have
unnoticed cuts and
wounds in your
hands
5<C
GOWNS/APRONS protect
you if your clothes
get soiled by the
patients body-fluids
FACE SH1ELDS/MASKS
protect you when
body fluids get
sprayed or splashed
on to your face
Avoid direct contact if you know you have a cut/wound.
B. Given below are the precautions that need to be taken while using NEEDLES and
INJECTING MATERIAL (syringes):
□ It is best to use disposable equipment, eg. needles, syringes, etc. However, it this is not
feasible, decontaminate ail equipment
□ To decontaminate all reusable equipment, use disinfectants or sterilization (See section on
sterilisation and disinfection for details)
□ In case of a needle-stick injury,
(a) Throw away torn-glove
(b) Wash wound until blood disappears
(c) get blood-tests done at regular intervals for next one year
□ Never reuse disposable equipment - put them into incinerator after use.
□ Always dispose disposable equipment in puncture-resistant containers.
PRECAUTIONS TO BE USED WHILE USING NEEDLEsS AND SYRINGES*
Do NOT REINSERT
needles
DO NOT BEND/
BREAK needles with
your hands
DO NOT REMOVE
needles from
disposable syringes
C. If you arc handling a patient’s LINEN/ DISPOSABLE HEMS :
□
□
□
Treat all soiled linen as ‘infectious’ and keep separate
Store and transport them, in leak-proof bags, to laundry
Use gloves while handling
D. If you arc going to perforin any INVASIVE PROCEDURE :
□_
Maintain strict adherence to recommended infection control guidelines
□, Use barrier-protection which is tailored to individual needs.
X
E. Isolate persons with IHV/AHXS only if....
□
□
□
□
□
Patient lacks personal hygiene
Patient suffers from communicable opportunistic infections
Bleeding is present
There is uncontrollable behaviour due to dementia
Co-patients who are themselves immunosuppressed are present.
OTHERWISE, ISOLATION IS UNNECESSARY.
F. For EMERGENCY RESUSCITATION :
□
Use a thin plastic sheath over the mouth before providing mouth to mouth
resuscitation.
G. Masks and protective eyewear should be used..
By
When
Health workers
Dealing with all patients who might be
infected or involve splashing of fluids
Suffering from communicable pulmonary infections
Patients
11. For AUTOPSY and MORTUARY Procedures :
□
□
□
□
1.
Presence of minimum number of attendants
Use Barrier protection
Decontamination of all equipment and surfaces
Careful disposal of body fluids, faeces etc, into sanitary sewer.
Health workers with HIV infection must be instructed to :
□
□
□
□
Always use barrier protection
Avoid mouth to mouth resuscitation
Avoid caring for immuno-suppressed patients.
Avoid direct patient handling if suffering from lesions, cuts, open wounds etc.
.MBWKffiarTT-acwracuwwmMra
THERE IS ABSOLUTELY NO REASON FOR HEALTH WORKERS OR
RELA LIVES, TO REFUSE CARE FOR PERSONS WITH HIV/AIDS.
(Only pregnant women with suppressed immunity may be exempt)
________ — i
iiiwb——— ***M*""1
’ ' ’ i control guidelines for the purpose of
Counsellors may suitably adapt the above
AlDS(PWAs)
at home.
guiding and training those caring lor persons wi.ith
--------.
XI
DISINFECTION AND STERILIZATION PROCEDURES
□
□
First wash equipment with COLD water and ordinarydetergent.
DO NOT SPLASH while rinsing.
Then use either heat or chemical disinfectants, depending on the equipment to be
disinfected or sterilised.
Heat (56° C) by using one of the following methods:
Autoclaving (Presssurized steam)
Boiling (30 mins);
Dry air-over
Chemical methods using some of the following:
Ethylene-oxide gas
Ethanol
Formalin
Dettol
Glutaraldehyde
Iodine
(Source : WHO: Self learning manual for HIV/A1DS for grass root level workers)
XII
(a/OSSARV
Acceptance : Receiving a client, unconditionally without reservation or judgement but with
warmth, genuineness and positive regard.
Accessibility : Implies that counselling facilities be available easily, at a neutral location and
should be conveniently approachable.
AIDS : Stands forAcquircd Immune Deficiency Syndrome. Acquired - one is not born with it
but gets it as a result of certain behaviours. Immune - this means protection. Deficiency Affected body’s immunity is depleted, there is not enough protection. Syndrome -A cluster of
symptoms.
Antibody : A protein molecule produced by the body’s immune system to interact with specific
antigen that has invaded the body.
Antigen : Any substance capable of inducing the production of antibodies by the immune system.
ARC : Stands for AIDS related complex. By the time that the HIV virus has severely damaged
the natural immune system the person may be suffering from diarrhoea, excessive loss of weight,
skia rashes, etc. At this stage the sufferer can sometimes be more ill than the “full blown AIDS
sufferer and may be in need of a great deal of care and support. These symptoms may persist for
many years.
Burn out : It is a term used to refer to a progressive loss of idealism, energy and purpose
experienced by helpers as a result of the conditions of their work.
Condom : A sheath usually made of rubber that fits over the penis during sexual activity A latex
condom can reduce the risk of HIV infection The risk factor depends on the quality of the
condom, state of mind of the individual using it and the sexual activity engaged.
Counselling : Involves two people, who meet to resolve a crisis, solve a problem or make
decisions involving personal, intimate matters and behaviours
Elisa : Enzyme Linked Immuno Sorbent Assay - HIV antibody test.
Empathy : Accurately
client.
sensing the clients world verbally sharing our understanding with the
Haemophilia : An inherited condition that affects the normal clotting of blood, thus leaving the
individual at risk of severe bleeding.
Heterosexual : People attracted to members of the opposite sex.
Kill
High risk behaviours Behaviours which make people more decisions involving personal,
intimate matters and behaviours.
HIV : Stands for Human Immunodeficiency Virus. HIV is the virus that eventually lead to AIDS.
Homosexual : Person attracted to members of ;he same sex.
Immune System : An efficient mechanism in the body that protects against diseases.
Immunity : The power of the body to resist any effects by micro-organisms and their products.
Infected : Refers to the person who has the HIV virus within his/her body.
Infection : HIV enters the body, the blood stream and starts infecting the cells.
Macrophages : One of the components of the immune system that destroys invading antigens.
Negative Test: No antibodies against HIV found in patients blood this time.
Opportunistic Infections : Infections that are caused by organisms which usually cannot induce
disease in people with normal immune systems.
Pandemic : A global epidemic.
Paraphrasing : Rephrasing of a clients' statement.
Positive Test: Patient is HIV positive i.e. his/her blood contains the antibodies produced by the
presence of HIV in the person.
PWA : Stands for Person With AIDS.
Reflecting : Paraphrasing or communicating the-affective component of a client's message.
Sero-conversion : Body begins producing-antibodies to fight off the virus. They can detected in
a blood test called ELISA.
Seropositive : Describes a person whose blood shows the presence of antibodies to the infection.
Antibodies to the HIV virus generally drop within three months after being infected.
Sexual Abstinence : Not having sex with anyone.
Sexual fidelity : Two people having sex with each other only.
STD : Stands for Sexually Transmitted Disease. Diseases that can be transmitted during sexual
contact, for eg. syphilis, herpes etc.
XIV
Vaccine : Any substance that is innoculatcd for prevention ol a particular disease.
Western Blot: HIV antibody test, used as a confirmatory lest,
Window Period : 6-12 week phase between HIV infection and sero-conversion in the biood. In
this period, a blood test may not reveal, the presence of the antibodoes. Hence, the person may not
find out if he/she is infected but he/she will be infectious.
Glossary of Training-Terms
Activities : An activity is a set of specific functions carried out by the trainees together with the
trainer in order to achieve the objectives.
Brainstorming : It is an activity used to open a discussion on an issue or to stimulate the group.
Trainees are asked to give their ideas and opinions on a specific topic while other trainees arc
asked not to pass judgement on those opinions. The trainers responsibility is to list everything
that is said on the blackboard. The aim is to continue exploration until all ideas have been
exhausted. This activity is done for a prc-dctcrmincd time.
Case Study : A case study is a story that can be analyzed, and from which learning can occur.
Group Discussion : Group discussion is a process that uses the group to disseminate
information, analyze ideas dr teach concepts. The process serves to increase trainee interaction
among peers. The size of the groups depends upon the nature of the topic being covered.
Group work: Group work is an activity carried by a small group of trainees through pooling
their collective thoughts, experiences and knowledge, together in order to perform a given task.
Mini Lecture : Mini-lecture is utilized in this manual to disseminate information directly from the
trainer to trainees. This method when combined with other instructional strategies, pi onto cs
greater motivation and learning.
Module: A module is the basic unit of this training manual which covers a specific topic.
Objective : An objective is a statement of purpose for each module.
OHP : Overhead Projector (an audio-visual aid).
Overhead Transparencies : Overhead transparencies are used throughout the’
Ma
visual aid to present and review information and to provide graphic examples. Overhead
is
projected through an overhead projector.
XV
d'aw"or pn,,,ed a"d ,hc
Role Play : Role Play is an activity which involves trainees in learning desired concepts or
practicing certain behaviours. For example, one trainee lakes the role of a counsellor and another
takes the role of a client. Together they act a given counselling session. Role plays can be highly
motivating because they actively involve the trainees. Using a video for recording the session and
immediate feedback is a powerful adjuvant lor training. Audio feedback is chcapci but less .
effective.
Review Questions: Review, questions are questions posed at the end of each module and help to
assess trainees’ intake of knowledge covered during the sessions.
Worksheet: A worksheet is training material with instructions on the way to use it which is
handed out to the trainees with an aim to sensitize or evaluate knowledge during a specific
exercise.
r/
i
xvi
LIST OK REFERENCES
Bancroft John, (1992):
Edinburgh: Churchill Livingstone.
Connoway, Ronda S. and Gentry, Martha A. (1988): Social Work Pra£li££,
New Jersey : Prentice Hall.
1
Edelwich. J. with Brodsky. A (1980): BurtLOUL
New York : Human Sciences Press.
Haas & Haas, (1993): Ltodgrstanding Sexuality
St Louis: Times Mirror / Mosby Publishing.
Kelly, Jeffry A and St. Lawrence, Janet S. (1988): 1 hg AIDS Health-Crisis*
Psychological and Social Lnlsmulkns. New york and London : Plenum Press.
l
Llewellyn - Jones Derek (1984): Every isaa- Oxford : Oxford University Press.
Mane P. & Malta S„ (1992): AlEiS-Prevsntian.
Bombay : Tata Institute of Social Sciences.
Mathews Grace. (1991): AnJdltmayphPn
Bombay : Tata Institute oi Social Sciences.
Meichenbaum, Dr. Donald (1983): Coping wilh_slwj§x
Toronto : John Wiley and Sons Canada Limited.
Ministry of Health, Govt of Zambia. Academy for Educational Development-John
Hopkins University School of Public Health (undated). ITtaliengSSJllALDS
counselling. A training guide for counsellors for use with the video.
Ministry of Human Resources Development. Government of India. (1993): AIDS
■;
Education for Student youth : Alairiillg.manuaL
WHO, (1993): Global programme on AIDS. HlY-prgyantion and .care .
modules for nurses and midwives. World Health Organisation.
l
t
I
WHO, (199'1):
NewDelhi: WHO-SEARO.
WHO (19923: H1V/AIDS counseliing,.A innnual-fPX-Ugg ?n trainiDg wpiksbops- WHO
Global Programme on AIDS.
■
A1D3COM CAREC, (1990):
. Caribbean.
XVil
r
f
- Media
16057.pdf
Position: 1400 (6 views)