Terry's case: A Youth at Risk

Counselling Guidelines for HIV Testing

Provided by the Canadian Medical Association
Prepared by the Expert Working Group on HIV Testing: Counselling Guidelines

• Abstract
• About these guidelines
  1. Underlying principles in testing for HIV
  2. Ethical and legal concerns and prerequisites
  3. Components of pretest counselling
  4. Tests for HIV infection
  5. Components of post-test counselling
  6. Women and their children
  7. Emerging issues
• References
• Resources
• HIV counselling checklist for physicians

Abstract

Objective: To provide physicians and other health care professionals with concise, easy-to-read counselling guidelines related to serologic testing for human immunodeficiency virus (HIV).

Options: Serologic testing for HIV without counselling has a psychological, medical and social impact on patients. Therefore, experts agree such testing must be preceded and followed by appropriate counselling by trained or experienced professionals. Kits for simple, rapid testing may mitigate against the recommended counselling process; these are not licensed for use in Canada.

Outcomes: When used appropriately, serologic testing for HIV with pre- and post-test counselling is an effective means by which physicians can diagnose disease, help patients manage their health and stop the spread of HIV infection.

Evidence: Recommendations presented in this document are based on the views of scientific experts and reports published to March 1995, as assessed by the Expert Working Group.

Benefits, harms and costs: Current tests for HIV are accurate and inexpensive. The potential benefits of testing and counselling outweigh the potential harm caused by uninformed and nonconsensual testing or refusal of testing.

Recommendations: Physicians should obtain a history of risk factors for their patients, and identify, when possible, the current reasons for testing. The purpose of testing for HIV must be to benefit patients, enable them to obtain care and counselling and make their behaviour safer for themselves and others. Testing should always be done with the patient's informed consent after a full discussion of the consequences of being tested, including if, when and under what circumstances test results might be disclosed to others. For those infected with HIV, counselling involves not only resolving the psychological and social consequences of this situation, but also continuing medical follow-up, promotion of safer behaviour and partner notification.

Validation: These guidelines were reviewed by a national advisory group composed of representatives from the Canadian AIDS Society, the Canadian Association of Nurses in AIDS Care, the Canadian Hemophilia Society, the Canadian Paediatric Society, the Canadian Public Health Association, the College of Family Physicians of Canada, and the Society of Obstetricians and Gynaecologists of Canada. They were then circulated to a broader range of physicians and other health care professionals. The comments of these professionals are reflected in this final report.

Sponsors: This project was funded by the AIDS Care, Treatment and Support Unit under the National AIDS Contribution Program of the National AIDS Strategy, Health Canada.

About these guidelines

These counselling guidelines begin with a discussion of principles underlying testing for HIV infection followed by ethical and legal issues and prerequisites for testing. The various stages of physician-patient interaction are outlined: pretest counselling, tests and post-test counselling. The special factors involved in counselling women and their children are highlighted, as are specific problems that physicians will encounter.

Where consultation with more experienced colleagues might be considered, the physician is directed to various sources: physicians with greater experience caring for people living with HIV or acquired immunodeficiency syndrome (AIDS), medical officers of health, provincial or territorial AIDS coordinators. Resources are listed at the end of the report, along with pre- and post-test counselling checklists, which may be photocopied and referred to during counselling sessions.

Guidelines in this document reflect the views of the Expert Working Group on HIV Testing: Counselling Guidelines. They do not necessarily reflect the views of the organizations that the members represent, including Health Canada, and they are not intended to be construed or to serve as a standard of medical care.

1. Underlying principles in testing for HIV

Testing for HIV should always be voluntary and carried out only after the patient has given informed consent. (See Encouraging testing for HIV.)

Testing for HIV is not compulsory in Canada. Therefore, it cannot be imposed in any circumstance, including following sexual assault (for the survivor or accused) or before surgical procedures.

Care for medical or surgical conditions or before a diagnostic procedure should not be withheld pending the availability of results of serologic testing.

2. Ethical and legal concerns and prerequisites

Informed consent

Obtaining informed consent involves educating, disclosing advantages and disadvantages of testing for HIV, listening, answering questions and seeking permission to proceed through each step of counselling and testing. Informed consent cannot be implied or presumed.

Informed consent is necessary when testing for HIV is required, for example if a person chooses to

• donate blood, organs, tissue (including sperm and ova) or breast milk
• obtain insurance or
• apply for a visa to travel to a foreign country.

  To obtain informed consent for testing for HIV:

• the patient must be deemed competent
• the patient must understand the purposes, risks, harms and benefits of being tested, as well as those of not being tested
• the person's consent must be voluntary.

If the person is not deemed competent, his or her legal guardian must consent voluntarily.

Consent for testing infants, children and youth

Policy and definitions regarding testing of emancipated or mature minors, both of whom have capacity to consent, vary among the provinces and territories. Where such definitions are directed by law, they should prevail. Otherwise, the working definitions accompanying this report may be helpful.

Generally, for children and minors without the legal capacity to consent, voluntary informed consent from parents or legal guardian is required.

Refusal to be tested

Although most patients are likely to consent to testing for HIV, some may refuse. Their reason for refusal may be explored and resolved through supportive counselling. Ultimately, refusals should be respected.

Reasons that may motivate a person's refusal to be tested for HIV include

• false or inaccurate information
  
• insufficient psychological or emotional preparation
  
• lack of social support
  
• fear of breach of confidentiality
  
• fear of testing procedures
  
• fear of losing employment, housing, insurance or other economic support
  
• fear of losing friends, partners or child custody
  
• past or current history of physical or sexual abuse, or both
  
• personal or cultural values or beliefs.

Confidentiality

Great harm may result from careless breach of a patient's trust. Physicians are responsible for ensuring that their nursing and support staff respect the confidentiality of information obtained during testing for HIV and counselling.

Any disclosure of confidential information - no matter how inconsequential it may seem, whether it occurs in public settings, over the telephone, on an answering machine, by mail or fax - requires the patient's consent except when disclosure is required by law.

During a clinical audit by third parties, physicians should ensure that patient confidentiality is respected by the auditing agency.

The patient should be informed of how information about his or her serologic test results is recorded and stored and how confidentiality is maintained by staff.

Pediatric confidentiality
No one except the child's parents, other guardians and the physician has a need to know the child's status regarding HIV infection.

The family has no obligation to inform school authorities. If the family chooses to inform school authorities, the child's right to privacy must be assured.

The physician or medical officer of health, or both, may be required to serve as an advocate for the child and family.

3. Components of pretest counselling

Principles

Pretest counselling is an educational opportunity and should be viewed as a means to initiate preventive and continuing care. The decision to be tested should always be the choice of the individual patient. More than one pretest counselling session may be required for patients who refuse testing or are unprepared for testing. (See Pointers for counsellors.)

Assess the person's risk of HIV infection

Assess risk by asking simple, open-ended questions such as:

• To enable you and me to understand your risk of HIV infection better, may I ask you some specific questions?
• Has your partner, or anyone who has had sex or used drugs with your partner, been found to have HIV infection or AIDS?
  
• When was the last time you had sex with a woman? With a man?
  
• What kinds of sexual activities do you have?
  
• How and when do you use condoms? Spermicides?
  
• Do you have sex when you are using drugs or alcohol?
  
• Have any of your partners had problems with alcohol or drugs?
  
• When was the last time you injected drugs? Anabolic steroids?
  
• Have you ever injected drugs when you were under the influence of drugs or alcohol?
  
• Has someone ever injected them for you?
  
• When was the last time you shared needles, "cookers" (syringes) or other drug-injecting equipment?
  
• Have you ever had a sexually transmitted disease (STD)? Hepatitis?
  
• Have you ever had surgery or a blood transfusion?

Assess the window period

The interval following infection and before the appearance of HIV antibodies is known as the serologic "window period." After being infected with HIV, 95% of adults and youth will produce HIV antibodies within 3 months of infection; 99% will produce antibodies within 6 months. People may prefer to be tested at 3 months, 6 months, or both, after the most recent risk event.

To determine the window period, help identify the most recent risk event (i.e., potential exposure to HIV) and plan the appropriate time of testing. If a patient is believed to be in the window period, discuss risk reduction to prevent exposure to HIV while he or she is waiting to be tested.

Provide information

Regardless of whether testing is undertaken, take advantage of this opportunity to discuss HIV infection, risk-producing activities and specific ways in which the person can avoid or reduce risk.

In providing information about HIV, physicians may use educational materials such as brochures and videotapes or refer the patient to other sources of information. Local public health units, AIDS service organizations and the National AIDS Clearinghouse can supply material to physicians for distribution. (See What the patient should know about HIV infection.)

Identify testing options available in the region

Anonymous testing

• Usually available through special clinics.
  
• The patient's only identifier is a code name or number assigned by clinic staff.
• The identity of the patient does not have to be revealed to the physician or staff.
  
• When informed by the patient of a positive test result obtained from an anonymous test site, physicians should confirm it with repeat testing and counselling.

Non-nominal testing

• The patient's name is replaced by a code on the testing requisition (e.g., billing code, initials).
  
• Only the physician and the patient know to whom the code refers.
  
• Test results are included in the patient's chart and cannot be deleted.

Nominal testing

• The name of the patient is written on the testing requisition.
  
• Anyone reading these forms will know the identity of the patient tested and the test result.
  
• As for non-nominal testing, results are included in the patient's chart and cannot be deleted.

Discuss record-keeping

Inform the patient that test results and information will be added to his or her medical record and will be available to other health professionals on a need-to-know basis. If the patient objects, anonymous testing should be discussed.

Unsubstantiated HIV-positive test results should not be recorded without verification.

Special identification by visual coding or tagging on the outside of HIV-positive patients' files is not recommended as it may lead to a breach of confidentiality.

Discuss the implications of testing

Take time to examine and discuss the issues raised by testing so that the patient has the opportunity to weigh the advantages and disadvantages of being tested and prepare for the potential consequences of a positive or negative test result (See Advantages, disadvantages and consequences). Testing should be carried out only when the patient considers the advantages to be greater than the disadvantages.

Discuss the confidentiality of test results in relation to office or clinic procedures, communication of results to other health care officials, partner notification and reporting requirements.

Evaluate the patient's capacity to cope with a positive test result.

Determine the timing of testing and the post-test visit

Seldom is the need to obtain HIV-test results so urgent that it must be done immediately. The patient's concerns should be examined in detail to determine whether testing is appropriate when first requested or if it should be deferred.

During the window period, serologic testing for HIV may not be accurate. Tests should take place 3 months after the most recent risk event. Help identify the most recent risk event and plan the appropriate time of testing.

Physicians should contact an experienced colleague or check with a laboratory to determine time needed for testing (turnaround time for enzyme-linked immunosorbent assay [ELISA] and confirmatory tests).

For patients who have no signs or symptoms of HIV infection and are willing to wait until the end of the window period, provide a requisition for testing 3 months after the most recent risk event. Some patients may request a baseline test for various reasons, including anxiety, occupational exposure, requirements of workers' compensation boards or in some cases of sexual assault. (When the assault carries a risk of HIV infection, blood can be drawn during the post-assault visit, if the patient agrees, to be tested or discarded later at his or her discretion.) This baseline test, if negative, cannot accurately reflect the patient's status vis-à-vis HIV infection unless a second test is done once the patient is outside the window period.

Arrange a post-test appointment, allowing enough time for confirmatory testing should it be required. Results will usually be available in 2 to 6 weeks.

Obtain and record informed consent

Encourage the person to ask any additional questions to clarify doubts or fears or to seek information. Informed consent may be verbal and need not involve a specific form. Once informed consent is expressed, it should be recorded in the patient's chart [example] (1).

Provide support and follow-up

Test results, whether positive or negative, must be given only in person, in a face-to-face interview. Informing patients of their test result by telephone is unacceptable, even when it is negative. It places the physician at risk of liability should disclosure to someone other than the patient inadvertently occur. Communicating test results face-to-face permits better appreciation of the patient's reaction and enables adequate counselling.

Patients should be encouraged to contact the physician, AIDS service organizations or support groups if they experience intolerable anxiety between the time the blood is drawn for testing and the time they receive their result.

4. Tests for HIV infection

The diseases caused by HIV-1 and HIV-2 are similar although there is some evidence that type 2 is less severe. HIV-2 is very rare in Canada.

A new subtype of HIV-1 has been identified as subtype 0. Antibodies to subtype 0 may not be detectable by ELISA; provincial laboratories are modifying their testing kits to identify this subtype. Specific questions about the incidence of this subtype should be directed to provincial public health authorities.

HIV tests are inexpensive. The detection of HIV antibodies by ELISA (also called EIA) is the most sensitive and commonly used test. However, all positive test results must be verified by a second independent assay, usually the Western blot or immunoblot.

Interpretation of test results

5. Components of post-test counselling

Post-test counselling involves working with the patient to understand the test result, address psychological reactions to it, promote behaviour changes and assess the need for follow-up and care.

Communicate the test result

The patient should be informed of the test result in a direct manner at the beginning of the post-test session. It is likely that he or she has been anxious about the test result and is both eager to learn it and apprehensive.

When the patient is a child who is not able to understand the meaning of the test result, parents or legal guardians should be told first. Disclosure of test results to a child is a complex process and consultation should be sought from an expert in this field.

Assess the person's understanding of the test result

Negative result
HIV-negative patients may express relief, surprise or disbelief, or sometimes feel invincibility or guilt. Counselling should be directed at helping the patient to change behaviour to avoid or reduce future exposure to HIV.

Indeterminate result
Patients with an indeterminate result must face another distressing period of uncertainty. True status can usually be clarified over several months. While serologic status is being confirmed, physicians should be available for support and they should identify AIDS service organizations and resources in their region.

Positive result
After diagnosis, an HIV-positive patient usually cannot absorb much more information. The first post-test visit may be mainly supportive in nature (see Breaking bad news).

Over several visits, counselling of patients whose test result was positive should:

• stress that the patient can remain healthy and productive for a long time
  
• emphasize the importance of medical follow-up, referral when appropriate, and health promotion and stress-reduction in general (2)
  
• include discussion of the reproductive consequences of HIV infection for both men and women, including intervention to reduce mother-to-child transmission (3)
  
• arrange psychological and social support services as needed
  
• encourage self-education on care and treatment and be available to discuss new developments in the management of HIV infection.

Discuss risk-reduction strategies

For all tests results - positive, negative or indeterminate -- emphasize the importance of reducing risk-producing behaviour.

Any activity that deposits blood, semen or vaginal fluid on intact skin or in a condom carries a low risk.

Exposure to HIV can be avoided by abstinence, monogamy of uninfected sexual partners and refusing to share equipment for injecting drugs. If these options are not realistic, risk- and harm-reduction strategies should be explored periodically, as behaviour of all patients may change over time.

Alcohol and other drugs may impair a person's judgement or cause impulsive behaviour, increasing the risk of acquiring or transmitting HIV.

Counselling safer sex

A complete and regularly updated history of the person's sexual activity should describe risk-producing activities, including current and past sexual partners, specific sexual practices and history of STDs and of sexual assault.

The risk from specific sexual practices can be reduced by the use of barriers (e.g., latex condoms and dental dams) that prevent potentially infectious body fluids from entering the partner's body.

Dental dams are square sheets of latex used by dentists to isolate a tooth and control infection. They are available from pharmacies, medical supply stores and sex-equipment or condom shops. Some people cut open an unused, unlubricated condom or latex glove to use as a substitute for dental dams.

Condoms should be used consistently by monogamous partners until both have established that they are not infected with HIV or have other STDs.

Repeated unprotected exposure to HIV should be avoided. If both partners are HIV-positive, the couple may reduce the risk of transmission of different types of HIV and other infections between them by practising safer sex. If one partner is HIV-positive, the couple should minimize unprotected sexual activity.

Counselling safer drug use

A complete history of nonmedical drug use, including anabolic steroids, should enable the physician to determine the possibility of HIV transmission by this means. Risk associated with drug use arises from sharing injection equipment, i.e., needles and syringes.

Discuss current and past drug use, frequency of use, routes of administration, effects of drug use on sexual activity, and any illnesses resulting from drug use.

Counsel patients to make choices that will reduce their risk of acquiring HIV and other blood-borne infections; for example, adopting safer injection practices or switching to safer modes of drug use such as smoking, "snorting" or ingesting.

Reducing other risk

Contaminated instruments and trauma to skin: Any skin-piercing instrument that is contaminated with someone else's blood can transmit HIV. Activities such as tattooing, ear and body piercing, acupuncture and scarification are considered to be risk-producing when equipment is not sterilized.

Artificial insemination by HIV-positive donors: Since 1988, Canadian guidelines have recommended that only semen that has been tested for HIV 6 months after donation be used for artificial insemination (5). Explain these procedures to the inseminated patient and help her find out if guidelines were followed.

Receiving contaminated blood, blood products, tissue and organs: Medical care in countries where the blood supply is not secure or where instruments are not sterilized may carry a risk of HIV exposure. Since November 1985 in Canada, only blood that does not contain HIV-1 (and more recently HIV-2) has been used for treatment. In addition, all preparations for blood coagulation are treated to inactivate any HIV that may be present (5).

Although recombinant factor VIII is now safe, people with hemophilia may continue to be at risk through other modes of HIV transmission. Counselling should be directed at reducing risk of acquisition or transmission of HIV, including emphasis on safer sexual practices.

Recipients of blood transfusions may be unaware of their serologic status and experience significant anxiety about their risk of HIV infection.

Occupational exposure: Transmission of HIV through occupational exposure (particularly in health care settings) is rare in Canada. The greatest and most common risk has been associated with injuries from hollow-bore needles; the risk of infection as a result of injury from a needle used on an HIV-positive person does not exceed 0.3%. Needles should never be recapped and should be disposed of promptly in rigid prescribed containers (6).

Partner notification

Address the HIV-positive patient's feelings of guilt or anxiety about exposing and possibly infecting others by discussing partner notification.

The patient and physician should determine who will inform the patient's partners (the patient alone or the patient with the assistance of the physician or a public health officer or nurse) and what information should be given to them.

If the physician notifies the partners, the patient's identity should not be disclosed. The physician should be prepared to answer questions. Public health authorities never disclose the identity of an infected person.

6. Women and their children

In Canada, 10% of people with HIV are women (see Special counselling issues for women). The most common way that women are infected is through unprotected sexual activity with men. However, sharing of drug-injecting equipment is a rapidly growing mode of transmission.

Some manifestations of HIV infection in women may differ from those in men. (3)

Lesbian and bisexual women should not be excluded from testing for HIV and counselling: they may have past or current risk factors.

Risk factors for HIV infection should be assessed and testing offered routinely at visits for Pap tests and consultations about contraception or STDs.

Mother-to-child transmission

HIV can be transmitted from an HIV-positive mother to her child during pregnancy, labour and delivery or breast-feeding. In developed countries, the rate of transmission from HIV-positive mother to child is 12% to 30%.

About 14% of uninfected infants who are breast-fed by HIV-positive mothers will become infected. Therefore, breast-feeding by HIV-positive mothers is generally discouraged in Canada.

Testing an infant's blood for HIV cannot show whether the infant is infected, but will indicate the mother's status. All infants of HIV-positive mothers will test positive at birth because the mother's HIV antibodies cross the placenta to the infant; they may persist in the infant's blood for 15 months or more.

Other methods, such as HIV culture and tests to detect HIV antigens (such as p24 antigen assay) or HIV genetic material (polymerase chain reaction [PCR]), must be carried out to determine whether an infant is infected.

A multicentre study showed a dramatic reduction in mother-to-child transmission of HIV from 25.5% to 8.3% following zidovudine treatment (7). (Zidovudine or ZDV was formerly known as AZT.)

Prenatal testing procedures

We recommend offering HIV testing and counselling to all pregnant women. However, the procedure should differ from that used for other prenatal tests, and should be carried out over several prenatal visits.

At the first prenatal visit

• Follow the standard practice of exploring desirability of pregnancy, presence of social support, living situation and stability of relationship.
• Discuss advantages and disadvantages of testing for HIV for both mother and child and discuss the availability of treatment to reduce the chance of transmission to the fetus.
• Provide information on mother-to-child transmission.
• Discuss strategies to reduce the risk of acquiring HIV and other STDs during pregnancy. Provide written material along with information about local resources.
• Provide a separate requisition for the HIV test, so that the woman may decide against HIV testing without jeopardizing other prenatal screening.

On subsequent visits

• If the woman has chosen not to be tested, explore and record the reason.
  
• If the woman has not yet decided, re-explore the advantages and disadvantages of testing during pregnancy.
  
• If the woman has chosen to be tested, obtain and record receipt of informed consent.

Communicating the test result

Pediatric testing for HIV

As with adults, testing children for HIV requires informed consent, confidentiality, and pre- and post-test counselling. When the issue of testing an infant arises, both the mother and infant will have a test result. Therefore, all issues pertaining to the testing of one of these people also apply to the other.

There is no need to prevent the placement of HIV-positive children in child care settings, including daycare centres, to protect personnel or other children because the risk of transmission of HIV in these settings is negligible. Universal precautions should be followed in all child care settings when blood or bloody fluids are being handled (8).

7. Emerging issues

Rapid, simple testing for HIV

New methods for testing for the presence of HIV provide a patient with a definite negative or preliminary positive result in 10 minutes or less. As of April 1995, none of these tests has been approved for sale in Canada. Such tests may be available for research purposes but they cannot be used in the diagnosis of HIV infection.

Rapid, simple testing for HIV may have advantages over current protocols in specific settings, such as remote areas, developing countries or outreach test sites.

The advent of these tests, which do not require complex laboratory equipment or advanced technical training to perform, raises significant scientific, technical, epidemiologic, cost and ethical issues.

The use of these tests would affect the content of counselling information provided. As a result, their introduction will have to be accompanied by changes to counselling guidelines. However, it would not, in any way, abbreviate counselling protocols.

The introduction of rapid, simple testing does not decrease the need for quality assurance in the testing methods and the training of those carrying out counselling and testing.

Screening for insurance purposes

Insurance companies may use urine or saliva tests for HIV as part of their screening procedures. Patients who have obtained positive results in this manner should be retested according to the testing and counselling protocol recommended in these guidelines.

Continuing unsafe behaviour

An ethical dilemma arises when a physician knows that an HIV-positive person is exposing drug-using or sexual partners through risk-producing behaviour. Fortunately, continuing unsafe behaviour among people with HIV is not frequently encountered.

The physician should intervene to motivate the patient to disclose or stop unsafe behaviours. The following steps should be taken in order:

• Counsel the patient by exploring impediments to risk-reduction strategies. These may include partner's refusal to use condoms, inaccurate information about risks for HIV infection, poor social or economic living situation, psychological or emotional state, or fear of disclosure to partner(s).
• Inform the patient of the physician's ethical requirement to safeguard others.
• Report the situation to public health authorities.

Patients who do not return for test results

Controversy exists as to what steps should be taken if a patient does not return for results of tests for HIV. Seek consultation from an expert colleague in the field of HIV infection to determine the most effective intervention for such people.

Specific counselling issues

People infected and affected by HIV come from varying backgrounds and living situations. In dealing with people who are alienated from society, have special needs that "mainstream" health care addresses poorly or lack influence owing to poverty, low self-esteem or other reasons, physicians must be flexible and sensitive to each person's unique circumstances.

Ethnic communities
Be sensitive to cultural issues that may affect vulnerability to HIV infection and understanding of the HIV epidemic, including:

• different interpretations of medicine, illness, sexuality, death, shame and reputation,
  
• monogamy, homosexuality, bisexuality, commercial sex, alcohol and drug use
  
• cultural beliefs about AIDS and HIV infection
  
• disparity in male-female roles.

Aboriginal peoples
Be aware of cultural, social, geographic and language issues specific to aboriginal communities. Many urban aboriginal peoples are estranged from their communities of origin and need to be informed of the resources available to them, such as outreach, repatriation and traditional healing.

Street-involved people
Young people and adults who spend time on the street are often confronted with difficulties that place them at high risk for HIV infection. They may use drugs; exchange sex for money, drugs, shelter or food; and feel rejected. They may often be non-compliant with medical care until trust is established with a physician. Being identified as HIV-positive may place these people at risk of physical violence.

Adolescents
Assess cognitive and emotional development of an adolescent; it may not be in step with his or her physical development or chronological age. Normal adolescent rebellion against parental and societal norms may include both sexual and drug exploration; education and preventive counselling on these issues are needed. Explore local support systems for adolescents.

Gay and bisexual adolescents may have difficulty in disclosing their sexual orientation; physicians must provide a safe, non-judgemental atmosphere in which these issues can be discussed.

Commercial sex workers
The personal life and sexual behaviour of those who trade sex for money (men, women and children) are often quite distinct from their "working" identity; physicians should inquire about both. Some patients are more vulnerable to exploitation and HIV infection because of past or ongoing history of physical or sexual abuse, drug use and social isolation. Injecting drugs and drug dependence may undermine the patient's ability to protect him- or herself and others against HIV.

Provide ongoing education about safer sex and safer drug use, including how to deal with partners who refuse to implement risk-reduction strategies.

Men who have sex with men
Some men who have sex with men do not identify themselves as either gay or bisexual. Be sensitive to the fact that many gay or bisexual men may be hostile or distrustful because of previous encounters with homophobic health care professionals.

Prisoners
Risk-producing activities, such as unprotected sex, sexual assault and sharing of drug-injecting equipment, may occur in correctional facilities. Discuss behaviours openly with a recognition that the inmate, parolee or previously incarcerated person may fear retribution for his or her frankness. Appropriate print material can be obtained from the National AIDS Clearinghouse to support counselling.

Physicians working with inmates should be particularly aware of a need for confidentiality in a setting that tends to deny privacy. Knowing institutional requirements for disclosure of a positive test for HIV before counselling inmates on testing is essential.

Psychiatric patients and the mentally challenged
Those whose insight, impulse control or capacity to perceive risk is impaired by psychiatric or neurological disorders are at increased risk of acquiring and transmitting HIV. These people may also be poor or marginalized, lack basic sex education, have multiple diagnoses and have a history of past or ongoing sexual abuse.

In counselling such people, use audiovisual material and identify any underlying thought process or cognitive distortion that could interfere with risk-reduction strategies.

References

Resources

HIV counselling checklist for physicians