Terry's case: A Youth at Risk

Members of the Expert Working Group on HIV Testing: Counselling Guidelines

Marc Steben, MD (chair)
Catherine A. Hankins, MD (co-chair)
Maria Nengeh Mensah (project coordinator)
Gerry Bally, MD
Michael O'Shaughnessy, PhD
Allan D. Peterkin, MD
David Walters, MD

Project coordinator: Maria Nengeh Mensah

With assistance from the CMA secretariat:
Millicent Toombs, BA, MHA (project manager)
Margo Rowan, PhD (research associate)
Anita Kothari, MHSc (project assistant)
Brenda Kostiuk (project secretary)

We gratefully acknowledge the contribution of Ron de Burger; Norbert Gilmore, MD; Michael Graydon; Daphne Handanos, MD; Susan King, MD; Mary Lou Miller; Bob Pelletier; Pamela Thompson; and Sydney Thomson, MD. We also thank those who prepared and reviewed this document.

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.

Encouraging Testing for HIV

A person's request for testing for HIV should be honoured.

Reasons for requesting repeated testing for HIV should be explored.

A negative history of risk factors for HIV infection does not eliminate the need for testing and counselling because the person may not want to reveal risk-producing behaviours or partners' risk behaviours or be aware that his or her, or the partner's behaviours are risk factors for HIV infection.

Even if a person chooses not to be tested at a specific time, appropriate counselling about risk-reduction is recommended.

Working Definitions

An emancipated minor is one who, by his or her life-style, is assuming responsibility for his or her own life.

A mature minor is one who meets the requirement of fully appreciating the nature and consequences of the treatment or procedure.

Requirements for partner notification and contact tracing

Each province and territory has different legal requirements for reporting HIV infection and AIDS.

During a pretest counselling session, patients should be informed that, if the test result is positive, the physician is ethically obliged to ensure that sexual and drug-use partners are made aware that they may have been exposed to HIV.

If an HIV-positive patient refuses or is unable to inform his or her partners, the possibility that either the physician or a public health professional will notify partners should be discussed with the patient before such disclosure occurs.

Pointers For Counsellors

• Be aware that your own values and attitudes about sexuality, drug use and other life-style issues may bias your counselling.
• Maintain a non-judgemental attitude and develop an atmosphere of trust.
• Use an individualized, flexible approach.
• Avoid technical jargon.
• Be available to provide support and recognize additional counselling needs.
• Be sensitive when you broach issues surrounding testing for HIV before the patient does.

What the patient should know about HIV infection

• HIV causes a progressive disease, with severe health problems usually occurring 10 to 14 years after infection.
  
• A positive serologic test for HIV means that a person has been infected and is assumed to be capable of transmitting the virus, regardless of whether he or she shows symptoms.
  
• HIV is found in blood, semen, pre-ejaculatory and vaginal fluids, and breast milk.
  
• HIV can be transmitted by sexual intercourse, sharing of equipment used for injecting drugs, in unscreened blood and from an HIV-positive mother to her child during pregnancy, childbirth or breast-feeding.
  
• Serologic testing is the only effective way for a person to determine whether he or she has acquired HIV.
  
• HIV exposure and transmission can be avoided or minimized by specific actions.

Advantages, Disadvantages and Consequences

Advantages of testing:

• To resolve uncertainty about HIV status.
  
• To prevent further HIV transmission.
  
• To assist in more-informed reproductive decision-making.

Disadvantages of testing:

• Psychological stress. (For some patients, being found HIV positive may trigger depression or, infrequently, suicide. If such a risk exists or coping skills and social support appear to be inadequate, testing should be deferred until such skills and support can be developed or the patient can be referred for extended counselling, therapy or both.)
  
• Anxiety from keeping test result secret from family, friends and community.

Consequences of a positive test result:

• Some patients can benefit from care and treatment.
• Some risk of losing partners and friends, or denial of employment, housing, insurance, educational and travel opportunities.

Record informed consent: chart example

04/08/95

Uphill Clinic

• Patient requests HIV testing.
• Pretest counselling performed.
• Patient consent obtained for HIV testing.

Breaking Bad News

• Find a quiet, private setting in which to sit and talk with the patient face-to-face.
  
• State the test result directly at the beginning of the post-test session.
  
• Listen and respond to the person's reactions and be alert for buried questions.
  
• Expect tears and be sure to have a supply of tissues available.
  
• Find out how much the person wants to know about HIV or AIDS.
  
• Assess the person's understanding of HIV infection so that the news is understood.
  
• Provide information in small chunks; the patient often cannot absorb much more.
  
• Ask if there are additional questions.
  
• Emphasize the availability of crisis support and explain how the patient can obtain it.
  
• Ensure follow-up and plan for a future meeting.

Risk of HIV Transmission Associated with Various Sexual Activities (4)

No risk

• dry kissing
  
• body-to-body rubbing
  
• massage
  
• nipple stimulation
  
• using unshared inserted sexual devices
  
• being masturbated by partner, without semen or vaginal fluids
  
• erotic bathing and showering
  
• contact with feces or urine on intact skin

Theoretical risk*

• *Theoretical risk of HIV transmission means that it is impossible to prove that an infection will never happen.
  
• wet kissing
  
• fellatio, with or without condom
  
• cunnilingus, with barrier
  
• anilingus
  
• digital-anal and digital-vaginal intercourse, with or without glove
  
• using shared but disinfected inserted sexual devices

Low risk

• sharing non-disinfected personal hygiene items (razors, toothbrushes)
  
• cunnilingus, without barrier, during or outside menstruation
  
• fellatio and ejaculation, with or without ingestion of semen
  
• penile-vaginal intercourse, with condom
  
• penile-anal intercourse, with condom

High risk

• penile-vaginal intercourse, without condom
  
• penile-anal intercourse, without condom
  
• coitus interruptus (intercourse with withdrawal before ejaculation)

Conditions that increase risk of HIV transmission

• inconsistent, intermittent or improper use of latex barriers such as condoms or dental dams, including condom failure by slippage and breakage
  
• any injuries or conditions that damage skin or mucosal integrity, including inadequate lubrication
  
• genital inflammation, such as that caused by STDs, vaginitis, spermicides or other irritants (e.g., douches) or allergens

Advice for patients who inject drugs into themselves or others

Always use new needles and syringes, which can be obtained through needle-syringe exchange programs in many cities or purchased from pharmacists, with or without a prescription, across the country.

If new equipment is not available, the risk of HIV transmission can be reduced by flushing the needle and syringe with undiluted bleach three times, "flicking" or agitating the syringe, then rinsing the needle and syringe with water at least three times before each use.

If bleach is not available, needles and syringes can be flushed with alcohol. Cleaning is not a substitute for using new equipment.

Special counselling issues for women

Women are often tested later in the course of their HIV infection because of the perception that they are not at risk.

Many female-specific issues related to HIV infection were not recognized until recently. For example, economic dependence may place a woman at risk because of her inability to refuse intercourse or risk-producing activities.

Discuss safer sex and safer drug-injection practices with all women, and help them develop negotiating skills to use with sexual partners.

If a partner cannot be persuaded to use condoms, promote female-dependent methods of protection, such as spermicides with or without a diaphragm or cervical cap, sponges and condoms for women.