Asking the Hard Questions: A Reproductive Health Provider’s Guide to Client-Centered HIV Risk Assessment This Guide was supported by Cooperative Agreement Number UT7/CCU113703-05/06 from the Centers for Disease Control and Prevention (CDC). Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the CDC. copyright ©, 2002, JSI Research & Training Institute, Inc. A P R I L
2 0 0 2
JSI Research & Training Institute, Inc. 44 Farnsworth Street ■ Boston, MA 02210-1211 Voice: (617) 482-9485 ■ Fax: (617) 482-0617 PROJECT MANAGER:
Michele Clark, MPH JSI Research & Training Institute, Inc.
PROJECT COORDINATOR:
Carolyn Bill JSI Research & Training Institute, Inc.
LEAD AUTHOR:
Joan Mogul Garrity, Consultant
EDITOR:
Deborah Dean, MSPH JSI Research & Training Institute, Inc.
DESIGNER:
Marina Blanter JSI Research & Training Institute, Inc.
REVIEW TEAM: Kathleen Ambler, CNM, MSN, Project RESPECT Coordinator, Family Planning Association of Maine
Myriam Hernandez Jennings, MA, Manager Region I Title X Family Planning Training Center, JSI Research & Training Institute, Inc.
Deborah Dill, MSN, WHNP, Clinical Manager, ABCD/Boston Family Planning
Natalie Kil, Project Coordinator, JSI Research & Training Institute, Inc.
Susan Grantham, MPP, Director of Women's Health, JSI Research & Training Institute, Inc.
Shelley Mains, MPH, Training Coordinator, ABCD/Boston Family Planning
Felicia Guest, MPH, CHES, Southeast AIDS Education and Training Center, Emory University School of Medicine
Rachel Shelton, Family Planning Training Coordinator, JSI Research & Training Institute, Inc.
Susan Hellen, Manager, Training and Special Projects, Planned Parenthood of Connecticut (PPCT)
Marcia Szymanski, MSW, Program Director, Attleboro Family Planning Clinic, Health Care of Southeastern Massachusetts, Inc. (HCSEM)
Sally Hellerman, APRN, Director of Medical Services, PPCT
Elizabeth Torrant, MPH, Director of Family Planning, HCSEM
This Guide and its companion Guide, Supporting Quality HIV Risk Assessment: A Guide for Reproductive Health Clinic Managers and Supervisors, can be downloaded from www.famplan.org.
FEEDBACK FORM Asking the Hard Questions: A Reproductive Health Provider’s Guide to Client-Centered HIV Risk Assessment I . Information About Yo u I am responding as a:
❒ Counselor ❒ Doctor ❒ Case Manager
❒ Nurse ❒ Clinic Supervisor/ Manager ❒ Other:
II. Your Feedback on the Provider's Guide 1
To a very low extent
2
To a low extent
4
To a significant extent
5
To a very high extent
3
To a moderate extent
Using the above rating scale, please circle the number that best represents your opinion. As a result of reading the P r o v i d e r ’s Guide, I... a. Understand what HIV risk assessment includes.
1
2
3
4
5
b. Can explain the value of conducting HIV risk assessment with every client.
1
2
3
4
5
c. Learned specific questions to ask in a HIV risk assessment.
1
2
3
4
5
d. Identified barriers to HIV risk assessment.
1
2
3
4
5
e. Identified ways to overcome barriers to HIV risk assessment.
1
2
3
4
5
f. Increased my comfort in taking an HIV risk assessment.
1
2
3
4
5
g. Developed strategies for integrating questions about HIV risk in my reproductive health counseling sessions with clients.
1
2
3
4
5
Please indicate other information you would like to have seen presented in the Provider’s Guide.
Is there anything else you would like to tell us about the Provider's Guide?
Th an k you! You r f ee dba ck w il l h elp u s dev el op an d re vi se d oc umen t s th at b est me et your overa ll n eed s. Pl ea se re tu rn t o:
Carolyn Bill JSI Research & Training Institute, Inc. 44 Farnsworth Street, Boston, MA 02210-1211 Fax: (617) 482-0617
Table of Contents
Section I
INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 A. The Reason for This Guide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 B. How to Use This Guide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 C. What This Guide Does Not Do . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Section II
WHAT IS HIV RISK ASSESSMENT? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 A. ‘Listening In’ On HIV Risk Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 B. Defining HIV Risk Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 C. Contents of an HIV Risk Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 D. The Importance of HIV Risk Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 1. HIV IS an Issue for Clients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14 2. Clients DO Want to Talk About These Things . . . . . . . . . . . . . . . . . . . . . . . . . . 16 3. Risk Assessment Works! . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Activity One: Identifying Reasons for and Barriers to . . . . . . . . . . . . . . . . . . 18 Risk Assessment
Section III
OVERCOMING BARRIERS TO RISK ASSESSMENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 A. Practical Concerns About the Work . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Activity Two: Practical Concerns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 B. Personal Attitudes of Clients and Providers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 1. Clients’ Concerns.....................................................................23 Activity Three: Clients’ Barriers to Risk Assessment . . . . . . . . . . . . . . . . . . . . 24 2. Providers’ Judgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .25 Activity Four: Our Own Values and Judgments. . . . . . . . . . . . . . . . . . . . . . . . . . 26 3. Tips for Dealing with Judgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 4. Providers’ Discomfort . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Section IV
HOW TO DO HIV RISK ASSESSMENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 A. Nurturing a Conversation: Keys to Effective Dialogue in HIV Risk Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31 1. Creating a Safe Environment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
B. Techniques for Client-Centered Dialogue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32 1. Sample Dialogue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 C. The Language of HIV Risk Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .37 1. The Words Clients Use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 Activity Five: The Words Clients Use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .38 2. Responding to Difficult Language Used By Clients . . . . . . . . . . . . . . . . . . . 39 3. The Words Providers Use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .39 Activity Six: The Words Providers Use. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 0 4. Clarifying Our Language . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4 1 5. Don’t Ask “Why” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4 3 Activity Seven: The Questions Providers Ask . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 4 6.Non-Verbal Communication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4 5 Activity Eight: Non-Verbal and Paraverbal Communication . . . . . . . . . . . 46 7. Responding to Difficult Questions and Statements . . . . . . . . . . . . . . . . . . . 47 8. The 3Cs Model . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .47 Activity Nine: Responding to Difficult Questions and Statements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .50 D. Some Questions About Doing HIV Risk Assessment . . . . . . . . . . . . . . . . . . . . . . . 51 E. Closing Thoughts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .52
Section V
RESOURCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .55 A. Sample HIV Risk Assessment Dialogue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .55 B. Awareness Raising Questionnaire for Clients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59 C. Using the 3Cs Model: An Exercise. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .61 D. List of Local Providers for Referral . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63 E. Internet Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .64 F. Endnotes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .67 G. Additional References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .69
Section 1:
INTRODUCTION
I
A. THE REASON FOR THIS GUIDE This Guide is designed to help you – the counselor, clinician, health educator, or other reproductive health care provider – feel more confident about doing client-centered HIV sexual behavior and substance use risk assessment. Risk assessment is the essential first step to HIV prevention counseling. It doesn’t replace prevention counseling; instead it helps you direct a more intensive intervention to those who need it most. Risk assessment can help clients recognize that they are at risk, and can support them to take steps to reduce their risk. It also gives you a chance to provide clients with basic information about HIV transmission and prevention, in an individualized style. That’s what is meant by “client-centered.” Instead of a standard way of collecting and presenting HIV riskrelated information to all clients, a client-centered risk assessment is a conversation based on what the individual client reveals, and on their unique needs and circumstances.
Your willingness to do this work, and your desire to do it well, is a gift you give to your clients. There aren’t many places where clients have the opportunity to share and learn about risky behavior, and receive caring support to make healthy changes. You can provide that place – this Guide will show you how.
B. HOW TO USE THIS GUIDE This Guide is designed as an interactive, self-instructional workbook. Throughout the Guide, activities are provided for you to use – by yourself, with other staff, or with your supervisor or clinic manager. These activities will help you express your own concerns and identify the skills you want to strengthen. New counselors and clinicians can use this Guide as a skill-building manual. Experienced staff can use it as a review and refresher.
This Guide includes: ◗
In-depth presentation of the components of risk assessment
◗
Background material on the importance of risk assessment
Asking the Hard Questions: A Reproductive Health Provider’s Guide to Client-Centered HIV Risk Assessment
1
Section I
INTRODUCTION
◗
Examples of specific questions to ask
◗
Consideration of common questions about doing risk assessment
◗
Examination of the barriers that can get in the way of doing risk assessment
◗
Strategies for overcoming those barriers
◗
The best ways of setting a comfortable tone and how to ask those difficult questions
◗
Sample dialogues of risk assessment interactions with clients
◗
Print, audio-visual, and web-based resources for further learning
Though this Guide is comprehensive, HIV risk assessment doesn’t take a long time to do. You can incorporate it into the work you are already doing with your clients. This can increase your efficiency because HIV risk assessment includes other important topics addressed in reproductive health, including pregnancy and sexually transmitted infections (STIs). Once you’ve finished reading this Introduction, you may want to focus on your areas of greatest interest or skill-development need. If you are new to this work, begin by reviewing the background information provided in Section II: What is HIV Risk Assessment? For the specific how-tos of the work, go to Section III: Overcoming Barriers to Risk Assessment and Section IV: How to Do HIV Risk Assessment. If you’re looking for fundamental facts about HIV and AIDS, or statistics about the impact of HIV on your region, turn to Section V: Resources. For clinic managers and supervisors, this guide is intended to be used with it’s companion guide, Supporting Quality HIV Risk Assessment: A Guide for Reproductive Health Clinic Managers and Supervisors. Clinic managers or supervisors may find the two guides useful in implementing HIV risk assessment activities in their clinic. The Guide has been designed to allow for photocopying and distribution. Please copy and circulate relevant sections in your clinic.
C. WHAT THIS GUIDE DOES NOT DO
2
◗
The Provider’s Guide is not intended to be a substitute for counseling and communication skills training. It is assumed that providers who use this Guide already have a familiarity with client-centered counseling skills. This previous knowledge is essential to helping providers respond to issues that may need to be addressed during or after the risk assessment.
◗
The Provider’s Guide does not provide content information on HIV and AIDS. That, too, is a necessary prerequisite to this work.
◗
While the Provider’s Guide references the importance of culturally sensitive dialogue with clients, the Guide assumes that staff will receive ongoing cultural sensitivity trainings to meet this need.
Asking the Hard Questions: A Reproductive Health Provider’s Guide to Client-Centered HIV Risk Assessment
INTRODUCTION
Section I
Notes about terms used in the Guide : The term “provider” includes counselors, clinicians, health educators, and any other staff who do HIV risk assessment. For ease of reading, the majority of pronouns used in this Guide are feminine. The phrase “substance use” is used rather than “drug use” or “substance abuse” for two reasons. First, the term “drug” is not always understood to include alcohol. The more awkward phrase, “alcohol and drug use,” suggests that alcohol is not a drug. Substance use includes both. Second, one does not have to use substances in an abusive or addictive manner to be at risk. Social use of substances places people at risk for HIV infection because it reduces inhibitions and impairs judgment.
We welcome your feedback on the Guide. Please complete the evaluation included in the front of this Guide.
Asking the Hard Questions: A Reproductive Health Provider’s Guide to Client-Centered HIV Risk Assessment
3
Section I
4
INTRODUCTION
Asking the Hard Questions: A Reproductive Health Provider’s Guide to Client-Centered HIV Risk Assessment
Section II:
WHAT IS HIV RISK ASSESSMENT?
II
A. ‘LISTENING IN’ ON HIV RISK ASSESSMENT Before focusing in on the “nuts and bolts” of HIV risk assessment, take a look at the following examples of risk assessment done in the context of a clinic visit. Here are two different providers’ approaches to the process of HIV risk assessment. ‘Listen in’ on the first minute of each exchange.
The client, Melissa, is 25 years old. This is her initial visit to the clinic. The first provider, Angie, has come to the part of history taking that focuses on sexual and drug use behavior.
Melissa:
I’m going to ask you some questions about your sex life. Are you currently sexually active? Yes.
Provider: Melissa:
When did you first become sexually active? [pauses] Uh, well, I guess you might say at 15.
Provider: Melissa:
Fifteen...Okay. How many sex partners have you had since then? [appears to be mentally counting] Well, I dunno...I guess maybe three, or four?
Provider: Melissa:
How about in the past year – how many in the past year? Just one. My boyfriend.
Provider: Melissa:
That’s great. Do you two always use condoms? [looks away from Provider] Not always...
Provider:
Why? I’m sure you know about sexually transmitted infections, like HIV. You really should use them, you know. So what kind of intercourse have you had – vaginal, anal, oral? [shaking her head] Boy, this does get nosy! I’ve...I’ve had ‘em all. I mean, don’t most people?
Provider:
Melissa: Provider: Melissa:
Yes, lots do. But you know that you can get infections from oral sex too, and anal sex is really dangerous. [very emphatically] But at least you can’t get pregnant that way!
Asking the Hard Questions: A Reproductive Health Provider’s Guide to Client-Centered HIV Risk Assessment
5
Section II
Provider: Melissa: Provider:
WHAT IS HIV RISK ASSESSMENT?
Well, sometimes semen can get on the outside of your vagina, even during anal sex, and then you could get pregnant. But is that really going to happen? It could. See, Melissa, we don’t want you to get pregnant, until you want to of course, and we don’t want you to get any diseases either. I really think you should talk to your boyfriend about using condoms. I want to show you how they work.
Now, ‘listen’ to how another provider, Carolyn, does risk assessment with the same client.
Provider:
Melissa: Provider: Melissa:
I know you came in today to get a method of birth control. What’s going on in your life right now, sexually speaking? [responds rapidly] I have a boyfriend – he’s a great guy. We’ve been together a year and-a-half. And we do have sex. Not a lot, I mean not as much as he wants [laughs] but we do. But, you know, that’s why I’m here – for birth control.
Provider: Melissa:
So what have you been doing to keep from getting pregnant? Well, he pulls out before he comes, and, I guess I’ve been lucky...[her voice trails off]
Provider:
It sounds like not getting pregnant is very important to you. You and your boyfriend have been using one of the most difficult methods around – withdrawal. Lots of people use it, and they’re surprised to learn that it’s not very effective. Yeah, I know.
Melissa:
Melissa:
The good news is that there are much, much more effective methods that are so much easier than withdrawal. Yeah. My boyfriend really wants me to get the pill.
Provider: Melissa:
How do you feel about taking the pill? Well, I’m sure not ready for a baby!
Provider:
6
Melissa, the part of your medical history that I’m going to go over now is about sexual behavior and drug use. I ask these questions of every client, because these things have a big impact on people’s health. Okay.
Asking the Hard Questions: A Reproductive Health Provider’s Guide to Client-Centered HIV Risk Assessment
WHAT IS HIV RISK ASSESSMENT?
Provider:
Melissa: Provider:
Melissa: Provider: Melissa: Provider:
Melissa:
Section II
When pills are taken correctly, they are very effective at preventing pregnancy. But – and you probably know this – the pill doesn’t protect against sexually transmitted infections. What are you doing to prevent getting STIs, like HIV, the virus that causes AIDS? [shaking her head “no”] I don’t really think that’s an issue for me. You know, I think it’s hard for any of us to imagine that these diseases could have anything to do with us. At the same time, I’ve seen so many young women learn the hard way about these diseases. [nodding] You’re right about that. Actually I got something once. “Calmidia,” I think it was called, but I got treated for that. That was a couple of years ago. Yes, chlamydia is one of the most common STIs. And luckily, it can be treated. I bet that was unnerving for you. [nods vigorously] You’re right about that. I couldn’t believe it. I was so embarrassed! I ended up breaking it off with that guy. And even though it was embarrassing, you took care of it. And you know from that experience that a person can get an infection when they don’t expect it at all. Here’s a tough question to think about: how does it feel to trust your boyfriend with your health, and maybe even your life? I never really thought of it that way. I know we’re supposed to use condoms, but guys just won’t use those things. Besides, we’re only having sex with each other!
Which of these two providers – Angie or Carolyn – would you want to do a risk assessment with you?
How did Angie do? Angie’s series of close-ended questions i seems only intended to gather HIV risk-related information. She quickly focuses on Melissa’s risky behavior – her lack of condom use – in a manner that sounds full of judgment and criticism. Instead of using the exchange to help Melissa consider how she might be at risk, Angie tells Melissa what she should do: “I really think you should talk to your boyfriend about using condoms.” You probably sense that Angie does care about Melissa’s well being. With some simple changes in approach, Angie could make her interaction more expressive of her caring, and more supportive of Melissa’s steps towards risk reduction. iA close-ended question has a “yes” or “no” response and tends to limit dialogue. For example,
“Do you use condoms?” An open-ended question starts with “what,” “how,” “when,” or “tell me,” to elicit an in-depth response from the client. Asking the Hard Questions: A Reproductive Health Provider’s Guide to Client-Centered HIV Risk Assessment
7
Section II
WHAT IS HIV RISK ASSESSMENT?
How did Carolyn do? Carolyn is beginning a genuine, individualized dialogue with Melissa. She starts out by letting Melissa know what she’s going to be doing, and why. She acknowledges and normalizes the discomfort Melissa might be feeling in response to her questions. By asking open-ended questions, Carolyn gathers risk assessment information, while the back-and-forth exchange begins to help Melissa assess her own level of risk, and consider what she may need to do to reduce that risk. At the point when we ‘interrupted’ the conversation, Melissa was saying, “I know we’r e supposed to use condoms, but guys just won’t use those things.” She’s stating what ‘should’ be happening, without Carolyn needing to give her an order. She’s also expressing what she sees as a barrier to condom use. This will give Carolyn a good idea of where she might start when she talks further about risk-reduction strategies.
B. DEFINING HIV RISK ASSESSMENT Delivering reproductive health care has become much more complex since Title X was created in 1970. Title X is the federally-funded program that provides reproductive health care services to low-income women. Whether working in a Title X clinic, or at any of the many other sites providing reproductive health care services – community health centers, STI clinics, managed care organizations, or hospital-based clinics – a major challenge throughout the past two decades has been strengthening our response to the HIV epidemic. HIV risk assessment is our primary tool to prevent infection and combat the epidemic. Client-centered HIV risk assessment is an interactive exchange between a provider and a client in which the provider asks open-ended questions designed to elicit responses and reflection that can raise a client’s self-perception of risk. In the course of the conversation the provider presents education about HIV risks and risk reduction to support a client’s willingness to make behavior change. This HIV risk assessment process helps the provider to target more intensive interventions to clients who need it most. Getting ‘yes/no’ answers to questions about condom use or needle sharing isn’t enough. The goal of HIV risk assessment is to have a dialogue with clients about their sexual and substance use histories so that they are more able to make the behavior changes that will help them to reduce their risks. HIV related risk assessment may be integrated into care for other reproductive health care concerns, such as pregnancy prevention, STI diagnosis, or STI treatment; it does not have to occur as a separately identified event.
Here’s an important idea to keep in mind: The purpose of doing HIV risk assessment isn’t to help us to find out what a client is doing that might be putting her at risk. The purpose of HIV risk assessment is to help the client discover for herself what is putting her at risk.
8
Asking the Hard Questions: A Reproductive Health Provider’s Guide to Client-Centered HIV Risk Assessment
WHAT IS HIV RISK ASSESSMENT?
Section II
C. CONTENTS OF AN HIV RISK ASSESSMENT An HIV sexual and substance use risk assessment should cover the following topics:1, 2
1.
Sexual Behaviors (current and in the recent past)
2. HIV/STI Risk Factors (including prior STI diagnoses and incarceration) 3. Substance Use History 4. Pregnancy Intentions 5. Sexual Functioning and Relationship Issues 6. Domestic Violence/ Sexual Assault or Abuse 7. Other HIV-Related Risks At a minimum, every client should be asked: ◗
What are you doing to protect yourself from HIV (the virus that causes AIDS)?
There are many ways to ask these risk assessment questions. Keeping in mind the concepts in this Guide, you may come up with your own ways to ask about the seven topics mentioned above.
When asking about specific behaviors, be sure to use questions that don’t sound judgmental. Avoid questions like, “You don’t do drugs, do you?” “You’ve never had anal sex, have you?” And be aware of nonverbal communication that also conveys judgment, like shaking your head “no” as you ask the questions or listen to answers. Here are examples of questions to use for each risk assessment topic. How far you go with any one topic depends on the answers you get. While you won’t go over all of the questions with every client, try to always include the checked (✓) questions. Most sets of suggested questions start with an open-ended question. Open-ended questions are effective because they invite the client to give detailed thorough answers, sometimes making further questions on that topic unnecessary. The dialogue fragments from the previous conversation between Melissa and the provider shows how risk assessment topics can be integrated into a conversation.
1) Sexual Behaviors Provider: Melissa:
I know you came in today to get a method of birth control. What’s going on in your life right now, sexually speaking? [responds rapidly] I have a boyfriend – he’s a great guy. We’ve been together a year and-a-half. And we do have sex. Not a lot, I mean not as much as he wants [laughs] but we do. But, you know, that’s why I’m here – for birth control.
Asking the Hard Questions: A Reproductive Health Provider’s Guide to Client-Centered HIV Risk Assessment
9
Section II
✓ ✓ ✓
WHAT IS HIV RISK ASSESSMENT?
Tell me about your current sexual relationship or relationships. Tell me about your sexual activity in the past. How old were you the first time you had a sexual experience with another person?
And, depending on the answers, ask the following: ◗
How long have you been with your current partner(s)?
◗
What do you know about the sexual activity of any partner or partners you were with in the past?
◗
Does your partner, or partners, have other sexual partners, in addition to you?
◗
About how often do you and your partner(s) have intercourse? This question is useful because the response has implications for choice of contraceptive method. You can use these additional prompts to make responding easier and to normalize responses: about once a day, 2-4 times a week, about once a week, a few times a month, or a few times a year.
◗
What kind of intercourse do you have? Vaginal? Anal? Oral?
◗
How many male partners have you had in the past ten years?
◗
How many female partners have you had in the past ten years?
2) HIV/STI Risk Factors Provider:
Melissa: Provider:
Melissa:
10
When pills are taken correctly, they are very effective at preventing pregnancy. But – and you probably know this – the pill doesn’t protect against sexually transmitted infections. What are you doing to prevent getting STIs, like HIV, the virus that causes AIDS? [shaking her head “no”] I don’t really think that’s an issue for me. You know, I think it’s hard for any of us to imagine that these diseases could have anything to do with us. At the same time, I’ve seen so many young women learn the hard way about these diseases. [nodding] you’re right about that. Actually I got something once. “Calmidia,” I think it was called, but I got treated for that. That was a couple of years ago.
✓
What are you doing now to protect yourself from HIV (the virus that causes AIDS) and other sexually transmitted infections? How about in the past?
✓
Have you ever had a sexually transmitted infection – such as chlamydia, trichomoniasis or “trich,” herpes, HPV or warts, gonorrhea, or syphilis?
✓ ✓
Have you ever been tested for HIV? If yes: What led you to be tested? Have you or any of your sex partners ever been in prison?
Asking the Hard Questions: A Reproductive Health Provider’s Guide to Client-Centered HIV Risk Assessment
WHAT IS HIV RISK ASSESSMENT?
Section II
And, depending on the answers, ask the following: ◗
How often do you use condoms – all the time, most of the time, hardly ever, or never? How about female condoms, or other barriers?
◗
Have you ever had sex with someone you didn’t know very well?
◗
Have you ever had sex to get drugs or money?
3) Substance Use History Provider: Melissa:
You talked before about knowing that HIV can be spread through shooting drugs. What experiences have you had with drugs? Well, I’ve never injected drugs, if that’s what you mean! I smoke a little dope every once in a while.
Provider: Melissa:
How about any of your sexual partners – have any of them injected drugs? No, no, I mean I sure don’t think so. I don’t hang out with that kind of crowd.
Provider:
For lots of people, getting high, with alcohol or any other drug, can affect their sexual behavior. What’s that been like for you? I guess a few times, not too many. I’ve had sex with a guy when I was high a lot faster than I would have if I hadn’t been.
Melissa:
Because much substance use, including under-age drinking, is illegal, clients may be reluctant to be truthful. It can be helpful to include a very general knowledge assessment question.
✓ ✓ ✓ ✓ ✓ ✓
Have you ever felt that alcohol or drugs were a problem for you? What have you heard about the connection between alcohol and drug use and HIV infection? How many times in the past week have you used alcohol or drugs? Have you ever injected drugs? To the best of your knowledge, have any of your sexual partners injected drugs? How has drinking or using drugs affected your sexual behavior?
And, depending on the answers, ask the following: ◗
Have you had sex when you were high, drunk, or stoned, so that you don’t remember the details of what happened?
◗
Do your share needles or works when you inject drugs?
◗
What have you heard about what someone can do to reduce the risk of HIV infection when injecting drugs?
Asking the Hard Questions: A Reproductive Health Provider’s Guide to Client-Centered HIV Risk Assessment
11
Section II
WHAT IS HIV RISK ASSESSMENT?
4) Pregnancy Intentions Provider: Melissa:
✓
So what have you been doing to keep from getting pregnant? Well, he pulls out before he comes, and, I guess I have been lucky... [her voice trails off]
What are you doing to avoid an unintended pregnancy?
If a client uses only a hormonal method of contraception, ask the following: ◗
That’s a great way to keep from getting pregnant. At the same time, that method won’t protect you from sexually transmitted infections. How do you feel about that?
◗
What could you do to protect yourself from STIs, including HIV?
5) Sexual Functioning and Relationship Issues Earlier questions will have often have touched on these issues. If needed, ask:
✓
How satisfied are you with your sexual relationship(s)?
6) Domestic Violence/ Sexual Assault or Abuse Provider: Melissa:
✓ ✓
Another situation that lots of people have been in is being forced to have sex when they didn’t want to. What’s your experience been with that? No, not really, that hasn’t happened to me. Like I said, I’ve given in a couple of times when I was high, but no one ever forced me.
Have you ever been forced to have sex when you didn’t want to? Has your partner ever tried to hurt you?
7) Other HIV-Related Risks
12
✓
Since 1977, have you had a blood transfusion? Have you had sex with someone who has had a blood transfusion?
✓ ✓
Do you have hemophilia? Have you had sex with someone who has hemophilia? Have you shared equipment for tattooing or body piercing?
Asking the Hard Questions: A Reproductive Health Provider’s Guide to Client-Centered HIV Risk Assessment
WHAT IS HIV RISK ASSESSMENT?
Section II
IF YOU DON’T HAVE ENOUGH TIME TO ASK ALL OF THESE QUESTIONS... If you only have a minute, ask:3 ✔ What are you doing to protect yourself from HIV (the virus that causes AIDS)? ✔ What are you doing to prevent an unplanned pregnancy? If you have more time, ask these additional questions: ◗
Tell me about your current sexual relationship or relationships.
◗
Have you ever felt that alcohol or drugs were a problem for you?
◗
How many times in the past week have you used alcohol or drugs?
◗
Have you or any of your sex partners ever been in prison?
◗
How satisfied are you with your current sexual relationship(s)?
◗
Have you ever had sex against your will?
◗
Has your partner ever tried to hurt you?
Asking the hard questions alone is not enough. The approach to presenting the questions is important in creating an atmosphere of trust and getting valid information. See Section IVA. Nurturing a Conversation: Keys to Effective Dialogue in HIV Risk Assessment to learn about setting the tone in a client-centered way. It is not expected that providers in reproductive health settings will have the experience or the time to fully respond to all risks revealed by the risk assessment. But they should be sensitive to their presence, and able to provide appropriate referral. A template for gathering resources in your community is in Section VD. List of Local Providers for Referral. Keeping updated resources is critical to this work.
D. THE IMPORTANCE OF HIV RISK ASSESSMENT HIV risk assessment is a required service in Title X-funded reproductive health care settings.4 Sometimes mandates are hard to understand, but that isn’t true in this case. HIV risk assessment is an essential component of our work and a major step toward fulfilling the mission of Title X. We are the primary source of health care for many women, particularly economically disadvantaged women – the very ones most affected by HIV. We are ideally positioned to intervene in the spread of the epidemic, both in prevention and early diagnosis.
Asking the Hard Questions: A Reproductive Health Provider’s Guide to Client-Centered HIV Risk Assessment
13
Section II
WHAT IS HIV RISK ASSESSMENT?
1. HIV IS an Issue for Clients The vast majority of women at risk for HIV infection, as well as those living with the disease, are women of childbearing age. To understand why HIV risk assessment needs to be a part of reproductive health care, take a look at the data. See Section VE. Internet Resources for information on where you can find additional statistics.
The National Scene 5,6 ◗
In 1981, adult and adolescent women made up only 8% of total AIDS cases. By the year 2000, they made up almost 23% of cases.
◗
HIV is the fifth leading cause of death for all women, ages 25 to 44.
◗
For African-American women HIV is the third leading cause of death, and for Latinas the fourth leading cause. These women of color make up only a quarter of the female population of the U.S. Yet they now represent over 77% of all AIDS cases among women in this country.
◗
In 2000, almost 60% of AIDS cases among adolescents, ages 13 to 19, were female. Among these young women, the majority reports that they contracted HIV through heterosexual contact.
Closer to Home – Women in New England Here are some findings from a 1996 survey of 2000 clients of family planning clinics in Massachusetts.7
14
◗
Of those who reported having more than one partner in the past 12 months, 65% did not use condoms at last intercourse. Almost 60% did not use condoms consistently.
◗
Almost half of the women who reported just one sex partner in the past 12 months, believed that their current partner, or a prior one, had other partners.
◗
Of those who had anal sex, over 85% had done so without using condoms.
◗
Over 35% reported the use of drugs and/or alcohol along with sexual activity.
◗
The younger a woman was when she first had intercourse, the more likely she was to have one or more of several risks – having ever had an STI, experienced coerced sex, and/or engaged in anal intercourse. And the younger she was when she first had intercourse, the more likely alcohol or drugs were involved.
◗
Teens were twice as likely as older women to have used non-injection drugs, and/or to have a partner who was using them, the last time they had intercourse.
Asking the Hard Questions: A Reproductive Health Provider’s Guide to Client-Centered HIV Risk Assessment
WHAT IS HIV RISK ASSESSMENT?
Section II
Lack of Communication Between Sex Partners Although we encourage clients to ask their partners about their sexual histories, they frequently hesitate to do so, and even if they do a partner’s honesty can’t be guaranteed. A 1998 Kaiser Family Foundation/Glamour Magazine Survey of Men and Women on Sexually Transmitted Infections 8 found the following: ◗
About 35% of both men and women who had ever had intercourse had not discussed STIs with partners.
◗
Of those who had ever had an STI, about 25% of both men and women said that their current partners were not aware of that.
◗
Of those who said that their current partner was aware of their past or current diagnosis of an STI, about half did not tell their partner about the STI prior to the first time they had intercourse.
The Sex and Drug Connection The connection between risky sexual behavior and substance use is extremely strong. We cannot adequately respond to our clients’ sexual and reproductive health care needs if we do not ask about substance use. ◗
In 1999, 40% of women diagnosed with AIDS were infected through heterosexual contact, often through sex with an injection drug user.5
◗
In 1999, almost 30% of women diagnosed with AIDS were infected via their own injection drug use. 5
◗
Substance use (alcohol and other drugs) is linked with unplanned pregnancies, sexual assault, domestic violence, and HIV.9
◗
Men and women of all ages are more likely to engage in unsafe sexual behaviors if they are under the influence of alcohol or other drugs.9
◗
Teens who use substances are more likely to have sex, to start having sex at younger ages, and to have multiple partners.9
◗
The overwhelming majority of primary care physicians are not adequately addressing their patients’ substance using behavior.10
Incarceration: Its Link to HIV 11 We see clients who have been incarcerated, as well as clients who have partners who have been incarcerated. Men and women in prison are especially affected by the HIV epidemic. ◗
The rate of AIDS is over five times higher among prisoners than in the general population.
◗
In the Northeast, HIV among incarcerated men is 7% and 13% among incarcerated women, as compared to 0.6% of men and 0.1% of women in the general population.
Asking the Hard Questions: A Reproductive Health Provider’s Guide to Client-Centered HIV Risk Assessment
15
Section II
WHAT IS HIV RISK ASSESSMENT?
◗
In 1995, HIV infection rose 88% among incarcerated women and 28% among incarcerated men.
◗
Incarcerated women report extremely high rates of drug use; 74% used drugs regularly.
◗
Incidence of sexual and physical abuse is extremely high for incarcerated women.
Domestic Violence and Sexual Abuse History12 Numerous studies have demonstrated the connection between HIV and domestic violence, as well as sexual and physical abuse. For some abused women, our sites may be the primary source of care that they utilize. It is essential that HIV risk assessment include questions about domestic violence. ◗
In a study of over 1000 women, higher rates of domestic violence occurred in women with a history of drug use; over 10 sex partners; a history of exchanging sex for money, shelter, or drugs; and with a past or present sex partner at risk for HIV.
◗
Over 30% of the women who reported domestic violence had experienced sexual abuse during childhood.
2. Clients DO Want to Talk About These Things How often has a health care provider asked you about your sexual behavior or drug or alcohol use? If your experience is typical, the answer is not very often or never. A Kaiser Family Foundation study, Talking About STIs with Health Professionals , reveals surprising data based on a survey of 482 women, ages 18 to 44.13 ◗
12% of the women reported that their health care professionals raised the subject of STIs during gynecological or obstetrical visits.
◗
83% of the women felt STIs should be a part of routine counseling.
◗
20% of the women felt their health care provider did not have enough information to truly assess their risk.
◗
30% of the women said the provider still did not have enough information for accurate risk assessment, even if the subject of STIs was raised.
The data shows that many women assume that they are tested for STIs as a part of routine gynecological care. In addition, women generally feel that it is the provider’s responsibility to raise issues relating to sexual behavior. They express relief when the provider initiates a conversation concerning STIs. Women also aren’t being asked about drug and alcohol use. One researcher states, “...drinking and drug abuse are bundled with high-risk sex. Yet despite the high coincidence of substance abuse and sexual activity, remarkably few public or private prevention, treatment and counseling programs deal with this connection.”14 As one respondent in a survey of
16
Asking the Hard Questions: A Reproductive Health Provider’s Guide to Client-Centered HIV Risk Assessment
WHAT IS HIV RISK ASSESSMENT?
Section II
Massachusetts family planning counselors said, “I can’t believe that I’ve had providers who don’t talk to me about these issues!”15 In short, women want to talk about the things in their lives that may put them at risk, but they’re not given many opportunities to do so.
3. Risk Assessment Works! A number of studies have shown that HIV prevention counseling works to reduce risky sexual behavior. Project RESPECT was a national study to evaluate the effectiveness of HIV prevention counseling in changing sexual behavior and preventing STIs.16 The study compared traditional, information-only sessions, with a client-centered counseling approach. The results were exciting; the clients who received the counseling intervention had significantly fewer STIs during the following year. Two other recent studies have shown that face-to-face interactions with clients, focused on the risks of sexual and drug use behaviors, resulted in a higher perception of risk and self-reported changes in behavior.17, 18
RISK ASSESSMENT CAN MAKE A REAL DIFFERENCE FOR OUR CLIENTS. To consider why HIV risk assessment is important for your clients, complete Activity One: Identifying Reasons for and Barriers to HIV Risk Assessment.
Asking the Hard Questions: A Reproductive Health Provider’s Guide to Client-Centered HIV Risk Assessment
17
Section II
WHAT IS HIV RISK ASSESSMENT?
ACTIVITY ONE: Identifying Reasons for and Barriers to HIV Risk Assessment What are some reasons HIV risk assessment should be done with your clients?
What are some barriers to doing HIV risk assessment?
Before you take on the task of HIV risk assessment, it is important to address potential barriers to doing the work, including Practical Concerns About the Work and Personal Attitudes of Clients and Providers.
18
Asking the Hard Questions: A Reproductive Health Provider’s Guide to Client-Centered HIV Risk Assessment
Section III:
OVERCOMING BARRIERS TO RISK ASSESSMENT
III
A. PRACTICAL CONCERNS ABOUT THE WORK Even if you know the importance of HIV risk assessment, it can be a challenge to figure out how to fit it into what you are already doing. Here are some practical statements and questions providers have raised regarding HIV risk assessment activities.
1) “We’re already asking clients about their sexual history. How is this different?” The information gathered on a standard medical history is part of a clinical evaluation. This data helps a clinician to determine a client’s medical needs. Client-centered risk assessment, however, is a conversation between a provider and a client aimed at supporting a client in reducing risk.
2) “There’s not enough time!” Risk assessment itself is a brief interaction. On average it should take less than ten minutes. Focusing on HIV risk can actually give you a chance to streamline your work. When you talk about HIV risk reduction, you’re covering almost all the bases of reproductive health care, such as contraceptive use and STIs. Think about the reproductive health issues that are raised when you ask the two questions below:
“What are you doing to protect yourself from HIV (the virus that causes AIDS)?” “What are you doing to prevent an unplanned pregnancy?” The HIV epidemic has increased our awareness that effective reproductive health care necessitates talking not only about pregnancy and STIs, but also about drug and alcohol use, domestic violence, and forced sexual experience.
3) “There’s not enough privacy!” If there isn’t enough privacy, work with your clinic supervisor or manager to arrange for it. The work is too important to let this barrier stand in the way.
Asking the Hard Questions: A Reproductive Health Provider’s Guide to Client-Centered HIV Risk Assessment
19
Section III
OVERCOMING BARRIERS TO RISK ASSESSMENT
4) “I can’t discuss these things if the client has someone else with her.” The presence of a third person may prevent the client from being honest and from asking questions. A possible solution is to enact a policy by which a client is always initially seen alone. You can simply say, “We always see a client alone first.” If the client says she wants the other person with her, you can use the one-to-one moment to describe what you will be discussing, so she can make a fully informed decision about having the other person present.
5) “My client speaks a language that I do not speak.” When a client speaks a language other than English, it’s important to have an interpreter who is familiar with HIV risk assessment. Ideally, a bilingual provider trained in HIV risk assessment is available. When there is no staff person who knows the client’s language, additional accommodations should be arranged. Spouses, partners, and children are often not appropriate translators, especially for these topics. At the same time, cultural norms may make it important for the other person – most likely the spouse – to be present. A good compromise would be to ask the family member or friend who is acting as translator and the client to come in for another visit. At that time, an independent translator can join the three of you. This might also give you a chance to find print materials in the client’s language. When working with a translator (for spoken or signed language), remember to direct all of your conversation towards your client. Look at the client, not at the translator, even when the translator is speaking to you.
6) “The client is already stressed. How can I bring these issues up?” Sometimes you can’t. At the same time, the issues that stress our clients most – unintended pregnancies and STIs – are often connected to risky behavior. Responding to those issues may naturally involve risk assessment.
7) “We see guys in the clinic, too. How can I talk to them about sex?” Males have a special burden when it comes to sex – they think that they’re supposed to know all the answers. Of course, young men grow up in the same world as women, and honest, open discussion of sexual issues is a rare event for them as well. The only thing that will get in your way of talking with a guy about sex is your own anxiety. If you are brave enough to ask, you may encourage him to be brave enough to answer...and to ask, too!
20
Asking the Hard Questions: A Reproductive Health Provider’s Guide to Client-Centered HIV Risk Assessment
OVERCOMING BARRIERS TO RISK ASSESSMENT
Section III
8) “How can I ask about sexual behavior and be culturally sensitive?” It is certainly true that for many of our clients, discussions concerning sexual matters are not acceptable within their communities. This makes our willingness to discuss such issues even more essential. You may be the only person who gives the client the opportunity to deal with her personal risk. Obviously you will want to approach the client in a sensitive manner. You will want to acknowledge that discussing personal sexual issues may feel strange and uncomfortable. You will want to be patient in waiting for answers, and accepting of different ways of communicating. You can’t be an expert in everyone’s cultural background and the behavioral norms associated with them. Be willing to admit confusion and ask questions when you don’t understand.
9) “What if I don’t have all the information a client needs or wants?” You don’t have to know the answer to every question to be of value to your clients. It is fine to say, “That’s a good question. I’m not sure of the answer. I’d like to check it out and get back to you, so I’m sure I’m giving you the right information. Would that be okay with you?” To find the answer to the question, ask a colleague or access one of the websites listed in Section VE. Internet Resources. Practice saying, “I don’t know.” When you’re with a client, if you follow that honest response with a promise to research and let her know the answer, or connect her with someone who does, then you have all the knowledge you need! To help you begin to cope with the practical issues affecting your ability to do HIV risk assessment, complete Activity Two: Practical Concerns.
Asking the Hard Questions: A Reproductive Health Provider’s Guide to Client-Centered HIV Risk Assessment
21
Section III
OVERCOMING BARRIERS TO RISK ASSESSMENT
AC TIV IT Y T WO: Practical Concerns
What do you see as practical barriers to doing HIV risk assessment with your clients? Write them down below. The list might include issues discussed in the Guide, as well as others you have.
Let your supervisor or clinic manager know about your concerns. She can then work with you on ways to address them.
22
Asking the Hard Questions: A Reproductive Health Provider’s Guide to Client-Centered HIV Risk Assessment
OVERCOMING BARRIERS TO RISK ASSESSMENT
Section III
B. PERSONAL ATTITUDES OF CLIENTS AND PROVIDERS The practical barriers, while significant, may be overcome when the clinic manager and staff work together. However, personal attitudes and concerns, both our own and those of our clients, form the most significant barrier to doing HIV risk assessment.
1. Clients’ Concerns Talking honestly about sexual behavior and substance use is very difficult. When discussing such behavior most people want to know if they are normal, and want to feel accepted. Even though these behaviors have been a part of all human history, in every country and culture, they are generally treated as taboo subjects. Complete Activity Three: Clients’ Barriers to Risk Assessment to help you think about why clients might have trouble talking about sexual and substance use behaviors.
Asking the Hard Questions: A Reproductive Health Provider’s Guide to Client-Centered HIV Risk Assessment
23
OVERCOMING BARRIERS TO RISK ASSESSMENT
Section III
ACTIVITY THREE: Clients’ Barriers to Risk Assessment
What attitudes, expectations, and concerns might a client have that would make it hard to talk about sexual and substance use behaviors with you? An example is listed to get you started.
Concern that you will judge her
Did you write down any concerns from a male perspective? If not, try to add some to the list. Put yourself in the client’s place. If you were the one being asked the questions, what might concern you?
24
Asking the Hard Questions: A Reproductive Health Provider’s Guide to Client-Centered HIV Risk Assessment
OVERCOMING BARRIERS TO RISK ASSESSMENT
Section III
2. Providers’ Judgments All of us are judgmental. We work in the reproductive health care field because quality care for all clients is important to us. We want our clients to have the best service we can provide, and we want them to be healthy. We, therefore, naturally have judgments about their behaviors. We might wish they would wait to be older before having intercourse. We wish they would take steps to avoid unintended pregnancy, STIs, and HIV. We wish they would avoid drug use altogether. Being non-judgmental doesn’t mean that that you are without judgments. It means that you are aware of your own values, beliefs, and prejudices so that you recognize when you’re feeling them, and can avoid conveying them to your client. When you know what triggers your judgmental responses, you are better able to respond to a client in a way that encourages continued open conversation. Use Activity Four: Our Own Values and Judgments as an opportunity to examine your judgments.
Asking the Hard Questions: A Reproductive Health Provider’s Guide to Client-Centered HIV Risk Assessment
25
Section III
OVERCOMING BARRIERS TO RISK ASSESSMENT
ACTIVITY FOUR: Our Own Values and Judgments Place a check mark (✔) in the column on the right if the client would be hard for you to deal with. Use the blank lines to add situations that “push your buttons.”
✔DIFFICULT FOR YOU 1. Client doesn’t want to become pregnant or infected with STIs/HIV; refuses to consider condom use. 2. Client has had 5 abortions. 3. 18 year-old client says she’s dating a 35 year-old man. 4. Client challenges you, “What gives you the right to ask me these questions?” 5. Client has gonorrhea, insists the clinician is wrong because “my boyfriend wouldn’t run around on me!” 6. Client refuses to answer any of your questions; just sits with arms crossed and looks at you angrily. 7. Client complains about everything that happens in the clinic. 8. Client says that her boyfriend is a “prick.” 9
Client says she/he doesn’t care what happens – “we’ve all gotta die of something!”
10. Client tells you she or he has been trading sex for money or drugs. 11. Client is high. 12. Client is lesbian or gay.
26
Asking the Hard Questions: A Reproductive Health Provider’s Guide to Client-Centered HIV Risk Assessment
Section III
OVERCOMING BARRIERS TO RISK ASSESSMENT
✔DIFFICULT FOR YOU 13. Client says drug use is “no big deal – everybody gets high sometimes!” 14. Client has 6 children, all under the age of 8. 15. Client brings two children with her to the clinic. The children are very disruptive, and she seems to be doing nothing about it. 16. A client tells you that condoms don’t fit him. 17. 18.
Take some time now to think about what it is that makes the checked items difficult for you. Some of the descriptions don’t say if the client is male or female. How would the client’s gender affect how the situation would feel to you?
Asking the Hard Questions: A Reproductive Health Provider’s Guide to Client-Centered HIV Risk Assessment
27
Section III
OVERCOMING BARRIERS TO RISK ASSESSMENT
3. Tips for Dealing with Judgments Check your assumptions Do you make judgments about a client based on age, appearance, speech, or medical history? Do you sometimes think you know what he or she ‘ought to do’ before you hear from the client? Be aware of your thoughts and be careful that such assumptions aren’t biasing your interaction. Here’s an example: A client says she’s having difficulty remembering to take birth control pills. Without asking any questions, the provider immediately tells her she should “get Depo.” Unfortunately, the provider is missing two important pieces of information: 1) The client has a job with constantly changing hours, which creates problems for her in remembering her pills, and 2) The client faints whenever she sees a needle – she’ll never be happy with Depo. A more helpful approach would be to start by asking the client what is making it difficult for her to remember her pills. This could lead to some practical problem solving.
Don’t take things personally If a client is ‘being difficult’, it’s probably because she’s having a hard time. Try not to take her anger personally. It’s not about you – you just happen to be the person who’s there. Being aware of this can help you to avoid reacting judgmentally to negative behavior. If you respond with kindness and interest, the client may be able to make a connection with you.
Take a look at your own issues Sometimes clients raise concerns or describe events that mirror issues in our own lives. In such cases, it is even more difficult to respond non-judgmentally. Just as talking about difficult matters may help clients, providers, too, can benefit from counseling interactions. If your agency participates in an employee assistance program (EAP), you may be able to get a referral to someone you can talk to.
28
Asking the Hard Questions: A Reproductive Health Provider’s Guide to Client-Centered HIV Risk Assessment
OVERCOMING BARRIERS TO RISK ASSESSMENT
Section III
DANGER SIGNALS TO LOOK OUT FOR While being cautious about assumptions, also be aware that there are sometimes warning signs in a client’s appearance, behavior, or situation that deserve additional attention. For example: ◗
If a very young client is accompanied by an older adult, especially a male father figure, who will not allow any conversation to take place without his presence, be alert to the possibility of abuse or incest. The level of suspicion rises if the adult will not provide any contact information for the client, or the client says she is not allowed to make or receive calls.
◗
An adult woman in an abusive relationship may also describe similar rules imposed on her by a partner.
◗
In talking with a client about her relationship, the following kinds of statements should be explored further: “He’d kill me if he knew I was here.” “He has a temper.” “I’m the one who starts it.” “You can’t tell him ‘NO’!” “He threw my pills away.” “I know he’s done some bad things to me, but I love him.”
◗
A survivor of sexual assault or rape may show any of the following: Emotional/ psychological symptoms – fear, anxiety, confusion, inability to concentrate, anger, guilt, nightmares, distrust of others, or extreme concern about STIs. Physical symptoms without a clear cause – nausea, urinary or bowel complaints, fatigue, difficulty sleeping, changes in eating patterns, jumpiness, and startle reactions.
◗
Suspect depression if a client reports or shows the following: thinking/talking about suicide, sleep and/or eating changes, loss of interest in activities, poor performance in school or work, neglect of personal appearance or hygiene, restlessness, or irritability.
While any of the above symptoms might be due to many different causes, it is always okay to explore your concern. The client’s reactions, both verbal and non-verbal, will help you know if further attention is needed. Note: 1.
It is not expected that providers in reproductive health settings will have the experience or the time to fully respond to these issues. But they should be sensitive to their presence, and able to provide appropriate referral. Providers should also understand their legal obligations to act.
2.
The focus on the male as ‘perpetrator’ in these examples is a function of the reproductive health care setting where most clients are females. This is not to suggest that women do not also physically and mentally abuse their partners.
Asking the Hard Questions: A Reproductive Health Provider’s Guide to Client-Centered HIV Risk Assessment
29
Section III
OVERCOMING BARRIERS TO RISK ASSESSMENT
4) Providers’ Discomfort When it comes to talking with perfect strangers about sex and drugs, some of us, whether clients or providers, will never be truly comfortable. A client who comes to a reproductive health clinic expects an experience that is not like her usual interactions with strangers; such as being asked the color and odor of vaginal discharges and someone touching her breasts to do a breast exam. These experiences are at least somewhat uncomfortable for many clients. But most clients handle the discomfort because they understand that there is an important reason for it. Risk assessment is just as important as the physical examinations. If we could protect clients from risk via a medical procedure, then perhaps we wouldn’t have to talk about sexual behavior and drug use. But when it comes to pregnancy, STIs, and HIV, the client’s own healthy behaviors are her best protection. We can only help her to make behavioral changes through talking about the behaviors. It’s okay to blush, fumble your words, or not know the answers to all the questions. it’s often helpful for both you and the client to introduce these topics by acknowledging the awkwardness of the risk assessment process. You can say:
“These can be uncomfortable questions to deal with.” “Lots of folks are uneasy talking about their sexual history.” The expectation is not that you will always be comfortable doing this difficult work, but rather that you can live and work with your discomfort.
Ask yourself this question: Is this work important enough that it’s worth putting up with my discomfort? Considering that your work could protect someone’s health, or even save someone’s life, the answer is probably ‘yes!’
30
Asking the Hard Questions: A Reproductive Health Provider’s Guide to Client-Centered HIV Risk Assessment
Section IV:
HOW TO DO HIV RISK ASSESSMENT
IV
A. NURTURING A CONVERSATION: KEYS TO EFFECTIVE DIALOGUE IN HIV RISK ASSESSMENT 1. Creating a Safe Environment Set the tone An important way to address clients’ expectations, fears, and concerns is to create a safe environment for conversation. Introduce yourself. Ensure that you have privacy. Tell your client what to expect, such as what kinds of things you’ll be asking, the reasons for the questions, and how much time the process will take. The more the client knows about what will happen, the more in control and less anxious she’ll feel. Use an opening statement, such as the following:
“I ask everyone I see in the clinic these next questions about their sexual history and about any drug use. These are such important issues; we wouldn’t be providing good care if we didn’t ask. At the same time, I know it can be uncomfortable to be asked about these things.” This statement informs the client that these questions are routinely asked, and normalizes the process of risk assessment. It also acknowledges the discomfort connected with the topics raised and the questions asked. If your client seems very reluctant to talk, you might add:
“You don’t have to tell me anything you don’t want to. The more you are able to tell me, the more useful I can be to you.” The client is in charge of what is shared. When you acknowledge the client’s control, she will often feel more comfortable about sharing information.
Asking the Hard Questions: A Reproductive Health Provider’s Guide to Client-Centered HIV Risk Assessment
31
Section IV
HOW TO DO HIV RISK ASSESSMENT
Explain confidentiality ii Notice that this doesn’t say, “promise confidentiality,” and for a very good reason – you can’t. Clients sometimes reveal information that cannot be kept confidential. A client who tells you she intends to harm herself, an adolescent who discloses sexual abuse – these clients deserve efforts toward protection, which frequently requires involving others. In fact, in most jurisdictions, these circumstances legally require your action. Confidentiality should be explained at the beginning of a discussion. Here’s a way to describe the meaning and the limits of confidentiality:
“Almost everything a client says to me is kept completely confidential; in other words, what you tell me is available only to other staff in the clinic so they can provide you with the best health care. No one else has access to it, without your knowledge. If a client ever lets me know that she is in danger of being harmed, or harming someone else, I would have to do everything I could to be sure that she is protected. And that can mean involving others.”
B. TECHNIQUES FOR CLIENT-CENTERED DIALOGUE In a recent survey of counselors in Massachusetts reproductive health clinics, respondents were asked how they would want a counselor or clinician to ask them questions about sexual and drug use behavior.15 Here are some of their answers: ◗
“I want to know that she is not judging my behavior in the past or present.”
◗
“Leave the power of decision making with me.”
◗
“Straight out. No tip-toeing around the subject matter.”
◗
“With compassion and understanding.”
◗
“In an open-ended, non-judgmental way”
◗
“I appreciate it when my doctor listens to what I have to say before getting into a routine of what needs to be addressed or checked off on some form.”
◗
“Respectfully and nicely. Clearly stating why the questions are being asked. I want to feel like she can really help me out.”
◗
“I want to feel comfortable with my counselor, and for her to be understanding.”
◗
“I want her to ask me how do I feel - What causes me to do what I do, etc...”
ii Refer to your state laws regarding confidentiality issues: i.e., parental access of medical records or requirements about informing parents of services provided to minors.
32
Asking the Hard Questions: A Reproductive Health Provider’s Guide to Client-Centered HIV Risk Assessment
Section IV
HOW TO DO HIV RISK ASSESSMENT
The sentiments stated above express very clearly how clients want to be treated in a risk assessment interview. Although discussion of sexual behavior and substance use is uncomfortable for most people, there are ways to ask about these issues that encourage clients to speak more openly. Here are some specific techniques to help you keep the conversation flowing:
WAYS TO ENCOURAGE DIALOGUE ◗
Use open-ended questions to encourage a more in depth response. “What’s going on in your life right now, sexually speaking?”
◗
Introduce sensitive questions. “Here’s a question that sometimes surprises people.” “Some of these things can be difficult to talk about.”
◗
Normalize clients’ responses when possible, to minimize embarrassment or discomfort. “That makes you like so many people.” “Many people are surprised to learn that...”
◗
Express caring and compassion for the client. Acknowledge client’s feelings and be supportive. “I’m sorry to hear about your cousin’s death. That means you know for real that AIDS is in your community.”
◗
Use “reflective listening” to ensure that you understand the client’s meaning and invite further discussion. “I get the feeling condoms aren’t your favorite things.” “It sounds like it’s hard to bring that up with your boyfriend.”
◗
Look for opportunities to support, rather than to chastise or correct. Support intentions to reduce risk. Acknowledge what is correct in the client’s information. “It sounds like not getting pregnant is very important to you.” “You know from that experience that a person can get an infection when they don’t expect it at all.”
◗
When providing information, present it clearly and in a conversational manner. Don’t lecture.
◗
Allow clients time to respond. If the client is shy, or hesitates for a moment, don’t rush to fill the void. Be silent for a few moments to give her time to speak.
◗
Give clients permission not to respond to something you’ve asked.
Asking the Hard Questions: A Reproductive Health Provider’s Guide to Client-Centered HIV Risk Assessment
33
Section IV
HOW TO DO HIV RISK ASSESSMENT
The following Sample Dialogue provides a good illustration of many of these techniques. For an additional example, see Section VA. Sample HIV Risk Assessment Dialogue.
1. Sample Dialogue The client is 19 year-old James. He has come into the clinic to check out a discharge from his penis. He’s been presumptively diagnosed with gonorrhea, and the provider wants to talk with him about condom use. She notices that James has indicated that he uses condoms ‘sometimes’ on the history form.
Provider: Thank you for going through that exam so well. It’s not an easy one to take! James: [nodding his head emphatically] You can say that again! Man! I never wanna go through that again! I mean, not that you did anything wrong, or anything. You know – [he fumbles for his words]
Offers immediate support; acknowledges feelings.
Provider: [smiling] I think I do know. I don’t think any guy likes this process. What had you heard about it before you came here today? James: Well, I know some guys who’ve been down here...they sorta told me what’s up with this. Continues offering support. The clinician hopes to make a connection with James.
Provider: So even though you knew that this was not a pleasant thing to go through, you still came in. That takes some guts! James: [shaking his head “no”] Not when something like that is happening! You know, something wrong with, with, my dick.
Provides some information in the guise of more support. The information makes James uncomfortable, which probably means it’s gotten close to something he’s concerned about, but can’t acknowledge.
Provider: Still, some guys put it off. And with some sexually transmitted infections, the symptoms go away, and they think they’re okay. But the infection is still in them, and doing harm. You came in, and the good thing is that this is an infection we can treat. James: Yeah, I heard something about that once. So, can I get outta here now?
Negotiates time – gives James a much-needed sense of control.
Provider: James, could I take just 5 minutes more of your time? You can keep track, and tell me when you’ve had enough. James: [looks resigned] I guess so.
34
Asking the Hard Questions: A Reproductive Health Provider’s Guide to Client-Centered HIV Risk Assessment
HOW TO DO HIV RISK ASSESSMENT
Section IV
Direct prevention question. Asks to check out James’s understanding.
Provider: Thank you. You know, you said a moment ago that you never want to go through this again. [James nods his head] And I believe you. So, what will you do so you don’t have to come back here again? James: Well I’m not going to hang with that woman no more!
Provider doesn’t react to James’s language instead offers more information.
Provider: This may sound like a stupid question, but how will not seeing her keep you from coming back here? James: [looks at provider as if she is stupid] She’s the one I got it from! Damn!
Gives an answer, then realizes she wants to hear what James knows.
Provider: It’s very possible she didn’t even know she had this. Lots of times women don’t get any symptoms, like you did, to show them something’s wrong. James: So how am I supposed to know who’s clean, then? Provider: Good question. And the answer is – you can’t know. But wait, before I say that, what have you heard about that? James: Oh, they say a lot of stuff out there, about how you can tell. But it sure didn’t work with her!
Responds to James’s nonverbal communication.
Provider: This is a heck of a way to find that out, isn’t it? [James nods] Lots of guys are surprised to learn that. And a lot of guys these days are using condoms. James: [looks down and away from the provider] Uh huh...
Normalizes, and very gently confronts.
Provider: I get the idea they’re not your favorite things. James: You’re right about that. I dunno, it just doesn’t feel, natural, you know. Provider: A lot of guys say that too. And some of them have decided that it’s worth having things feel different, if it means not getting an infection. You know, gonorrhea can be cured, but some infections can’t be cured. James: [beginning to look anxious to go] Uh, huh
Provider is hoping to reconnect with him, by offering more normalization. She happens to say something that grabs his interest. Talking openly about sex often does that!
Provider: [talking quickly] But, you know, James, guys have a lot of different problems using condoms. Some guys lose their erections when they try to put ‘em on; some say they don’t fit right. Some actually come too fast, just from putting it on James: [looks up at that last remark] Yeah?
Asking the Hard Questions: A Reproductive Health Provider’s Guide to Client-Centered HIV Risk Assessment
35
Section IV
Shares her genuine concern.
HOW TO DO HIV RISK ASSESSMENT
Provider: And I guess I always say, well then they’ve got the fun of getting erect again! [laughs] James: [laughs with her] Boy, you’re all right! Provider: It’s just that I worry that someone who has gotten gonorrhea might come in next time with something I can’t cure, like HIV. James: I don’t want nothin’ to do with that!
Suggests testing. This really pushes James.
Provider: Actually, it might be a good idea to get tested, to see if you have HIV. James: [angrily] Are you saying you think I’ve got that shit? This is no joke!
Provider: No, James, no, that’s not what I’m saying. A lot of people do feel that getting tested is a good idea, because if someone’s infected, around prevention issues, it gives them a chance to start doing things right away, to help so doesn’t press testing them stay healthy. at this moment. She does James: No, no, I’m not doing that. I told you, I don’t want nothin’ to explain why it would be do with AIDS.
She doesn’t want to lose the work she’s doing
a good idea.
Provider: [speaks firmly] And you don’t want to get it. James: You’re right about that! Confronts, with a recognition of how this might be to hear.
Provider: James, since that’s so important to you, I want to say something difficult to you. People get HIV exactly the same way you got gonorrhea. And almost always they get it from someone who didn’t know that she, or he, had it. James: Yeah, I know that. Provider: What have you heard about the other ways someone can get infected with HIV? James: [looks confident of his answer, speaks boldly] Fags get it. Junkies. [looks down] I had a cousin...he died of AIDS.
Empathizes with James’s sadness. Recognizes that this is a sensitive issue.
Provider: Oh, I’m sorry to hear about that James. [pauses] That means you know for real that AIDS is in your community. James: Uh huh. Are you about done?
She wants to keep the connection open.
36
Provider: Almost – thanks for the reminder. You know, using condoms is a pain. At the same time, it could save your life. [picks up some brochures and talks rapidly] Can I give you some of these brochures to take...maybe there’s someone you know you could share these with, someone who isn’t as knowledgeable about AIDS as you are... And, while we’re at it – how about talking a handful of these condoms? You can have as many as you want.
Asking the Hard Questions: A Reproductive Health Provider’s Guide to Client-Centered HIV Risk Assessment
HOW TO DO HIV RISK ASSESSMENT
James:
Section IV
I mean, I guess, I hope I don’t see you next time...Oh, you know what I mean [looks a bit awkward]
Provider: I do, James, I do. But if you ever want to talk about any of this, or get some more condoms, I hope you’ll come back.
This exchange took about 4 minutes. The provider would have liked to speak further with James, but look how much she covered in a short time. Without making James tell her anything specific about what was going on with his condom use, she offered normalization of several possible problems. His self-perception of risk was certainly increased; the fact that he got angry shows that. She didn’t get to talk about substance use, although James clearly knows the connection. She didn’t take his language or behavior personally. Instead of being the person in power for James to react to, she became someone with whom he could risk a little. Talking about his cousin’s death was a risky show of emotion for James – no wonder he wanted to leave! And rather than try to hold him there, to meet her agenda, she honored his need. Making a connection with a client like James is the most important outcome of this interaction. If he were pushed too hard, he’d not only shut her off, he’d be reluctant to come back. By having a real conversation and having the courage to talk openly about sexual issues, this provider used risk assessment as a tool for prevention.
C. THE LANGUAGE OF RISK ASSESSMENT There are probably more words in the English language to describe sexual acts and to identify the ’sexual’ parts of our bodies than any other words. In addition, there are dozens of terms for alcohol and other drugs, and all the behaviors connected with substance use. Language can be a barrier to HIV risk assessment in two directions – the words clients use, and the words we use.
1. The Words Clients Use Words can really get in the way! Complete Activity Five: The Words Clients Use to explore ways in which certain words used by clients can hinder the risk assessment conversation.
Asking the Hard Questions: A Reproductive Health Provider’s Guide to Client-Centered HIV Risk Assessment
37
Section IV
HOW TO DO HIV RISK ASSESSMENT
ACTIVITY FIVE: The Words Clients Use Write down words or phrases a client might use when talking about sexual or substance use behavior that could make you feel some discomfort – perhaps a lot of discomfort! Words for Sexual Behaviors
Words for Substance Use Behaviors
How did you feel writing down those words? Were some words more difficult to write than others? Which ones were hardest?
Has a client ever used any of those words when talking with you? How did you respond? How do you feel about your response?
38
Asking the Hard Questions: A Reproductive Health Provider’s Guide to Client-Centered HIV Risk Assessment
HOW TO DO HIV RISK ASSESSMENT
Section IV
2. Responding to Difficult Language Used By Clients Why might a client use words that make you feel uncomfortable? Consider these possibilities: ◗
The client was checking to see how you would react. Based on your reaction, the client might decide whether or not to reveal sensitive information.
◗
The client is concerned that you will be judgmental about what she has shared, so is using words that she thinks will keep you from assuming something about her.
◗
The client doesn’t know any other word to use.
Here’s an example: James is a 19 year-old client, in for a STI check. The provider asks, “What have you heard about how people get HIV
(the virus that causes AIDS)?” He answers, “I’ve heard that homos and junkies get it!” His language would offend many people. At the same time, James has stated some accurate information – just not the whole story. A good response might be, “You’re right. A lot of men who have sex with men, and people who inject drugs have been infected with HIV. What we know now is that it can also infect lots of other people, people just like you and me.” This response offers additional information, and provides some different language, without judgment. Whatever James’s reason for those words, this response works. If a client uses language that offends you, you could try saying, “I’ll feel more comfortable
saying [insert the word you prefer], instead of [use the client’s word, if you can]. Will that mean the same thing for you?” Sometimes it’s hard to know what the client means. The words people use to talk about sex, alcohol, and other drugs are changing all the time. Different communities and age groups have different ways to say the same things. If you’re not sure of what’s being said, ask, “I’m not sure
I understand what [insert client’s word] means. Could you tell me what that means to you?” If the client uses “street” terms, you might want to use them, too. This depends on your own comfort level with those words. If you choose not to use the client’s language, make sure that you understand one another. For example, you could say, “I’ll feel more comfortable saying intercourse instead of screwing. Will that mean the same thing to you?”
3. The Words Providers Use While most providers avoid the use of “street” language, they often use words that sound judgmental, or are unfamiliar to clients. Try Activity Six: The Words Providers Use to take a look at some words you may use that may make your clients uncomfortable.
Asking the Hard Questions: A Reproductive Health Provider’s Guide to Client-Centered HIV Risk Assessment
39
Section IV
HOW TO DO HIV RISK ASSESSMENT
ACTIVITY SIX: The Words Providers Use
Take a look at the words listed. Imagine how these words might sound to a client. Next to each word, write another non-judgmental way to express the idea. If you can think of others, add them to the list. Promiscuous Non-compliant Resistant Immature Hooker Victim (of abuse/incest) Illegitimate Illegal (as in illegal alien) Manipulative Difficult Abnormal Junkie
40
Asking the Hard Questions: A Reproductive Health Provider’s Guide to Client-Centered HIV Risk Assessment
HOW TO DO HIV RISK ASSESSMENT
Section IV
4. Clarifying Our Language Reproductive health care providers sometimes use medical jargon that is often not clearly understood by clients. Here are some “jargon terms” along with clearer ways to say the same thing: IV drug user/ IDU – someone who uses needles, who ‘shoots up’ drugs. It doesn’t have to go into a vein (i.e., be intravenous or “IV”) to be risky. “Skin popping” – injecting just below the skin surface, is risky as well. Insertive partner – the person who is putting his penis into the other person’s body. Receptive partner – the person who is having a penis go into her/his body- into vagina, mouth, or anus. Antibodies – proteins made by the white blood cells in the immune system that can recognize and attack an invading virus. The antibodies to HIV are not able to fight the virus because HIV takes over the immune system itself, so that instead of producing antibodies, the immune system begins producing more HIV. Window period – the length of time it takes for a person’s immune system to produce enough antibodies to a virus, like HIV, that a test for antibodies can detect their presence. Safer sex – a way of having sex, especially vaginal, oral, or anal intercourse, that reduces the chance of becoming infected with HIV, as well as other STIs. Most often it refers to the use of condoms, or other barriers, such as dental dams or gloves. “Sexually active” is a phrase that’s used a lot in reproductive health settings. Here’s why you might want to consider avoiding its use. When providers ask, “Are you sexually active?” they are usually referring to intercourse. Yet, rather than clearly asking for this information, they use the phrase “sexually active” which shrinks the entire range of sexual behaviors into one act. Ask exactly what you want to know. “Are you having intercourse? Are you having vaginal/oral/anal intercourse?” Depending on your client’s level of understanding, you might use simpler language. “Does your partner put his penis inside your vagina?” “Does your partner put his penis in your anus (rectum/butt)?”
Asking the Hard Questions: A Reproductive Health Provider’s Guide to Client-Centered HIV Risk Assessment
41
Section IV
HOW TO DO HIV RISK ASSESSMENT
A WORD ABOUT “SEXUAL ORIENTATION” TERMS The majority of our clients are involved in sexual behavior with someone of the opposite sex. We also see clients who have sexual contact with same sex partners. The label attached to a person to define his or her sexual orientation – heterosexual, homosexual, bisexual – doesn’t necessarily tell you what that individual’s sexual behavior is, or with whom they’re doing it. Use the term “partner” to refer to the person with whom the client is sexually involved, until the client identifies the partner’s gender. Even if a client has been pregnant, or fathered a child, that client’s sexual orientation may not be heterosexual, or bisexual. A person whose sexual orientation is exclusively or primarily towards same sex partners might have intercourse with someone of the opposite sex for a variety of reasons; desire for pregnancy, just to experience it, out of obligation, for money or safety, to avoid violence, to be seen as heterosexual, to try to suppress desires, or to conform to familial, religious, or cultural norms. Assuming that we all know to never use blatantly offensive terms like “fag,” “homo,” “queer,” “dyke,” “fruit,” or “fairy,” we should also avoid the following terms: ◗
Homosexual “tendencies” or “persuasion”
◗
“Choosing” one’s orientation
◗
“Avowed” homosexual
◗
“Latent” homosexual
For complete list of words to avoid, including many categories in addition to sexual orientation, check out these websites: http://www.totse.com/en/ego/literary_genius/terms.html http://members.tripod.co.uk/ZakWebber/lgsTheFacts.htm
42
Asking the Hard Questions: A Reproductive Health Provider’s Guide to Client-Centered HIV Risk Assessment
HOW TO DO HIV RISK ASSESSMENT
Section IV
5. Don’t Ask “Why” Finally, the word “why” could be included in that list of words that might be offensive. “Why” questions often make people feel judged, defensive, and as though they need to explain their behavior. Try a question that begins with “what” or “how” instead. These two words begin open-ended questions - questions that invite an extended response, and avoid sounding judgmental. Activity Seven: The Questions Providers Ask will give you some practice.
Asking the Hard Questions: A Reproductive Health Provider’s Guide to Client-Centered HIV Risk Assessment
43
Section IV
HOW TO DO HIV RISK ASSESSMENT
ACTIVITY SEVEN: The Questions Providers Ask Here are some “why” questions. For each one, try composing an open-ended question, starting with “what” or “how.” An example is given to get you started.
THE “WHY” APPROACH
OPEN-ENDED APPROACH
Why aren’t you using condoms?
How do you feel about using condoms? What keeps you from using condoms?
Why do you think you can’t get infected?
Why won’t you get tested for HIV?
Why are you late for your appointment?
Why can’t you talk to your partner about STIs and HIV?
Why don’t you stop using drugs?
44
Asking the Hard Questions: A Reproductive Health Provider’s Guide to Client-Centered HIV Risk Assessment
HOW TO DO HIV RISK ASSESSMENT
Section IV
6. Non-Verbal Communication Studies suggest that as much as 90% of the meaning derived in face-to-face communication is based on non-verbal cues, such as facial expression, eye contact, hand gestures, and the body’s posture and position. The person being spoken to will base her interpretation of the message, and the intentions of the speaker, on the non-verbal cues. In addition to the observable, physical aspects of how the message is being sent, there are the paraverbals – the way a voice sounds, the tone and pitch, and the speed with which one speaks. Paraverbals communicate emotion more accurately than the words being said. Here are some tips to enhance your non-verbal communication: ◗
Beware of sounding ‘professional,’ that is clinical, detached, humorless, or controlled. You will connect much more easily with most clients if you sound warm and caring, and talk as if you were having a conversation, rather than conducting an interview.
◗
Don’t assume that you can always ‘read’ a client’s body language. Many non-verbal behaviors, such as eye contact or comfort with distance between individuals, are influenced by a person’s culture.
◗
Be careful with touch. Offering your hand when first meeting a client is usually an acceptable gesture. Always tell a client when she is going to be touched during an exam. For any other kind of touching, like a hug, ask permission first. Many people are uncomfortable with uninvited touch; this can be especially true of survivors of sexual abuse.
◗
Observe your own style of non-verbal communication. Have an audio or videotape made of you, while doing a real, or mock, session with a client. Watch or listen alone first. Then invite a trusted peer to watch or listen with you, and discuss what you’ve discovered about yourself.
Try Activity Eight: Non-Verbal and Paraverbal Communication to explore these issues further.
Remember: How you look, how you sound, and what your body says convey an immediate response to clients. The challenge for you is to be attentive to what you are communicating, before you even say a word. The better you know your attitudes and reactions, the better you’ll be able to monitor and control your total response.
Asking the Hard Questions: A Reproductive Health Provider’s Guide to Client-Centered HIV Risk Assessment
45
Section IV
HOW TO DO HIV RISK ASSESSMENT
ACTIVITY EIGHT: Non-Verbal and Paraverbal Communication19 This list gives both effective (✓) and less effective (X) examples of many forms of non-verbal expression. Take a moment to review the list. Eye Contact
Vocal Quality
✔ Spontaneous eye contact and eye movement ✔ Looking directly at speaker when speaking ✔ Looking directly at speaker when listening ✘ Breaking eye contact ✘ Staring too intensely ✘ Looking down ✘ Looking away ✘ Staring blankly
✔ Pleasant intonation ✔ Appropriate loudness ✔ Moderate rate of speech ✔ Simple, precise language ✔ Fluid speech ✘ Monotone ✘ Too much effort ✘ Too loud
Body Posture
Distracting Personal Habits
✔ Slight forward lean ✔ Body facing speaker ✔ Relaxed posture ✔ Relaxed hand position ✔ Spontaneous hand and arm movements ✔ Gestures for emphasis ✔ Relaxed leg position ✘ Slouching ✘ Fixed, rigid position ✘ Physically too close to speaker ✘ Physically distant from speaker ✘ Arms across chest ✘ Body turned sideways ✘ Leaning away
✘ Playing with hair ✘ Fiddling with pen or pencil ✘ Chewing gum ✘ Eating or drinking ✘ Tapping fingers or feet
In the space below, describe how you would want a provider to look and sound while asking you about your sexual and substance use behaviors.
46
Asking the Hard Questions: A Reproductive Health Provider’s Guide to Client-Centered HIV Risk Assessment
Section IV
HOW TO DO HIV RISK ASSESSMENT
7. Responding to Difficult Questions and Statements For many of us, the challenge of responding to difficult questions and statements is what makes the work of HIV risk assessment hard. We may ask ourselves, “What do I say?” “Do I have the right information?” “Do I have time to deal with this?” “Do I have the experience to deal with this?” “Is this my responsibility?” Experts in the field of sexuality counseling tell us that two simple steps can go a long way in addressing many of the questions and concerns clients have.20
1.
Giving a client permission to ask questions, to not know information, or to be concerned about an issue. 2. Providing limited information in response to those questions and concerns.
Let’s take a closer look at the skills involved in those steps, through a simple model for brief interactions in response to difficult issues.
8. The 3Cs Model 21 The 3Cs Model is a simple guide for responding to difficult questions and statements. The model begins with a respectful, empathetic, and very brief acknowledgment of what the client has said. This is followed by a request for more information. These steps give the provider a chance to assess her own ability to respond to the client, and determine how she will proceed.
3C S – 3 ST E P S STEP 1.
C O N F I R M
Begin by offering a confirmation of 1) the act of questioning; 2) the general subject of the question; and/or 3) recognition of the client’s emotions regarding the question or issue.
STEP 2.
C L A R I F Y
Ask an open-ended question to encourage the client to talk more about the concern. This facilitates a better understanding of the issue for both you and the client, and gives you a chance to assess your ability to respond to the issue.
STEP 3.
C O NT E N T
O R
C O NT R A C T
If you feel that the issue can be addressed by providing information and you have the knowledge and time, a content response could be given. Follow the content response with another clarification question to check if the answer is sufficient. If you don’t feel skilled enough to handle the client’s issue, or don’t have sufficient time, then a contract for referral or another appointment could be given.
Asking the Hard Questions: A Reproductive Health Provider’s Guide to Client-Centered HIV Risk Assessment
47
Section IV
HOW TO DO HIV RISK ASSESSMENT
Here is an example to illustrate the 3Cs approach:
You ask a client about her current sexual behavior, and then quietly the client says, “I just don’t seem to be enjoying sex with my husband.” Your first thought might be that this is a subject that requires a more in-depth intervention with a specially trained person. But before you rush to make that referral, you might try the 3Cs approach. You might say to her, “It looks like this isn’t an easy thing for you to talk about.” Confirmation of her feelings, based on her non-verbal and paraverbal communication. “Tell me a little more about what’s going on.” Clarification question. She responds, “Well, I really love him, and sex used to be so good. But it seems that lately I just don’t get...you know...wet anymore, and it hurts.” Now you have some information that might help you to help her. It could be that she’s taking oral contraceptives, or getting Depo Provera shots, both of which can decrease lubrication. If that is the case, you might say, “I know you’re taking the pill now. A lot of women find that they don’t get as wet when they’re on the pill. Using a lubricating jelly, like KY, seems to help a lot. What do you think about that?” Confirmation, followed by a content response, then a further clarification question, inviting more questions or thoughts from her. Her next answer should let you know if you’ve offered a good suggestion, or if this is really a more complex problem, perhaps a relationship problem that needs more intervention than you can provide. At that point, contracting for a referral would be best.
48
Asking the Hard Questions: A Reproductive Health Provider’s Guide to Client-Centered HIV Risk Assessment
HOW TO DO HIV RISK ASSESSMENT
Section IV
The 3Cs Model can also be useful for handling one of the toughest kinds of questions we get – when a client asks us about our own experiences.
For example, when she says, “Do you always use condoms?” “Have you ever had a guy cheat on you, and give you an infection?” “Have you ever had an abortion?” A client doesn’t ask these questions because she’s really interested in your life. She asks for reasons that have to do with her needs, such as not wanting to feel alone, wondering if you can understand, hoping a shared experience means that you won’t be critical of her. A confirmation statement can respond to the feelings that underlie such questions. For example: “It can feel comforting to know that someone else has had an experience that you’ve had.” Or, “Sometimes people ask that because they think that if I’ve had the same experience, I can do a better job helping them with it.” A clarification question could be: “ How will it be helpful to you to know if I’ve had that experience or not?” Based on the client’s response, you might offer something like: “You know, even if I have had the same experience, I don’t want to assume that means I understand what this is like for you. Tell me some more...” If you decide to simply answer her question, what’s most important is to get the attention back to the client. Talking about your own experiences can change the focus of your session with her. Try saying something like: “ I have had that experience. But I don’t think that means I know what this is like for you. Tell me some more...”
Complete Activity Nine: Responding to Difficult Questions and Statements. Try out the 3Cs Model to respond to one or two of the difficult statements identified. It’s especially helpful if you can do this with another person. Push yourself to include the initial confirmation step – it’s the one most often omitted. For additional practice, see Section VC. Using the 3Cs Model: An Exercise.
Asking the Hard Questions: A Reproductive Health Provider’s Guide to Client-Centered HIV Risk Assessment
49
Section IV
HOW TO DO HIV RISK ASSESSMENT
ACTIVITY NINE: Responding to Difficult Questions and Statements In the first column, write the most difficult questions or statements clients have ever presented to you, or ones you hope you never hear. In the second column, write your thoughts about what makes this question or statement hard for you.
Difficult Question or Statement
50
What Makes This Hard for You?
Asking the Hard Questions: A Reproductive Health Provider’s Guide to Client-Centered HIV Risk Assessment
HOW TO DO HIV RISK ASSESSMENT
Section IV
D. SOME QUESTIONS ABOUT DOING HIV RISK ASSESSMENT “Should I do risk assessment with everybody?” Yes. In order to determine whether someone needs intervention around HIV risks, you have to assess. The answers to those two simple questions offered earlier – “What are you doing to protect yourself from HIV (the virus that causes AIDS)?” “What are you doing to prevent an unplanned pregnancy?” – can give you a good sense of what degree of intervention is needed. Not every client is at risk. For example, a person in a long term, mutually monogamous relationship, who does not use injection drugs and whose partner does not use injection drugs, could be considered “risk-free,” as long as neither partner were HIV infected prior to beginning their relationship. What’s tricky, of course, is that a client’s knowledge about a partner’s behavior is largely based on assumption and trust. And if a client asks her partner, there’s no guarantee that all answers will be honest. Even if a client’s risk assessment doesn’t seem to show that she is at risk, she deserves to receive information about all activities that place people at risk for infection. Provide every client with educational materials – brochures and handouts – with the suggestion that the materials can be shared with others. This gives that client who “doesn’t look like a drug-user,” but is, a chance to find out what she or he needs to know.
“How do I avoid insulting the client who is in a mutually monogamous relationship?” If you’re concerned that you might insult your client, you might say something like:
“Some married women are offended when I ask these questions. At the same time, most of us, married or not, know someone who’s had a partner step out on her or him. I might miss giving some important information to a client who needs it if I assume she doesn’t need it.” If she says she’s not at risk, and her medical history gives you no reason to doubt her, let go of any need to do extensive risk assessment and reduction work with her, beyond gathering the data requested for your medical history form. Offer any educational materials you have. You can suggest she share them with someone else, if they’re not of interest to her. On the other hand, if a client denies any risk, yet her medical history shows you otherwise – treatment for STIs, unintended pregnancy, especially if those events are recent – you might want to respectfully challenge.
“You’re telling me that you don’t think that you’re at any risk. At the same time, I see that you were recently treated for chlamydia. What are you doing differently now to protect yourself?” You might also add this question, “How comfortable are you with trusting your partner with your health, your life?” Asking the Hard Questions: A Reproductive Health Provider’s Guide to Client-Centered HIV Risk Assessment
51
Section IV
HOW TO DO HIV RISK ASSESSMENT
Remember: Your client has the right to take the risk of trusting his or her partner. Any of us who are in a relationship that we assume is mutually monogamous, may be taking that risk every time we have unprotected sex with our partner. We are saying, “I trust you with my health; I trust you with my life.”
“At my site, clients complete the medical history forms on their own. What is my role in that situation?” When clients fill out their own forms, they still deserve the opportunity to have someone review the information with them. Take time to review the client’s responses, and open the door to further discussion with a statement like,
“ One of the things we’re talking about to everyone we see now is HIV and AIDS – how people get infected, and how they can protect themselves. What questions or concerns do you have about HIV?” The open-ended question at the end of that statement invites a client to talk. A closedended question, “Do you have any concerns about HIV and AIDS?” just asks for a “yes” or “no” response. In Section VC: Resources, there is a questionnaire, Personal Questionnaire, that you can give to clients, along with the self-administered history form used in your site. The client just reads it over; no answers need to be written. It raises issues of concern that might motivate a client to talk with you about HIV risks. At a minimum, ask these two simple questions at each visit:
1) “What are you doing to protect yourself from HIV (the virus that causes AIDS)?” 2) “What are you doing to prevent an unplanned pregnancy?” The answers will let you know if more prevention work is needed.
E. CLOSING THOUGHTS In the reproductive health care setting, clients confront us with an ever-changing array of challenges. The interactive skills essential to HIV risk assessment and prevention are demanding, and it’s important to have many opportunities to practice them. In addition, listening to the stories and situations of clients’ lives can be emotionally difficult. We need chances to talk to one another about these experiences, and feel supported. Knowledge changes too. As the HIV epidemic continues, more is understood about the virus and different ways are discovered to fight it. We need opportunities for continuing professional education.
52
Asking the Hard Questions: A Reproductive Health Provider’s Guide to Client-Centered HIV Risk Assessment
HOW TO DO HIV RISK ASSESSMENT
Section IV
As you embark on the work of HIV risk assessment, think about where you will find these opportunities for learning and supervision. If you feel you need additional support, be sure to let your supervisor or clinic manager know. Together you can identify ways to help you perform HIV risk assessment, along with your other responsibilities, with the excellence you hope for, and your clients deserve.
Your willingness and courage to raise difficult issues is a gift you give to your clients. And the trust and intimacy of what they reveal is a gift they give to you.
Asking the Hard Questions: A Reproductive Health Provider’s Guide to Client-Centered HIV Risk Assessment
53
Section IV
54
HOW TO DO HIV RISK ASSESSMENT
Asking the Hard Questions: A Reproductive Health Provider’s Guide to Client-Centered HIV Risk Assessment
Section V:
RESOURCES
V
In this section you will find resources to support the activities described in this Guide. The Resources section includes: ◗
Sample HIV Risk Assessment Dialogue
◗
Awareness Raining Questionnaire for Clients
◗
Using the 3Cs Model: An Exercise
◗
List of Local Providers for Referral
◗
Internet Resources
◗
Endnotes
◗
Additional References
A. SAMPLE HIV RISK ASSESSMENT DIALOGUE Here is another dialogue that illustrates the concepts in Section IVB. Techniques for Client-Centered Dialogue. As you read this, imagine what your response would be to the client.
The client is 25 year-old Melissa. This is her initial visit to the clinic. The provider has been going over Melissa’s medical history, and is at the part that focuses on sexual and substance use behavior.
Begins by explaining and normalizing the process.
Provider: Melissa, the part of your medical history that I’m going to go over now is about sexual behavior and drug use. I ask these questions of every client, because these things have a big impact on people’s health. Melissa: Okay.
Open-ended question, “What’s going on...?” gathers a lot of information from client.
Provider: I know you came in today to get a method of birth control. What’s going on in your life right now, sexually speaking? Melissa: [responds rapidly] I have a boyfriend – he’s a great guy. We’ve been together a year and-a-half. And we do have sex. Not a lot, I mean not as much as he wants [laughs] but we do. But, you know, that’s why I’m here – for birth control.
Asking the Hard Questions: A Reproductive Health Provider’s Guide to Client-Centered HIV Risk Assessment
55
Section V
RESOURCES
Open-ended question.
Provider: So what have you been doing to keep from getting pregnant? Melissa: Well, he pulls out before he comes, and, I guess I’ve been lucky... [her voice trails off]
Doesn’t criticize Melissa’s admission; offers praise; adds information in a supportive and normalizing way.
Provider: It sounds like not getting pregnant is very important to you. You and your boyfriend have been using one of the most difficult methods around – withdrawal. Lots of people use it, and they’re surprised to learn that it’s not very effective. Melissa: Yeah, I know. Provider: The good news is that there are much, much more effective methods that are so much easier than withdrawal. Melissa: Yeah. My boyfriend really wants me to get the pill
Open-ended question.
Provider: How do you feel about taking the pill? Melissa: Well, I’m sure not ready for a baby!
Information presented without challenging Melissa’s knowledge; open-ended question.
Provider: When pills are taken correctly, they are very effective at preventing pregnancy. But – and you probably know this – the pill doesn’t protect against sexually transmitted infections. What are you doing to prevent getting STIs, like HIV, the virus that causes AIDS? Melissa: [shaking her head “no”] I don’t really think that’s an issue for me.
3rd person normalization, with a gentle confrontation.
Provider: You know, I think it’s hard for any of us to imagine that these diseases could have anything to do with us. At the same time, I’ve seen so many young women learn the hard way about these diseases. Melissa: [nodding] You’re right about that. Actually I got something once. “Calmidia”, I think it was called, but I got treated for that. That was a couple of years ago.
Not important to correct her mistake explicitly. Attends to Melissa’s feelings –“I bet that was unnerving...”
Provider: Chlamydia is one of the most common STIs. And luckily, it can be treated. I bet that was unnerving for you. Melissa: [nods vigorously] You’re right about that. I couldn’t believe it. I was so embarrassed! I ended up breaking it off with that guy.
More support for Melissa’s behavior. Provider precedes an open-ended question used to confront, with acknowledgement that it’s “tough” one.
Provider: And even though it was embarrassing, you took care of it. And you know from that experience that a person can get an infection when they don’t expect it at all. Here’s a tough question to think about. How does it feel to trust your boyfriend with your health, and maybe even your life? Melissa: I never really thought of it that way. I know we’re supposed to use condoms, but guys just don’t want to use those thing. Besides, we’re only having sex with each other!
56
Asking the Hard Questions: A Reproductive Health Provider’s Guide to Client-Centered HIV Risk Assessment
Section V
RESOURCES
Starts by praising Melissa’s behavior. Melissa may not have even thought about her monogamy in terms of risk reduction.This can help give her the sense that she’s able to take such steps. Confronts with a normalizing statement – “What’s sometimes hard to think about is...”
Provider: Only having sex with someone who’s only having sex with you is a big part of protection. What’s sometimes hard to think about is that people we’re with, or have been with in the past, probably had sex with other people at some time. And with many STIs, like HIV, not only would you not know that person had it, he might well not know either. Melissa: Yeah, I guess that’s true... [her voice trails off]
Open-ended question.
Provider: What has your boyfriend told you about his sexual history? Melissa: Not much, really. I guess I haven’t really asked.
Confirming; open-ended question.
Provider: It’s not an easy thing to do. What would it be like to talk with him about using condoms? Melissa: [very hesitantly] Not easy...he might think I’ve got something. I dunno... guess I should... [stops talking]
Offers strategizing support, asks permission to pursue her agenda a bit longer; this also takes some pressure off Melissa. Melissa’s discomfort is indication that her risk perception has been raised.
Provider: If you like, we could talk some more in a moment about how you might bring this issue up with him. Would it be okay if I finish up these history questions first? Melissa: [looks relieved] Sure.
Avoids “sexually active.”
Provider: And how many sexual partners have you had since then? Melissa: [appears to be mentally counting, then looks up] Four...no, actually five.
Provider: How old were you when you first had intercourse? Melissa: Fifteen, I think...yeah, fifteen.
Provider: And you’ve told me you’ve been with your current boyfriend over a year – am I remembering that right? Melissa: Yes. Introduces sensitive questions.
Provider: Here are two questions that sometimes surprise people. First, I know you’ve had sex with men, how about with a woman? Melissa: No, never. Do lesbians come here, too?
Provides a bit of information without sounding like she’s teaching.
Provider: Yes, and also people who’ve had sex with both men and women. Here’s another question that can feel awkward; what kind of intercourse do you have with men? Vaginal intercourse? Melissa: Yes. Provider: Oral sex? Melissa: Yeah...what guy doesn’t like that!
Asking the Hard Questions: A Reproductive Health Provider’s Guide to Client-Centered HIV Risk Assessment
57
Section V
RESOURCES
Normalizes.
Provider: And lots of women do too. How about anal intercourse? Melissa: Just once or twice. I guess I’ve done it all! [looks a little embarrassed]
Responds to Melissa’s embarrassment with normalization. Asks open-ended question to begin focusing in on HIV once more.
Provider: And that makes you like so many people. Melissa, what have you heard about HIV and AIDS, about how people get it? Melissa: [speaks confidently] I’ve heard lots of stuff about AIDS. I know people get it from shooting drugs, and having unprotected sex, and babies from their mothers.
Praise; open-ended question.
Provider: You’ve got all that right. What experiences have you had with drugs? Melissa: [forcefully] Well, I’ve never injected drugs, if that’s what you mean! [pauses, then says] I smoke a little dope every once in a while.
3rd person normalization of social use of substances, combined with information on the connection between that behavior and HIV risks.
Provider: How about any of your sexual partners – have any of them injected drugs? Melissa: No, no, I mean I sure don’t think so. I don’t hang out with that kind if crowd.
Attends to Melissa’s non-verbal expression of feeling with an openended question to surface feeling identification.
Provider: For lots of people, getting high, with alcohol or any other drug, can affect their sexual behavior. What’s that been like for you? Melissa: I guess a few times, not too many, I’ve had sex with a guy when I was high a lot faster than I would have if I hadn’t been. [looks annoyed]
Offers a strategy using the 3rd person, which allows Melissa to more honestly say what she thinks about the strategy than she might if it came directly from the provider.
Provider: How do you feel about that? Melissa: [shaking her head and looking down] I felt awful about it the next day.
Continues strategizing with use of open-ended question.
58
Provider: Some women decide to be sure they at least have condoms with them if they think they might be in that situation. Still, it can be hard to remember to use them when you’re high. Melissa: Yeah, you’re right about that. I don’t think I’ll be in that situation again, though. Provider: What could you do if you realized a situation like that was developing? Melissa: Like I said, I don’t think it will happen again, but if it did, I’d just leave before things got messy.
Asking the Hard Questions: A Reproductive Health Provider’s Guide to Client-Centered HIV Risk Assessment
Section V
RESOURCES
Supports Melissa’s intention.
Provider:
3rd person approach to transition into another possibly sensitive subject.
Melissa:
Provider:
Melissa:
Sounds like a good plan. Another situation that lots of people have been in is being forced to have sex when they didn’t want to. What’s your experience been with that? It hasn’t really happened to me. Like I said, I’ve given in a couple of times when I was high, but no one ever forced me. So what you’re saying is that, for now, the one situation you want to think about is the one with your boyfriend. Would it be okay if we talked some more about how to talk with him about sexually transmitted infections, how to bring up using condoms? Yes, sure.
This portion of a longer session took a little less than 6 minutes. The provider has taken every opportunity to offer genuine praise and support. She has anticipated and normalized any uncomfortable reactions, and attended to feelings she sensed in Melissa. In the course of a genuine, client-centered interaction, she managed to accomplish a lot in a very short amount of time. In addition, by creating a comfortable relationship with the client, she’s helped to build an even more important relationship – Melissa’s connection to the clinic.
B. AWARENESS RAISING QUESTIONNAIRE FOR CLIENTS If a self-administered medical history, is used in your setting, you might want to supplement it with this Personal Questionnaire.22 Give the Personal Questionnaire to a client for review, and explain that no answers need to be recorded. The purpose of the questionnaire is not information gathering; it is to raise the client’s awareness of the factors that affect HIV risk and to encourage her to express her questions and concerns.
Asking the Hard Questions: A Reproductive Health Provider’s Guide to Client-Centered HIV Risk Assessment
59
Section V
RESOURCES
PERSONAL QUEST I O N N A I R E This questionnaire is to let you know what kinds of activities might expose you to HIV, the virus that causes AIDS. Please read this over while waiting for your visit. You will have a chance to discuss any questions or concerns with a counselor or clinician today. THIS IS FOR YOUR INFORMATION ONLY. YOU DO NOT NEED TO WRITE ANYTHING DOWN.
1. Have I had more than one sexual partner in the last ten years? 2. Have I ever been with a sexual partner who had had other sexual partners? 3. Have I ever had sex with someone who was infected with HIV? 4. Have I ever had sex without a condom, when I didn't know whether or not my partner had any kind of infection? 5. (For men) Have I ever had sex with a man? (For women) Have I ever had sex with a man who also has had sex with other men? 6. Have I ever had sex with a partner whom I didn't know very well? Did I have sex with that person without using a condom (rubber)? 7. Have I ever shared needles to shoot drugs? 8. Have I ever had a partner who shared needles to shoot drugs? 9. Have I ever had a sexually transmitted infection – chlamydia, trichomoniasis or "trich,” herpes, HPV or warts, gonorrhea, or syphilis? 10. Have there ever been times when my sexual behavior was affected by alcohol or other drug use? Is alcohol or drug use currently affecting my sexual behavior? 11. Have I ever had sex for money, drugs, or safety? If you answered “yes” to any of the questions above, you might be at risk for HIV infection. You might want to consider having an HIV-antibody test. The result of that test is especially important if you think you are pregnant, or want to become pregnant. And for someone who does have HIV, early testing can lead to early treatment. Your counselor or clinician can answer your questions and give you more information. Please feel free to ask any questions about HIV and AIDS, and any other sexually transmitted infection.
60
Asking the Hard Questions: A Reproductive Health Provider’s Guide to Client-Centered HIV Risk Assessment
RESOURCES
Section V
C. USING THE 3CS MODEL: AN EXERCISE Here is another example that illustrates the concepts in Section IVC(8). The 3Cs Model. Imagine that you’re talking to a client about condom use. She is listening to you, but looks very uncomfortable. You say to her that it looks like she’s thinking about something important, and she says,
“I really feel yucky when I look at my boyfriend’s...penis.”
What do you imagine you would say to her in response? Write it down here.
It’s likely you responded in one of several ways: ◗
You asked a question to find out why she’s reacting this way.
◗
You encouraged her not to feel that way.
◗
You empathized with her feelings.
Now consider what might be underlying her statement. Here are some possibilities: ◗
Her boyfriend has something wrong with his penis, making it look “yucky.”
◗
She’s a survivor of incest or sexual abuse, and is repulsed by anything sexual, or repulsed specifically by a penis.
◗
Her boyfriend wants her to have oral sex with him, and she’s not interested.
◗
Her boyfriend wants her to have oral sex with him, and she is interested, but she’s uncomfortable about feeling that way, and trying to present herself as someone who “wouldn’t do that.”
◗
She is uncertain about whether it’s okay to be looking.
◗
She has never seen a penis before, so it looks strange to her.
◗
She has only seen either circumcised or uncircumcised penises, and her boyfriend’s is different from what she’s used to seeing.
◗
Prior partners have always kept the lights off during sex; this boyfriend wants to see.
◗
She’s uncomfortable about discussing sex or condom use with you, and is trying to find a way to cut short the discussion.
Asking the Hard Questions: A Reproductive Health Provider’s Guide to Client-Centered HIV Risk Assessment
61
Section V
RESOURCES
Based on her statement, you don’t yet really know what’s going on. Any response you make now is going to be based on your assumptions. Instead of responding, start with a confirmation. While you can’t honestly tell her that this is a statement you frequently hear, you can confirm a very generalized notion of what the statement is about.
“People react in lots of different ways when they look at someone else’s body.” Follow with a clarification:
“Tell me some more about what’s going on for you.” Her response will likely give you a good idea of your ability to address her concerns. If it turns out that she just needs some simple information, give her some content. For example,
“Sounds like your partner’s penis is not circumcised. That could make it look different from what you’re used to.” If there’s not a simple, informational response to give, but you do feel able to talk with her, you might contract with her for another visit. If you’re not prepared to deal with the issue, you would contract for referral.
62
Asking the Hard Questions: A Reproductive Health Provider’s Guide to Client-Centered HIV Risk Assessment
Section V
RESOURCES
D. LIST OF LOCAL PROVIDERS FOR REFERRAL Here is a sample template for gathering resources in your community so that you can refer clients as needed. Keeping updated resources is critical to offering comprehensive services to clients.
Service Provided
Agency Name
Contact Name/ Address/ Phone/Email
Hours of Operation
Additional Comments
Date of Last Update
HIV Counseling/ Testing HIV Medical Services Substance Abuse Counseling/ Treatment Program Methadone Treatment Program Domestic Violence Services Gay, Lesbian, Bisexual, Transgender Services
Other
Asking the Hard Questions: A Reproductive Health Provider’s Guide to Client-Centered HIV Risk Assessment
63
Section V
RESOURCES
E. INTERNET RESOURCES National Statistics Centers for Disease Control and Prevention http://www.cdc.gov ◗
Division of HIV/AIDS Prevention Basic Statistics http://www.cdc.gov/hiv/stats.htm
◗
Division of HIV/AIDS Prevention HIV/AIDS Surveillance Report (contains tabular and graphic information about U.S. AIDS and HIV case reports) http://www.cdc.gov/hiv/stats/hasrlink.htm
◗
Division of HIV/AIDS Prevention HIV/AIDS Among US Women: Minority and Young Women at Continuing Risk http://www.cdc.gov/hiv/pubs/facts/women.htm
◗
CDC’s Reproductive Health Information Source Adolescent Pregnancy/Unintended Pregnancy http://www.cdc.gov/nccdphp/drh/up_adolpreg.htm
Region I Resources New England AIDS Education & Training Center http://www.neaetc.org Region I Family Planning Training Center http://www.famplan.org STD/HIV Prevention Training Center of New England http://www.state.ma.us/dph/cdc/stdtcmai/stdtcmai.htm
National & International HIV/AIDS Sites Association of Nurses in AIDS Care http://www.anacnet.org CDC National Prevention Information Network http://www.cdcnpin.org
64
Asking the Hard Questions: A Reproductive Health Provider’s Guide to Client-Centered HIV Risk Assessment
RESOURCES
Section V
DHHS AIDS Treatment Information Service (ATIS) http://www.hivatis.org Health Resources and Services Administration http://www.hrsa.dhhs.gov HIV/AIDS Treatment Information Network http://www.hivline.com International Association of Physicians in AIDS Care http://www.iapac.org National AIDS Education & Training Centers Site http://www.ucsf.edu/warmline/aetc.html National AIDS Treatment Information Project http://www.natip.org Occupational Post-Exposure Prophylaxis (PEP) and Pregnant Health Care Workers http://ari.ucsf.edu/pdf/Posters/dong.pdf National HIV Telephone Consultation Service (Warmline) http://www.ucsf.edu/warmline/warmline.html National Library of Medicine HIV/AIDS Resources http://sis.nlm.nih.gov/aidsHIV/HIVMain.html National Minority AIDS Council http://www.nmac.org National Network of STD/HIV Prevention Training Centers http://depts.washington.edu/nnptc Office of Family Planning http://opa.osophs.dhhs.gov/titlex/ofp/html Office of Population Affairs http://opa.osophs.dhhs.gov/index.html
Other AIDS Educational Training Centers (AETCs) ETC Evaluation Center http://www.aids-ed.org/r_eval.html Delta Region AIDS ETC (AR, LA, MS) http://www.aids-ed.org/r_delta.html Florida Regional AIDS ETC http://www.aids-ed.org/r_florida.html
Asking the Hard Questions: A Reproductive Health Provider’s Guide to Client-Centered HIV Risk Assessment
65
Section V
RESOURCES
Great Lakes to Tennessee Valley AIDS ETC (OH, MI, TN, KY) http://www.aids-ed.org/r_lakes.html Midwest AIDS Training and Education Center (IL, IN, IA, MN, MO, WI) http://www.aids-ed.org/r_midwest.html Mountain Plains Regional AIDS ETC (ND, SD, UT, CO, NM, NE, KS, WY) http://www.aids-ed.org/r_mountain.html National Minority AIDS ETC http://www.aids-ed.org/r_nmaetc.html New Jersey AIDS ETC http://www.aids-ed.org/r_nj.html New York/ Virgin Islands AIDS ETC http://www.aids-ed.org/r_ny.html Northwest AIDS ETC (WA, AK, MT, ID, OR) http://www.aids-ed.org/r_northwest.html Pacific AIDS ETC (NV, AR, HI, CA) http://www.aids-ed.org/r_paetc.html Pennsylvania/Mid Atlantic AIDS ETC (PA, VA, WV, MD, DE) http://www.aids-ed.org/r_penn.html Puerto Rico AIDS ETC http://www.aids-ed.org/r_puerto.html Southeast AIDS ETC (SC, NC, GA, AL) http://www.seatec.emory.edu/ Texas and Oklahoma AIDS ETC http://www.aids-ed.org/r_texas.html
Other Resources and Information Sites THE BODY Website http://www.thebody.com Community Research Initiative of New England http://www.crine.org HelpHorizons http://www.helphorizons.com HIVdent http://www.hivdent.org
66
Asking the Hard Questions: A Reproductive Health Provider’s Guide to Client-Centered HIV Risk Assessment
RESOURCES
Section V
HIV InfoWeb http://www.aegis.com HIV InSite (University of California/ San Francisco General Hospital) http://hivinsite.ucsf.edu Johns Hopkins AIDS Service http://www.hopkins-aids.edu Medscape http://www.medscape.com The Office Of Community Programs http://www.umassmed.edu/ocp The HCV Advocate http://www.hcvadvocate.org Project Inform (Treatment Information Network) http://www.projinf.org Nutrition/Infection Unit at the Tufts University School of Medicine http://www.tufts.edu/med/nutrition_HIV/index.html
F. ENDNOTES 1. Guest, F. “Brief Sexual History and Counseling Techniques,” in Contraceptive Technology, Sixteenth Revised Edition , ed. Hatcher, R., Trussell, J., Stewart, F., Stewart, G., Kowal, D., Guest, F., Cates, W., and Policar, M. (New York: Irvington Publishers, Inc., 1994), 2935. 2. Guest, F. “HIV Prevention in the Reproductive Health Care Setting,” in Contraceptive Technology, Seventeenth Revised Edition, ed. Hatcher, R., Trussell, J., Stewart, F., Cates, W., Stewart, G., Guest, F., and Kowal, D. (New York: Ardent Media, Inc., 1998), 141145. 3. Policar, M. An Approach for Taking a Sexual History: A Clinician’s Perspective in the 1990s. [Videotape of a satellite downlink] Indianapolis, IN: Health Care Education and Training, Inc., Region V, July 18, 1997. 4. U.S. Department of Health and Human Services, Office of Population Affairs, Office of Family Planning. Program Guidelines for Project Grants for Family Planning Services , January 2001. 5. Centers for Disease Control and Prevention. HIV/AIDS among US Women: Minority and Young Women at Continuing Risk, January 31, 2001. Available at http://www.cdc.gov/hiv/pubs/facts/women.htm.
Asking the Hard Questions: A Reproductive Health Provider’s Guide to Client-Centered HIV Risk Assessment
67
Section V
RESOURCES
6. Kaiser Daily HIV/AIDS Report. Women Increasingly Bearing the Burden of HIV/AIDS, Study Finds, May 4, 2001. Available at http://www.kaisernetwork.org/daily_reports/print_report.cfm?DR_ID=4415&dr_cat=1. 7. Massachusetts Department of Public Health, Office of Statistics and Evaluation. Family Planning Clients and HIV Risk: A Survey of Massachusetts Women, 1998. Available at http/www.state.ma.us/dph/ose/fpcexec.htm. 8. Kaiser Family Foundation. “Survey of Men and Women on Sexually Transmitted Infections.” Glamour Magazine, August 1999. Available at http://www.cdc.gov/hiv/pubs/facts/women.htm. 9. The National Center on Addiction and Substance Abuse at Columbia University (CASA). Dangerous Liaisons: Substance Abuse and Sex, December 1999. Available at http//www.casacolumbia.org/usr_doc/21598.pdf. 10. The National Center on Addiction and Substance Abuse at Columbia University (CASA). Substance Abuse and The American Woman, June 5, 1996. Available at http://www.casacolumbia.org/usr_doc/5894.pdf. 11. De Groot, A.“HIV Infection Among Incarcerated Women: An Epidemic Behind the Walls.” HEPP News, HIV Education/Prison Project (April 2000). Available at http://www.brown.edu/departments/BRUNAP/ Brown University AIDS Program, http://www.hivcorrections.org/archives/april00/. 12. Cohen, M., Deamant, C., Barkan, S, et al. “Domestic Violence and Childhood Sexual Abuse in HIV-Infected Women and Women at Risk for HIV.” American Journal of Public Health. Vol. 90, No. 4, (April 2000): 560. Abstract available at http://www.lawihs.com/ abstracts/abstract_PREVALENCEOFDOMESTICVIOLENCEANDCHILDHOOD ABUSEAMONGWOMENWITHHIVANDHIGHRISKUNINFECTEDWOMEN.htm . 13. Kaiser Family Foundation. Talking About STIs with Health Professionals: Women’s Experiences, 1997. Available at http://www.kff.org/content/archive/1313/stds.html. 14. Foster, S. CASA Study Reveals Dangerous Connection Between Teen Substance Use and Sex. The National Center on Addiction and Substance Abuse at Columbia University (CASA), 1999. Available at http://www.theantidrug.com/drug_info/studies_casa_sex.html. 15. JSI Research & Training Institute, Inc. Reproductive Health Counselor/Provider Feedback Survey in MA: HIV Risk Assessment Activities, March 2001. 16. Kamb, M.L., et al. “Efficacy of Risk-Reduction Counseling to prevent Human Immunodeficiency Virus and Sexually Transmitted Diseases.” Journal of the American Medical Association. 280 (13) (1998): 1161-1167. Available at http://www.cdc.gov/hiv/projects/respect/default.htm.
68
Asking the Hard Questions: A Reproductive Health Provider’s Guide to Client-Centered HIV Risk Assessment
Section V
RESOURCES
17. Cottler L.B., Leukefeld, C., Hoffman, J., Desmond, D., Wechsberg, W., Inciardi, J.A., Compton, W.M., Abdillah, B.A., Cunningham-Williams, R., and Woodson, S. “Effectiveness of HIV risk reduction initiatives among out-of-treatment non-injection drug users.” Journal of Psychoactive Drugs . 30(3) (May 4, 2001): 279-290. 18. Weinardt, L.S., Carey, K.B., and Carey, M.P. “HIV Risk Assessments May Motivate Participants to Reduce Risk Behavior.” Journal of Behavioral Medicine. 23 (4) (May 4, 2001): 393-398. 19. Center for Rural Studies. Exercise Five: Non-Verbal Expression , April 1, 1997. Available at http://crs.uvm.edu/gopher/nerl/personal/comm/f.html. 20. Annon, J. The Behavioral Treatment of Sexual Problems . Volume 1. Honolulu, Hawaii: Enabling Systems, Inc., 1976. 21. Beresford, T., and Garrity, J. Short Term Counseling of Sexual Concerns: A Self Instructional Manual. Baltimore, MD: Planned Parenthood of Maryland, 1982. 22. Garrity, J. “Personal Questionnaire” form. Baltimore, MD: 1988, revised 2001.
G. Additional References Centers for Disease Control and Prevention. Project Respect Brief Counseling Intervention Manual, 1993. Available at http://www.cdc.gov/hiv/projects/respect/bcim.pdf. Centers for Disease Control and Prevention. “HIV and AIDS - United States, 1981-2000.” Morbidity and Mortality Weekly Report. 50 (21) (June 1, 2001): 430-434. Available at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5021a2.htm. “Client-Centered Counseling.” Center for Health Training, Region VI, 1999. [Videotape] Austin, TX. Garrity J. “Understanding and Supporting Health Behavioral Change – Focus on HIV.” SIECUS Repor t. 20(1) (October/November 1991): 8-10. Haggerty, M.F. “Incarcerated Populations & HIV.” CRIA Update . Vol. 9 No 3. (Summer 2000). Available at http://www.thebody.com/cria/summer00/prison.html. Kyck, F. “Seek Support to Stop Domestic Violence.” Women Alive. (Spring 1999). Available at http//www.thebody.com/wa/spring99/violence.html. Miller, W., and Rollnick, S. Motivational Interviewing: Preparing People to Change Addictive Behavior. New York: The Guilford Press, 1991.
Asking the Hard Questions: A Reproductive Health Provider’s Guide to Client-Centered HIV Risk Assessment
69
Section V
RESOURCES
Mountain Plains Regional AIDS Education and Training Center. HIV/AIDS Prevention, Early Intervention and Health Promotion: A Self-Study Module for Rural Health Car e Provider – Module I , 1999. Available at http://www.uchsc.edu/sm/aids/ssm/pc1.htm. Ponton, L.E. The Romance of Risk. New York: Basic Books, 1997. Retzlaff, C. “Women, Healthcare & Violence.” Journal of the International Association of Physicians in AIDS Car e. (March 1999). Available at http://www.thebody.com/iapac/violence-women.html. Ruiz, M.S., Gable, A.R., Kaplan, E.H., Stoto, M.A., Fineberg, H.V., and Trussell, J. “The Prevention Portfolio: Interventions to Prevent HIV Infection,” in No Time to Lose: Getting More from HIV Prevention. (National Academy Press, 2001): 116-123. Available at http://www.nap.edu/html/HIV_prevention/appb.pdf. The Family Planning Councils of America, Inc. Available at http://www.fpcai.org/fpworksf.htm. The National Center on Addiction and Substance Abuse at Columbia University (CASA). Missed Opportunity: National Survey of Primary Care Physicians and Patients on Substance Abuse, May 2000. Available at http://www.casacolumbia.org/usr_doc/21598.pdf.
70
Asking the Hard Questions: A Reproductive Health Provider’s Guide to Client-Centered HIV Risk Assessment
