Couples HIV Counselling and Testing

PowerPoint Slides

2009

Module 1 Objectives • By the end of this module, participants will be able to:

Module 1: Introduction to Couples HIV Counseling and Testing

– State the objectives of the training – Provide an overview of the HIV counseling and testing context in Uganda – Discuss the advantages of couples HIV counseling and testing

Couples HIV Counseling and Testing Training

Module 1

Session 1.1.1: Welcome and Opening

Participant Introductions

• By the end of this session, participants will be able to:

• • • •

Name Agency or organization Educational background Experience with HIV counseling and testing • One interesting fact about yourself • One thing you hope to gain from the training

– Articulate the goals and objectives of the training course

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Goal of CHCT Training

Module 1

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Objectives of CHCT Training • By the end of this training, participants will be able to:

• To build the capacity of trained counselors in HIV counseling and testing for couples

Module 1

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– Appreciate the importance of couples HIV counseling and testing and the need for HIV prevention, care and support – Describe the concept of and explain issues that surround couples HIV counseling and testing in Uganda – Educate clients, their families and the community about HIV discordance – Conduct effective pre-test HIV counseling services to couples – Provide couples with HIV results and support to make risk reduction plans – Identify HIV prevention and support services for positive concordant couples, negative concordant couples and discordant couples at health unit and community levels – Support discordant couples to adopt preventive strategies within their relationships 5

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Session 1.1.2: CHCT Pre-Course Knowledge Assessment

Session 1.2.1: Overview of Couples HIV Counseling and Testing in Uganda

• By the end of this session, participants will be able to:

• By the end of this session, participants will be able to:

– Identify their knowledge gaps in couples HIV counseling and testing

– Describe the HCT context in Uganda – Provide justification for the need for couples HCT in Uganda

Module 1

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How many people in Uganda have ever tested for HIV and received their results? A. B. C. D.

0-5% 10-15% 30-35% 50-55%

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Who is more likely to be HIV positive: married men and women, or those never married? A. Those never married B. Married men and women C. They are equally likely to be HIV positive

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Married persons account for what percentage of new HIV infections? A. B. C. D.

Module 1

25% 50% 65% 90%

Module 1

What proportion of Ugandans do not know the HIV status of any of their partners? A. B. C. D.

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6% 23% 62% 89%

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What proportion of couples in Uganda are HIV discordant? A. B. C. D.

In what percentage of discordant couples is the male infected?

1% 2% 5% 10%

A. B. C. D.

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1% 2% 3% 4%

A. B. C. D.

Module 1

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What proportion of Ugandans believe that if one partner is infected with HIV, the other partner always is, too? A. B. C. D.

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What proportion of cohabiting couples in Uganda are HIV positive concordant?

In what percentage of discordant couples is the female infected? A. B. C. D.

1% 2% 3% 4%

1% 2% 3% 4%

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Overview of HCT in Uganda • Only 13% of women and 11% of men have ever tested for HIV and received their results • Only 4% have done so in the last 12 months • Married couples are at higher risk of HIV infection: 6.3% of those in marital union are estimated to be HIV positive, compared to 1.6% of those never married • Married persons account for an estimated 65% of new infections

25% 50% 75% 100%

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Overview of HCT in Uganda

Rationale for CHCT in Uganda

• 89% of Ugandans do not know the HIV status of any of their partners or spouses • One in every 20 couples living together in Uganda is discordant (5%), with the male infected in 3% and the female in 2% • 3% of cohabiting couples are HIV positive concordant • 75% of men and women incorrectly believe that if one partner is infected with HIV, the other partner always is, too Module 1

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Session 1.2.2: Introduction to Couples HIV Counseling and Testing • By the end of this session, participants will be able to: – Define the meaning of a couple in the context of couples HIV counseling and testing – State the goal of couples HCT – Understand the challenges of couples HCT – Differentiate between individual and couples HCT – Give advantages of couples HCT Module 1

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Task Debrief

• The majority of the country has not tested for HIV and received their results • There are high HIV infection rates among married couples • Couple communication around HIV in general and HIV status in particular is low • Discordance is common in Uganda • Many people do not believe discordance is possible • Transmission risk is highest in steady discordant relationships • CHCT has been shown to increase condom use among discordant couples Module 1

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Task • In groups of three, select one person to observe the activity, and two to perform the exercise • Pairs should quietly envision their dream house • Without talking, pairs draw their dream house, with both holding onto the same pen • Observers watch the process and make mental notes without interfering

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Task Debrief

• Pairs: – What challenges did you face as you drew the house? – Was one person more dominant while doing the task? Who?

• Each person represents the perspective of someone in a CHCT session – Observer = Counselor – Pairs = Couple members – Pen = Couple as a unit

• Observers: – What did you observe as the couples drew their house? Module 1

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Definition of Couple HIV Counseling

Goal of CHCT

• Couple counseling is where 2 individuals (man and woman) who have had or intend to have sexual relations are counseled together

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• To help couples come to a shared vision of HIV in their lives

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Individual and Couples HCT Individual HCT

Couples HCT

Client learns only his/her HIV status

Client’s learn each other’s HIV status

Client is faced with the burden of disclosing to his/her partner

Disclosure to partner is immediate and 100%

Couple has to deal with issues of tension and blame on their own

Counselor can help to ease tension and diffuse blame

Only one couple member hears the information

Partners hear information together, enhancing likelihood of shared understanding

Counseling messages take into account only one client’s status

Counseling messages are based on the results of both couple members, and can be tailored to positive concordant, negative concordant, and discordant couples

There is no moderated opportunity for couples to talk through difficult issues

The counselor creates a safe environment and can help couples talk through difficult issues they may not have discussed before

Treatment and care decisions are more Treatment and care decisions can be made likely to be made in isolation together Module 1 27

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Module 2 Objectives • By the end of this module, participants will be able to:

Module 2: Couples HIV Counseling and Testing Skills

– Appreciate how a counselor’s personal issues may influence his or her ability to provide quality services to couples – Discuss the importance of building alliances during a CHCT session – Discuss and demonstrate basic and couplesspecific counseling skills

Couples HIV Counseling and Testing Training

Module 2

Session 2.1.1: The Importance of Counselor Self-Awareness

Counselor Self-Awareness • Refers to the ability to understand how personal beliefs and experiences affect how a counselor reacts and responds in a counseling session • Personal biases can influence a counselor’s ability to provide high-quality services to couples • Counselors regularly need to examine their own issues and improve their counseling skills to prevent their personal biases from interfering with their counseling sessions

• By the end of this session, participants will be able to: – Identify issues that may influence a counselor’s ability to provide quality HCT services to couples

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Importance of Counselor SelfAwareness

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Importance of Counselor SelfAwareness

• Being self-aware allows counselors to:

• Being self-aware allows counselors to:

– Hear and understand the couple’s concerns – Offer genuine sympathy and support – Skillfully and effectively manage the couple counseling session – Empower the couple

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– Provide high quality services to couples – Ensure that personal values, beliefs, and experiences do not influence interaction with the couple – Reduce the potential for biasing the couple’s decisions – Understand that he or she is not responsible for the test results or the couple’s relationship 5

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Issues That May Influence Counselor’s Ability to Provide Quality Services to Couples

Issues That May Influence Counselor’s Ability to Provide Quality Services to Couples

• Counselor’s experiences, values, and feelings relating to couple relationships, including gender roles and expectations • Dreams and aspirations counselor has for his or her own relationship, family and future • Counselor’s relationship with his or her partner

• Counselor’s experience receiving individual HIV counseling and testing services • Counselor’s willingness to receive couple HIV counseling and testing services • Counselor’s feelings about whether or not to disclose HIV test result to partner • Partner’s reaction if counselor did disclose and the impact on the relationship

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Session 2.2.1: Review of Basic Counseling Concepts and Skills

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Basic Counseling Skills

• By the end of this session, participants will be able to:

• Active listening • Checking understanding • Asking questions

– Review basic counseling skills

– Open-ended vs. closed-ended questions

• Answering questions

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Non-Verbal Communication • • • • • • •

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Verbal Communication • Paraphrasing

Sitting posture (ROLES) Facial expressions Gestures Nodding Tone of voice Encouragers Constructive use of silence Module 2

Module 2

– Restate what was said in a nonjudgmental way

• Prompting – “What else?” “And then?”

• Clarifying – “What did you mean when you said…”

• Reflecting feelings – “It sounds like you…”

• Repeating – Repeating important information that the couple may not have understood initially 11

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Session 2.2.2: Couples-Specific Counseling and Testing Skills

Verbal Communication • Probing – Use open-ended questions to find out more about an issue

• Rehearsing

– Articulate the key considerations when counseling couples – Form alliances with couples during CHCT – Discuss skills specific to couple counseling – Demonstrate skills specific to couple counseling

– Clients practice/demonstrate

• Prioritizing – Help client decide which issues need to be handled first

• Externalizing – Separate the problem from a client

• Summarizing – Review what was said Module 2

• By the end of this session, participants will be able to:

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Module 2

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Key Considerations When Counseling Couples

Forming an Alliance Between the Counselor and Couple

• HIV-related issues may be emotionally intense, especially when a couple is involved • Relationships are full of contradictions • Relationships take place in the context of cultural values and norms • Couples who volunteer for CHCT are invested in the process • Small behavior changes can lead to bigger ones • It is the couple’s present and future that is the most important

• An alliance is a partnership between the counselor and the couple • The alliance is the foundation that permits the couple to:

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Essential Alliances in Couple Counseling

Man

Woman Couple

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• Offer genuine warmth, kindness and compassion • Respect the couple and where they are coming from emotionally and culturally • Give each person a chance to speak, and listen for responses • Use appropriate body language such as smiling and nodding to convey warmth and understanding

Counselor

Woman

Module 2

Examples of Ways to Form an Alliance

Man Counselor

– Engage in the session – Explore issues – Disclose and address challenging HIV-related issues

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Module 2

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Directing Communication in Couple Counseling

• Demonstrate neutrality and non-biased concern for both members of the couple • Normalize feelings, reactions and experiences • Express confidence in the couple’s ability to deal with HIV-related issues and admire the couple’s willingness to contend with the challenges of HIV in their lives

Counselor

Man

Woman

Module 2

Couples Counseling and Testing Skills: Group 1

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Module 2

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Couples Counseling and Testing Skills: Group 2

Couples Counseling and Testing Skills: Group 3

• Raise the difficult issues that the couple may need to address • Focus on the present and future. The past cannot be changed. • Avoid and deflect questions aimed at identifying the source of infection • Redirect and reframe questions and discussions that are blaming or potentially hostile

• Calmly and gently name and acknowledge the behavior being observed • Build on the couple’s strengths, rather than weaknesses • Focus on solutions instead of dwelling on problems

Module 2

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Role Play: Questions for Counselors

Task • In your assigned groups, write out 1-2 sentence examples of how a counselor would express these skills in words to a couple in a CHCT session

Module 2

Module 2

• How did it feel to work with this couple? • What skills did you practice to help you effectively conduct the session? • What skills did you use to establish and reinforce alliances with the couple? • How did your own personal biases affect the session? 23

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Role Play: Questions for Couples • How did it feel to be counseled by this counselor? • How effective were your counselor’s techniques? • Did you feel that the counselor treated you both equally? Why or why not?

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Module 3 Objectives • By the end of this module, participants will be able to:

Module 3: Couples HIV PreTest Counseling Session

– Review the situations or reasons why couples seek HIV counseling and testing services – Review the CHCT pre-test counseling protocol – Identify the requirements of the couple in the CHCT session – Inform the couple about the counseling process

Couples HIV Counseling and Testing Training

Module 3

Types of Couples Who May Seek CHCT

Session 3.1.1: Characteristics and Motivations of Couples Who Receive CHCT • • • • • • •

• By the end of this session, participants will be able to: – Describe different types of couples that may come for CHCT services – Describe the reasons that couples come for CHCT services

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Before engaging in sex Engaged in a sexual relationship Engaged for marriage Married or cohabiting Polygamous Reuniting Each of these types may: – Not have children – Have children and want more – Not want any more children

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Task

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Before Engaging in Sex

• In small groups, discuss the possible issues these types of couple may face – Each small group considers a different type of couple (see previous slide)

• Consider the implications if the couple has children, does not have children, wants children, and/or does not want any more children Module 3

Module 3

• May use CHCT to decide whether to continue a long-term relationship based on their results • If discordant: – Relationship may dissolve – HIV-infected partner may be concerned that HIV-negative partner will disclose test results – Counseling session may focus on how the couple will manage the relationship

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Module 3

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Engaged in Sexual Relationship

Engaged for Marriage

• Have already initiated sexual relations • May or may not be planning to marry • May use CHCT to decide whether to continue a long-term relationship based on their results • Level of commitment may affect risk reduction plans • May have or be planning to have a child

• Have often already made testimonials to their commitment • Family and friends have often publicly recognized the relationship • Elaborate wedding plans may have already been made • May have limited skills/experience dealing with stressful difficult circumstances as a couple • May have difficulty continuing the relationship if discordant • Confidentiality and disclosure implications result if the partners alter plans based on test results

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Married or Cohabiting Couples

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• Have complex dynamics • Wives may not be equal partners with the husband • If only one wife comes with the husband, test results may impact another wife who is not present

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Couples who want to have children

Reuniting Couples • Reasons for the separation may influence the dynamics of the counseling session • Couples may have been separated for a long time (e.g. employment, education, conflict) • May have struggled with issues of trust, faithfulness, communication • Counselor must acknowledge existence of past issues but keep focused on present and future Module 3

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Polygamous Couples

• Define their lives collectively as a partnership • May be more interdependent socially, financially, emotionally • Have skills/experience dealing with problems together • May have pre-existing conflicts/issues in their relationship that hinders their ability to work together to address HIV issues Module 3

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• May be desire to end relationship if one partner is HIV positive • Family and social pressure to have children may contribute to increased risk behavior

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Couples who have children and want more • Partners are likely to continue relationship regardless of test results • Perceive themselves and are perceived by others to be a family • Well-being and future of their children is a powerful influence • Need to consider issues of disclosure • Desire for more children may influence couple’s risk reduction decisions Module 3

• Need to consider issues such as disclosure and planning for the future of their children

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Session 3.1.2: Creating an Effective CHCT Environment

Motivations for Seeking CHCT • One or both couples members are ill • Child is sick • Suspicion or discovery of an outside sexual relationship • Learned of CHCT experience from a friend or family member • Heard/saw a message about CHCT Module 3

Couples who are finished having children

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Requirements for Receiving CHCT Services

• By the end of this sessions, participants will be able to: – Describe the requirements couples should agree to before starting a CHCT session – Articulate the realities of CHCT sessions – Explain Johari’s Window, and how it relates to CHCT – Give advantages and limitations of conducting individual and couple risk assessments Module 3

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Realities of Couple HIV Counseling and Testing

• Each partner agrees to:

• CHCT is not marriage counseling • The couple’s issues are more important than individual issues • The couple may reveal feelings not previously discussed within the couple if the counselor forms alliances and creates a safe, open atmosphere

– Discuss HIV risk concerns – Participate equally in the discussion – Treat each other with respect and dignity – Be as open and honest as possible – Agree to receive HIV test results together – Make decisions about disclosure together • Couples should agree not to tell anyone their test results until both partners agree Module 3

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Realities of Couple HIV Counseling and Testing

Johari’s Window for Couples

• Couple may want to use CHCT to address longstanding issues in their relationship • Couples may have issues in their relationship unrelated to HIV • The couple, not the counselor, is ultimately responsible for what happens in the relationship

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Johari’s Window for Couples Known to Self

Known to Others

Not Known to Others

• Johari’s Window is a tool often used in counseling couples • It helps to identify what thoughts and feelings individuals willingly share with others and what things they keep to themselves, particularly in a counseling situation

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Johari’s Window: Open Box

Not Known to Self

OPEN Issues that are open, shared, discussed

• Issues that are shared and discussed openly and directly • Talking about them helps counselor establish a relationship with the couple • Couple begins to open up as talk about thing they are comfortable with • Counselor is able to show interest and validate couple’s situation • Examples:

PRIVATELY DISCUSSED Issues that are understood, acknowledged, or privately discussed

NOT DISCUSSED

HIDDEN

Issues that are imagined or believed and rarely, if ever, discussed

Issues that are hidden, protected, and kept secret

Module 3

– “Tell me about your relationship” – “Tell me about your children”

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Johari’s Window: Privately Discussed Box

Johari’s Window: Not Discussed Box

• Issues are acknowledged, understood and privately discussed with partner • Once counselor has formed alliance with couple, these issues may be brought up • Should be addressed gently with sensitivity and understanding • Examples:

• Issues that are known about but rarely, if ever, discussed • Couple may bring up these issues if counselor establishes safe and open environment • Counselor should never ask questions or push a couple to discuss things in this box • Examples:

– Details of a recent death in the family – Financial situation Module 3

– Suspicions that partner is unfaithful, has a drinking problem, or does not like your mother 23

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Johari’s Window: Not Discussed Box Continued • How to address this situation – Use similar situations or stories with solutions – Speak about it in terms of other people rather than the couple – Address the issues in the abstract without making the couple verbalize them – “Some couples who are apart from each other often worry about their spouse being faithful. In those cases we would discuss how each partner would protect themselves from HIV by remaining faithful or using condoms.” Module 3

Johari’s Window: Hidden Issues • Issues are hidden, protected and secret • Often considered shameful or embarrassing • Should never be discussed directly in a counseling session • May be brought up in the abstract, but never referred to directly unless couple brings it up • Examples: – Details about a previous relationship – Something that happened when drunk – Sexual fantasies

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Individual Risk Assessments • Advantages: – Allows the counselor to have complete knowledge of each couple member’s risk situation

• Limitations: – Undermines the couple’s decision to deal with HIV in their relationship together – Separating partners implies there are secrets, which may result in distrust and show lack of communication – Confidential issues may influence counselor to support one partner unintentionally Module 3

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Uganda’s Couples Risk Assessment Guidelines

Couple Risk Assessments • Advantages:

• Conduct an initial risk assessment with both couple members together • Separate the couple for individual risk assessments • Bring the couple back together and give them an opportunity to share any issues with the assistance of the counselor

– It reinforces the couple’s commitment to deal with HIV issues together – Mutual discussion reinforces trust, communication, and cooperation

• Limitations: – Issues in the “Not discussed” or “Hidden” boxes may never be brought up Module 3

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Components of the Initial CHCT Session

Session 3.2.1: Overview of the CHCT Pre-Test Counseling Protocol • By the end of this session, participants will be able to:

1. Introduce couple to CHCT and obtain concurrence to receive couples services 2. Explore couple’s relationship and reason for seeking CHCT services 3. Discuss couple’s HIV risk concerns together and separately 4. Prepare for testing and discuss possible results Then: HIV Test

– Introduce the couple to CHCT and obtain concurrence to receive couples services – Explore the couple’s relationship and reason for seeking CHCT services – Discuss the couple’s HIV risk concerns – Prepare the couple for testing and discuss possible test results – Choose how to deliver HIV test results and prepare the couple Module 3

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1. Introduce couple to CHCT and obtain concurrence to receive couples services

• Describe the requirements for receiving CHCT services – Refer to slide 3-17

• Obtain concurrence to receive CHCT – Make sure the couple understands and agrees to the requirements – If either partner is uncomfortable with the requirements of the session, find out more about their concerns and try to counsel to bring the couple to agreement – If they cannot agree, discuss individual HIV counseling and testing

– Learn HIV status together – Provide an opportunity for both partners to deal with HIV concerns together – Plan for the future together

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1. Introduce couple to CHCT and obtain concurrence to receive couples services

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2. Explore the couple’s relationship and reason for seeking CHCT services

• Give a session overview so the couple knows what will happen

• Establish the nature and duration of the couple’s relationship

– Review of the couple’s situation – Discussion of risk issues and concerns, both together and separate – Preparing for the HIV test and discussing possible results – Taking the rapid HIV test – Receiving results – Counseling based on results Module 3

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1. Introduce couple to CHCT and obtain concurrence to receive couples services

• Introduce yourself • Describe your role as a counselor • Discuss the benefits of CHCT

Module 3

Module 3

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– Living arrangements, marital status, plans for the future

• Address family planning and childbearing choices – Does the couple have children? Want children? Module 3

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2. Explore the couple’s relationship and reason for seeking CHCT services • Review how the couple decided to seek CHCT services • Assess the couple’s feelings about receiving CHCT

• Discuss possible HIV risks in the abstract – Explain that HIV has affected every community and family; anyone can be infected – If you have had sex with someone whose HIV status you did not know, and did not use a condom, you may have been exposed to HIV – Remind the couple to focus on the present and future and not blame each other for what might have occurred in the past

– Get input from both partner’s – Understand, validate, and normalize the couple’s experience

• Summarize and reflect on the couple’s situation – Show that you understand their circumstances Module 3

3. Discuss couple’s HIV risk issues and concerns

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Module 3

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3. Discuss couple’s HIV risk issues and concerns

3. Discuss couple’s HIV risk issues and concerns

• Address factors of increased risk together

• Address safer sex practices within the couple

– What makes them think they are at risk of HIV? – Do they have any particular concerns about HIV? – Has either had symptoms that make them think they may have HIV? – Listen for possible risk circumstances: • Separation because of travel/work, alcohol or drug use, multiple sexual partners, unprotected sex, men having sex with men, commercial sex workers, occupational exposure Module 3

• Conduct individual risk assessments – Bring out anything the couple members did not reveal previously

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3. Discuss couple’s HIV risk issues and concerns

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When Discussing Couple’s HIV Risk Issues and Concerns • Focus on couple’s present and future

• Bring the couple back together and provide an opportunity to share issues discussed in the individual sessions • Summarize the risk discussion and provide motivation and support

Module 3

– History of condom use – Condom skills – Condom demonstration

– The past cannot be changed; leave it in the past

• Diffuse blame – Discussion of when and by whom a partner became infected is discouraged – In a country where many people are infected with HIV, anyone could be HIV positive

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• Address risk issues each partner is capable of disclosing • Emphasize communication and cooperation 3 • Deal with undisclosedModule issues in the abstract

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4. Prepare for testing and discuss possible test results

4. Prepare for testing and discuss possible test results

• Explain the meaning of positive and negative test results

• Explain that the couple could have the same test results

– HIV positive means the person is infected with HIV – HIV negative means the person is not infected with HIV

– Concordant positive – both are HIV positive – Concordant negative – both are HIV negative

• Explain that the couple could have different test results – When one partner is HIV positive and one is HIV negative, it is known as discordance

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4. Prepare for testing and discuss possible test results

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4. Prepare for testing and discuss possible test results

• Discuss discordance

• Guide the couple through the testing process and describe how the results will be provided

– Explain discordance – Clarify implications – Address any myths and misconceptions – It is extremely important that couples know that discordance is possible

Module 3

Module 3

– Blood test – Results will be ready in approximately [how long] – The couple will have results that are either similar or different – Results will be provided to the couple together – Post-test counseling will be provided based on test results 45

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Delivering HIV Test Results to a Couple

Delivering HIV Test Results to a Couple

• Partners chose to come together to learn their HIV status as a couple • The couple is concordant or discordant • Each partner is individually HIV positive or HIV negative • Counselor should support the couple to address HIV in terms of “we” and “our,” rather than “I,” “his,”or “hers”

• First give a summary of the results – this reinforces that partners are dealing with the results together • If concordant:

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– “Both of you have tested HIV positive” or – “Both of you have tested HIV negative”

• If discordant: – FIRST: “Your test results are different” – THEN: Provide HIV-positive result to infected Module 3 48 partner

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Steps in Proper Condom Use

Steps in Proper Condom Use

• Inspect the condom

• Put on the condom

– Do not use if there are tears or it is past the expiry date

• Open the condom – Lay the condom on the palm of your hand and squeeze the condom in the package to one edge – Tear the condom-free edge of package and take out the condom. Ensure that your nails do not cause a tear in the condom. Module 3

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Steps in Proper Condom Use

Module 3

• Safely dispose of the condom

– Hold on to the condom at the base of the penis and withdraw from the vagina while the penis is still erect/hard

• Remove the condom from the penis – Hold the condom at the base of the penis as well as the tip and slide the condom off the penis, ensuring that the semen collected at the tip does not spill or leak out

– Tie a knot on the condom to prevent the spilling or leaking out of semen – Dispose of the condom in a safe place where it can not be handled by another person – Wash your hands to ensure that there is no potentially infected semen or vaginal secretions on the hands

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Session 3.3.1: CHCT Pre-Test Counseling Session Role Plays

Module 3

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Guidelines for Role Plays

• By the end of this session, participants will be able to: – Conduct an entire CHCT pre-test counseling session

• Counselors: – Use the script to help you through the process – Use the couples-specific skills discussed in the previous module: • • • •

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Steps in Proper Condom Use

• Use the condom • Withdraw the condom after sex

Module 3

– Inspect the condom to determine how it will unroll when placed on the penis – Squeeze the tip of the condom to take out the air – Place the condom on the “glans” (head/tip) of the erect penis – While holding onto the tip, unroll the condom down the shaft of the penis all the way to the base of penis

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Focus on solutions, not problems Ease tension and diffuse blame Focus on the present and future Avoid and deflect questions aimed at identifying the potential source of infection Module 3

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Guidelines for Role Plays

Guidelines for Role Plays

• Couple members:

• Remember, this is a learning process for the counselor. He/she may:

– Read your partner description carefully – Play your part realistically – Agree as a couple to receive couple HIV counseling and testing services – Pay attention to: • • • • •

How it feels to be in a couple receiving CHCT services What questions were helpful or thought-provoking What questions created tension or made you uncomfortable If your issues/concerns as a couple were addressed What skills the counselor used Module 3 55

Guidelines for Role Plays

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Role Play Debrief: Counselors • What skills did you practice to help you effectively conduct the session? • How easy/difficult was it to:

• If your role play finishes before time is called, spend a few moments quietly providing feedback to the counselor: – Tell him or her something you thought he or she did really well – Suggest something you feel he or she should do more of – Provide constructive recommendations Module 3

– Read some from the protocol questions – Look down to make sure he or she is covering each task in each component of the protocol – Need to pause and think about what to ask next, how to respond or what skills to use – Repeat a question because this is new

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– Establish and reinforce alliances with the couple? – Get the couple to agree to the requirements of the CHCT session? – Explore the couple’s life stage and discuss their reasons for coming for CHCT? – Conduct risk assessments both together and separately?

• How did your own personal biases affect the session, if at all? Module 3

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Role Play Debrief: Couples • What skills did your counselor use to conduct the session? • How effective were your counselor’s techniques? • Did you feel that the counselor treated you both equally? Why or why not? • What were the counselors strengths? • In what areas do the counselors need to improve? Module 3

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Module 4 Objectives • By the end of this module, participants will be able to:

Module 4: Couple HIV PostTest Counseling Session

– Provide HIV negative concordant results to couples – Provide HIV positive concordant results to couples – Provide HIV discordant results to couples

Couples HIV Counseling and Testing Training

Module 4

Session 4.1.1: Understanding HIV Negative Concordant Results

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Definition of HIV Negative Concordant Test Results

• By the end of this session, participants will be able to:

• Both couple members are HIV negative • Neither partner is infected with HIV

– Explain the meaning of an HIV negative concordant result – Anticipate typical responses from HIV negative concordant couples – Justify the need for thorough counseling for HIV negative concordant couples

Module 4

3

Module 4

Typical Reactions to HIV Negative Concordant Results • • • • •

Reasons Why Counselors May Spend Little Time Counseling -/- Couples • • • • • • • • • •

Happiness Relief Disbelief Shock Denial

Module 4

4

5

Heavy workload Little time Feel there is little to discuss Take it for granted that they don’t need counseling Do not understand implications of negative results Institutional priority for HIV positives Few job aids/resources for HIV concordant negatives Counselor attitudes Absence of strong emotions from couples Lack of emphasis on HIV concordant negative couples in previous trainings Module 4

6

21

Reasons Why Counselors Should Spend More Time Counseling HIV -ve/-ve Couples

Session 4.1.2: The Protocol for Providing HIV Negative Concordant Results

• • • •

• By the end of this session, participants will be able to:

To prevent HIV infection Couples are still at risk To promote couple communication To prevent ongoing risk and avoid future risk • To enhance mutual sexual faithfulness

Module 4

– Provide HIV negative concordant results – Discuss risk reduction with couples

7

Module 4

Components of Providing HIV Negative Concordant Results

Protocol: Provide HIV Negative Concordant Results • Inform the couple that their test results are available • Provide the couple’s results simply and clearly: Both test results are negative, which indicates that neither partner is infected • Ask if the couple understands their results • Explore the couple’s reaction to their results

• Provide HIV negative concordant results • Discuss risk reduction

Module 4

9

Module 4

Protocol: Provide HIV Negative Concordant Results

10

Couple’s Motivations to Remain HIV Negative

• Discuss with couple their personal reasons for avoiding HIV • Discuss results in the context of any recent risks outside of their relationship (window period)

Module 4

8

11

• • • •

To live a healthier life To prevent MTCT To support the family and children To maintain our status as an uninfected couple • To achieve life goals

Module 4

12

22

How to Counsel on the Window Period

How to Counsel on the Window Period

• Explain that the window period is the time it takes for HIV to show up in the body (usually 2-3 weeks) • Inform couples that there is a very small chance that this test did not detect HIV if you were infected very recently • If you are concerned about a recent exposure to HIV, such as from another partner, you should get another test in about 3 weeks from the time of exposure Module 4

13

Risk Reduction Strategies for HIV Concordant Negative Couples

Module 4

14

• Having more than one regular sexual partner at the same time • Can overlap for months or years • “Away games,” “balanced diet,” “side dish,” “pretesting”, “spare tyre”, “left hand”, “suitcase”, “side mirror”, “extra time”, “panadol”, “take-away” • Result in sexual networks, where many people are connected through their sexual partners • Are a main driver of the HIV epidemic

Mutual sexual faithfulness/partner reduction Condom use Other safer sex practices Medical male circumcision HIV testing for other partners Disclosure of HIV status Open communication Module 4

– You do not want couples to think the test results are inaccurate, and that they are actually HIV positive if in fact they are negative – You do not want to confuse couples

Multiple Concurrent Sexual Partnerships

• Risk reduction – the process of reducing an individual or couple’s chances of becoming infected with HIV • Risk reduction strategies include: – – – – – – –

• Keep discussions regarding the window period brief

15

Module 4

16

The Risk of Multiple Concurrent Sexual Partnerships

Sexual Networks

• People are most likely to infect others in the first 3-4 weeks of infection, when there is high viral load, and when they are unlikely to know they are infected (window period) • Multiple concurrent partners allow rapid dissemination when a new infection is introduced • The combined effects of sexual networks and the spike in viral load means that as soon as one person in a network of concurrent relationships contracts HIV, everyone else is placed at risk • This includes persons who: • Are just starting a sexual relationship • Who are monogamous with a partner who is not Module 4

17

Module 4

18

23

Protocol: Discuss Risk Reduction

Protocol: Discuss Risk Reduction

• Address the risk associated with other partners • Discuss couple’s specific HIV concerns or risks based on pre-test discussion • Emphasize that condoms must always be used if either partner has sex outside the relationship • Explore skills to reduce risk, such as open communication and commitment to protect the relationship from HIV

• Encourage the couple to communicate openly with each other about risk reduction and to stay faithful • Convey confidence in the couple’s ability to complete the plan and to protect each other • Encourage the couple to become ambassadors for couples HIV counseling and testing services • Provide needed referrals for services regarding STIs, family planning, care during pregnancy, or support

Module 4

19

Session 4.1.3: Practicing Delivering HIV Negative Concordant Results • By the end of this session, participants will be able to: – Provide HIV concordant negative results to couples and counsel them appropriately

Module 4

20

Role Play Debrief: Counselors • How did it feel to provide HIV negative concordant results? • How easy/difficult was it to: – Explain the window period? Why? – Develop a risk reduction plan? Why?

21

Role Play Debrief: Couples

Module 4

22

Role Play Debrief: Observers

• How did it feel to work with this counselor? • What skills did your counselor use? • How did it feel to discuss risk reduction and being faithful?

Module 4

Module 4

23

• How closely did the counselors follow the protocol? • What were the counselors biggest challenges in the session? • In what areas do the counselors need more support?

Module 4

24

24

Session 4.2.1: Understanding HIV Positive Concordant Results • By the end of this session, participants will be able to: – Explain the meaning of HIV positive concordant results – Anticipate typical reactions from HIV positive concordant couples

Module 4

26

• By the end of this session, participants will be able to: – – – – –

Provide HIV positive concordant results Discuss coping and mutual support Discuss positive living and HIV care and treatment Discuss risk reduction Discuss children, family planning, and PMTCT options – Discuss disclosure and getting support

27

Components of Providing HIV Positive Concordant Results

Module 4

28

Protocol: Provide HIV concordant positive test results • Inform the couple that their test results are available • Provide test results to the couple in a simply and clearly language: Your test results are both positive. This means that you are both infected with HIV. • Allow the couple time to absorb the meaning of the results • Ask if the couple understand the results • Encourage mutual support and diffuse blame

• Provide concordant positive test results • Discuss coping and mutual support • Discuss positive living and HIV care and treatment • Discuss risk reduction • Discuss children, family planning, and PMTCT options • Discuss disclosure and getting support Module 4

Module 4

Session 4.2.2: The Protocol for Providing HIV Positive Concordant Results

Blame Sadness Anger Fear Shame Denial Disbelief Confusion Desire to divorce/separate Suicidal tendencies Withdrawn attitude Module 4

• Both couple members are HIV positive • Both partners are infected with HIV

25

Typical Reactions to HIV Positive Concordant Results • • • • • • • • • • •

Definition of HIV Positive Concordant Test Results

29

Module 4

30

25

Protocol: Discuss coping and mutual support

Positive Living

• Invite both partners to express their feelings and concerns • Validate and normalize the couple’s feelings and acknowledge the challenges of dealing with a positive result • Ask how the partners can best support each other • Recall the couple’s strengths. Convey optimism that the couple will be able to cope and adjust to living with HIV. • Address the couple’s immediate concerns Module 4

31

Positive Living

• Positive prevention – Negotiation for safer sex, condom use, FP, PMTCT, prevention on alcohol/substance abuse

• Psychosocial support – Counseling, support groups, spiritual well-being, disclosure, stigma reduction 33

Module 4

32

Module 4

34

Protocol: Discuss positive living and HIV care and treatment

ARV Basics • ARVs must be taken for life • ARVs lower the level of virus in the blood if taken (as directed) without missing doses • It is still possible to transmit the virus when on ARVs • Not everyone infected with HIV needs ARVs right away • Another treatment is often given before ARVs are needed. All people living with HIV should take Cotrimoxazole (Septrin) every day. Module 4

Cotrimoxazole (Septrin) prophylaxis CD4 count Proper use of ARVs Prevention and management of OIs TB screening Seeking medical treatment promptly Malaria prevention Prevention of diarrhoea

• Antiretroviral treatments are medications used to treat HIV • “ARV” is the abbreviation commonly used to refer to these drugs • ARVs help infected persons feel better and delay the effects of HIV on their health. ARVs can prolong life. • ARVs do not cure HIV or AIDS

Proper nourishment/nutrition Personal hygiene Light physical exercise Enough rest

Module 4

– – – – – – – –

ARV Basics

• Physical care – – – –

• Taking care of yourself in order to improve the quality of your life and to stay well longer, including: • Medical care

• Discuss positive living • Address the need for preventive health care • Encourage the couple to access appropriate care and treatment services

35

Module 4

36

26

Protocol: Discuss positive living and HIV care and treatment

Protocol: Discuss risk reduction

• Discuss things the couple can do at home to keep healthy: – Safe drinking water to prevent diarrhea – Using bed nets to prevent malaria – The importance of good nutrition

• Discuss the importance of being faithful and not having sex with outside partners • Inform couple of the need to protect partners if they choose to have sex outside their relationship

• Provide needed referrals to the HIV clinic and other services. Identify and problemsolve obstacles. Module 4

37

The Importance of Talking About Outside Partners

• With regard to reproductive health, the objective is to: – Prevent unintended pregnancies – Reduce the risk of HIV transmission to infants born to infected mothers

• The most effective way to prevent HIV transmission to an infant is for the couple not to have additional children and to have protected sex only • In terms of human rights, the couple should be supported to make informed reproductive choices and their choices respected 39

Reproductive Options for HIVInfected Couples

Module 4

40

Factors That May Influence a Couple’s Decision to Have Children • Having children is highly valued by society • Extended family may play an important role in influencing a couple’s decision to have children • Whether or not you already have children, sex of the children • Financial situation • Presence of HIV in the relationship • Competition within polygamous relationships

• Choosing not to have additional children • Preventing unintended pregnancies • Using dual contraception: using condoms and one other method to prevent pregnancy • Accessing PMTCT antenatal services

Module 4

38

Objectives of Counseling on Reproductive Health Issues

• Because discordance is possible, outside partners could be HIV-negative • Outside partners could have STIs that would make the couple sicker • Individuals in a couple are HIV-positive and need to use condoms with outside partners

Module 4

Module 4

41

Module 4

42

27

Protocol: Discuss children, family planning, and PMTCT options

Protocol: Discuss children, family planning, and PMTCT options

• Discuss the issue of HIV testing of children – Because both partners are HIV-positive, there is a possibility that young children may have become HIV infected through their mother – Encourage the couple to bring their children for HIV testing so that, if the children are positive, they can get the care and treatment they need

• Revisit the couple’s intentions concerning having children. Discuss the couple’s reproductive options. Module 4

43

PMTCT Basics

Module 4

44

• PMTCT interventions can greatly reduce this risk

– Pregnancy – Labor and delivery – Breastfeeding

– Giving medication to the mother during pregnancy and labor – Having a safe delivery in a clinic or hospital – Giving medication to the infant immediately after birth – Making appropriate infant feeding decisions with the assistance of a health care provider 45

Module 4

46

Benefits of Disclosure for the HIV Positive Person

Task

• May build a network of social and emotional support, which helps reduce the sense of isolation and anxiety • May enhance opportunities for those with HIV to receive support in obtaining proper medical care and treatment • Helps HIV-infected individuals take medication properly by allowing the individual to:

• In 4 groups, discuss and record on flipchart paper the benefits of disclosure for: – The HIV-infected person – Outside sex partner(s) – The family and community – Children under 18 years

Module 4

– Any HIV positive woman who is pregnant MUST be referred to ANC and PMTCT services

PMTCT Basics

• HIV can be transmitted from mother to child through

Module 4

• Describe PMTCT programs and services and identify where the couple can access services • Address the couple’s questions and concerns regarding PMTCT services • Provide needed referrals

– Take medication openly – Acknowledge HIV status – Receive support during treatment 47

Module 4

48

28

Benefits of Disclosure for Outside Sex Partner(s)

Benefits of Disclosure for Family and Community

• Allows sex partner or partners to know of exposure risk • Allows sex partner or partners to seek testing and to reduce the likelihood of acquiring or transmitting HIV • Enhances the ability of the sex partner or partners to understand and support behavior changes needed to reduce risk Module 4

• Helps infected individuals, couples, and families prepare for the future • It gives an opportunity to address children’s fears and anxieties • It provides a role model to friends, families, and the community • It allows health care providers to take appropriate precautions 49

Module 4

Disclosing to Children

Benefits of Disclosing to Children • Not knowing can be stressful for children – they often know something is wrong even if the parent has not disclose • It is best for children to learn about their parents’ HIV status from the parents themselves • Opens communication between parents and children and allows parents to address children’s fears and misperceptions • Lowers parents’ stress and may reduce depression Module 4

51

• Base the decision to and how to tell a child on: – – – –

Child’s age and maturity Family dynamics Social circumstances Health status of the parent

• Young children should receive simple explanations about what to expect with their parent’s HIV status – Focus on the immediate future and addressing fears and misperceptions

• Older children have a better capacity to cope with their parent’s status and to understand the implications of being HIV-positive Module 4

52

Protocol: Discuss disclosure and getting support

Disclosing to Children • Disclosure may initially cause stress and tension – Children might need time to adjust to and accept their parents’ HIV status

• It can be stressful and burdensome for children when a parent discloses his or her HIV status and then requires them to keep it a secret from others • Consider disclosing to other adults who are close to the children – This can create a support network of adults who can help the children cope with and process their feelings.

• Parents experiencing intense feelings of anger or severe depression may want to wait to disclose until after they have learned to cope with their status Module 4

50

53

• Explain the benefits for the couple to disclose their HIV status to others • Reinforce that the decision to disclose is mutual • Explore the possibility of participating in a support group and additional counseling sessions

Module 4

54

29

Protocol: Discuss disclosure and getting support

Disclosure Basics • Who will you disclose to first?

• Explore the couple’s feelings about sharing their results with a trusted friend, relative, or clergy (optional) • Discuss steps to disclosure (optional) • Answer remaining questions and provide support

– Who is most likely to be supportive and understanding?

• When and where will you tell this person? – Find a private and quiet place and time for the discussion

• How will you tell this person? – Develop a script of what to say – Practice!

Module 4

55

Disclosure Basics

• In plenary, identify the name, location, contact information, and fee for places in the community where counselors can refer couples for the following types of support: – Medical care (ART, TB, STIs, OIs) – ANC/PMTCT – Family Planning – Post-test clubs 57

Session 4.2.3: Practicing Delivering HIV Positive Concordant Results • By the end of this session, participants will be able to: – Provide HIV positive concordant results to couples and counsel them appropriately

Module 4

56

Task

• Request that the conversation be kept confidential • Be clear and specific about what support is needed and what would be helpful • Anticipate both supportive and non-supportive responses, and how you will react to such responses • When deciding which outside sex partners to disclose to, prioritize those who may have been exposed to HIV Module 4

Module 4

59

Module 4

58

Role Play Debrief: Counselors • How did you feel when telling the couple that both of them were infected with HIV? • How easy was it to transition away from addressing the couple’s feelings and emotions toward clinical care, treatment, and preventive services? • How challenging was it to address disclosure and risk reduction issues? Module 4

60

30

Role Play Debrief: Couples

Role Play Debrief: Observers

• How did the counselor’s demeanor affect receiving a positive result? • Did your counselor cover essential information and provide referral to FP and other appropriate programs for a couple in your situation? • Was the discussion of risk transmission to partners outside of the relationship handled diplomatically and in general terms? • Did you leave your session fully understanding the value and importance of accessing appropriate care? Module 4

61

Session 4.3.1: Understanding HIV Discordance • By the end of this session, participants will be able to:

• How closely did the counselor follow the protocol for providing HIV positive concordant results? • What was good about the counselor’s approach? • What are the areas for improvement?

Module 4

62

Definition of HIV Discordance • When one partner in a couple is HIV positive and the other is HIV negative

– Define HIV discordance – Explain the magnitude of HIV discordance – Explain why discordance occurs – Dispel myths about discordance – Explain the key messages about discordance

Module 4

63

Module 4

64

Facts About Discordance

Discordance in Uganda

HIV discordance is common HIV discordance is NOT a sure sign of infidelity NO ONE is immune from HIV infection A couple can remain HIV discordant for a long time HIV is NOT transmitted on every exposure; the chance that HIV is transmitted depends on a number of factors • HIV negative partners in discordant couples are at very high risk of infection • HIV transmission with discordant couples CAN be prevented

• One out of every 20 couples living together in Uganda (5%) are discordant • On average in a year, 10-12% of discordant couples will transmit HIV to the negative partner • Negative partners in discordant couples are the highest known risk group in Uganda today, with a risk ~10 times higher than that of the general population

Module 4

Module 4

• • • • •

65

66

31

• • • • •

Explanation of the Bean Game

How Discordance is Possible

Red beans = healthy blood cells White beans = HIV-infected blood cells Trainer = HIV-positive person Participant = HIV-negative person Beans = Number of sexual rounds with a partner

• It is not every time you have sex with an HIV positive person that you acquire HIV • HIV transmission happens by chance and depends on a number of factors

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67

Factors Affecting HIV Transmission • • • • • • • • •

Presence of STIs Viral load Recent infection with HIV Use of condoms Abstinence Male circumcision Frequency of sexual exposures Injury of genital tract Type of sex (vaginal, anal, oral) Module 4

68

Discordance Analogies • When fetching water, the chance of getting algae in your container depends, for instance, on the amount of algae naturally present in the water, and how many times you scooped. • If a thief was going to break into someone’s house, tightly closed windows and doors, having burglar proofing, and not leaving attractive things in the sitting room would minimize the chances of being robbed.

69

Discordance Analogies

Module 4

70

True or False?

If a person is passing through a dangerous street where thieves are suspected to be, the chances of being robbed may increase if this person is carrying attractive things or if s/he passes the street at night when there are no lights. However, with an ‘askari’ or policeman, s/he may be protected. Module 4

Module 4

71

• If one partner is HIV positive, the other partner automatically is, too. • FALSE. Just because one partner is infected does not necessarily mean the other partner is, too. The only way to find out is through an HIV test.

Module 4

72

32

True or False?

True or False?

• If one partner is HIV negative, the other partner automatically is, too.

• Special blood protects some people from HIV. People with blood group “O” cannot get infected with HIV.

• FALSE. Just because one partner does not have HIV does not necessarily mean the other partner is HIV negative, too. The only way to find out is through an HIV test.

Module 4

73

True or False?

74

• The testing machines are unreliable.

• FALSE. It is possible for one partner to be infected with HIV while the other is not. The window period lasts about 2-3 weeks. Unless the negative partner has been exposed in the last 23 weeks, then the virus will be detected.

75

True or False?

• FALSE. Three different tests are used to ensure results are accurate.

Module 4

76

True or False?

• If you have gentle/lubricated sex, you can’t transmit HIV.

• HIV negative status is a protection from God. • FALSE. The HIV negative partner can become infected at any time if you do not take risk reduction measures.

• FALSE. Gentle/lubricated sex does not protect against HIV.

Module 4

Module 4

True or False?

• The negative partner is really infected, the virus is just hiding or taking long to show up in the blood.

Module 4

• FALSE. No blood group protects against HIV. Everyone is at risk of HIV infection.

77

Module 4

78

33

Common Challenges in Providing Discordant Results

True or False?

• Explaining discordance so that the couple understands their results • Diffusing blame, negative emotions and reactions to different results • Denial of results • Disagreement over risk reduction plan and way forward • Desire for separation • Ensuring continued care and support for the HIV positive person • Mutual coping

• If you have unprotected sex once you might as well continue. • FALSE. HIV is not transmitted on every exposure. It is never too late to take risk reduction measures.

Module 4

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Common Emotional Reactions to Discordant Results • • • • • • •

Module 4

80

Session 4.3.2: Risk Reduction Options Among Discordant Couples

Shock Disbelief Confusion Blame Anger Relief Worry

• By the end of this session, participants will be able to: – Identify motivations for couples to remain discordant – Explain the benefits and limitations of available risk reduction options

Module 4

81

Module 4

Motivations for Not Transmitting HIV to the Negative Partner

Risk Reduction Strategies

• Feeling the responsibility to save the negative partner’s life • Partner availability for care and support • Reduced cost of care • Partner availability for child care

Module 4

82

• • • • •

83

Use condoms every time you have sex Abstain or reduce frequency of sex Diagnose and treat STDs Seek on-going support (Couples club) Consider separation

Module 4

84

34

Session 4.3.3: The Protocol for Providing HIV Discordant Results

Components of Providing HIV Discordant Results

• By the end of this session, participants will be able to: – Explain the meaning and implications of discordant HIV test results to the couple in a factually correct manner – Support a couple to cope with the results and identify sources of support – Support a couple to identify safer goal behaviors and develop a risk reduction plan – Discuss disclosure of HIV status to other sexual partners and significant others – Demonstrate the ability to counsel discordant couples Module 4

• Provide discordant test results • Discuss coping and mutual support • Discuss positive living and HIV care and treatment • Discuss protecting the negative partner from HIV • Discuss PMTCT and family planning options • Discuss disclosure

85

Module 4

Protocol: Provide Discordant Test Results

Protocol: Discuss Coping and Mutual Support • Invite both partners to express their feelings and concerns • Validate and normalize the couple’s feelings and acknowledge the challenges of dealing with different results • Ask the uninfected partner how he or she could best support the infected partner • Recall the couple’s strengths – convey optimism that the couple will be able to cope and adjust to the situation • Address the couple’s immediate concerns

• Notify the couple that their results are ready and they will be receiving them as a couple • State that the couple’s results are not the same • Provide HIV positive test results to the infected partner • Allow the couple to absorb the meaning of this partner’s results • Covey support and empathy • Provide the negative results to the uninfected partner • Assess couple’s understanding of their results • Review explanation of discordance

Module 4

87

Module 4

Protocol: Discuss Positive Living and HIV Care and Treatment •

• • •

88

Protocol: Discuss Positive Living and HIV Care and Treatment

Discuss positive living and the importance of getting care for the HIVinfected partner Discuss positive living Address the need for preventive health care Encourage the infected partner to access appropriate care and treatment services Module 4

86

89

•

Discuss things the couple can do at home to keep healthy: – – –

• •

Safe drinking water to prevent diarrhea Using bed nets to prevent malaria The importance of good nutrition

Encourage the uninfected partner to serve as an advocate for the infected partner Provide needed referrals to the HIV clinic and other services. Identify and problem-solve obstacles. Module 4

90

35

Protocol: Discuss Protecting the Negative Partner from HIV

Protocol: Discuss PMTCT and Family Planning Options

• Address risk reduction within the couple. Explore long-term measures to reduce the risk of HIV transmission to the uninfected partner. • Assess condom-related issues • Address regular HIV testing for HIV-negative partner. • Inform couple that condoms must always be used with outside partners. Address the possibility that any other partners should be tested for HIV. Module 4

91

• Explain the benefits for the couple to disclose their HIV status to others • Reinforce that the decision to disclose is mutual • Explore the possibility of participating in a support group and additional counseling sessions • Explore couple’s feelings about sharing their results with a trusted friend, relative, or clergy (optional) • Discuss steps to disclosure (optional) • Answer remaining questions, provide support and summarize

93

• • • •

Module 4

92

• By the end of this session, participants will be able to: – Provide HIV discordant results to couples and counsel them appropriately

Module 4

94

Role Play Debrief: Couples

Role Play Debrief: Counselors • How did you feel when providing the couple with discordant results? • How easy was it to balance the session between the needs of both the HIV positive and HIV negative partner?

Module 4

•

Revisit the couple’s intentions concerning having children Address the risk to the uninfected partner should the couple decide to have a child Discuss the couple’s reproductive options Describe the country’s PMTCT programs and services and identify where couples can access services Address issue of testing of young children if the woman is HIV-positive Provide needed referrals (family planning, ANC, MCH)

Session 4.3.4: Practicing Delivering HIV Discordant Results

Protocol: Discuss Disclosure

Module 4

•

• How effectively did the counselor address all your concerns? • What did the counselor do well? • In what areas does the counselor need to improve? How?

95

Module 4

96

36

Role Play Debrief: Observers • How closely did the counselor follow the protocol? • What did the counselor do well? • In what areas do the counselors need to improve? How?

Module 4

97

37

Module 5 Objectives • By the end of this module, participants will be able to:

Module 5: Ongoing Support for Couples After HIV Testing

– Identify the challenges HIV positive concordant, HIV negative concordant, and HIV discordant couples face after testing for HIV and receiving the results – Discuss the concept of ongoing support – Identify sources of ongoing support, including their advantages and limitations – Facilitate the establishment and maintenance of posttest couples clubs

Couples HIV Counseling and Testing Training

Module 5

Session 5.1.1: Providing Ongoing Support to Couples After Testing

Task

• By the end of this session, participants will be able to:

• In 3 groups, identify the challenges these types of couples face as they strive to prevent and/or live with HIV in their relationship after they find out their HIV statuses

– Name the major challenges faced by HIV positive concordant, HIV negative concordant, and HIV discordant couples after they have received their results – Explain the concept of ongoing support for couples – Identify sources of ongoing support for couples, as well as their advantages and limitations – Discuss key issues involved in the formation and maintenance of post-test couples clubs Module 5

– HIV positive concordant – HIV negative concordant – HIV discordant 3

Module 5

Key Challenges for HIV Negative Concordant Couples

Key Challenges for Concordant Positive Couples

• Adhering to a risk reduction plan • Remaining faithful; the risk of HIV entering the relationship as a result of unprotected sex with outside partners • Understanding the window period • Repeat testing

• Blaming of partners • Need to deal with rallying psychological and financial resources to obtain care and support for both of them • Concerns about ability to care for their children should they both fall ill • Planning for the future may seem particularly daunting

Module 5

2

5

Module 5

4

6

38

Key Challenges for Concordant Positive Couples

Key Challenges for Discordant Couples

• Extended family may need to be involved earlier for providing care, support, and planning for the future • Reproductive choices will be influenced by the fact that both are HIV positive • High chances of MTCT • Condom use for prevention of reinfection, STI prevention in established relationships • Preventing infection to outside partners • Couple may experience a profound sense of loss Module 5

• Difficulty believing that HIV discordance is possible • Attention is focused on providing support to the HIV-infected partner • One partner may feel responsible for bringing HIV into the relationship • There is more possibility of blame – issue of other partners may be raised • There may be concerns about abandonment, especially if the woman is infected 7

Module 5

Key Challenges for Discordant Couples

Task

• If the breadwinner is infected, there may be concerns about his/her ability to continue to provide for the family • Need to protect the uninfected partner from becoming infected with HIV, especially if the man is infected • Condom use within an established relationship • Increased possibility the couple will decide to separate • HIV-infected partner may have greater disclosure concerns Module 5

• Write clearly on a card what you understand by the term “ongoing support”

9

Module 5

10

Task

Ongoing Support

• In groups, record on flipchart paper the type of support, and benefits and limitations of seeking support for this source for the following sources of support:

• Continuous support provided to couples after testing in order to help them cope with challenges often faced • Ongoing support focuses mainly on:

– – – – –

– Psychosocial support – Medical support – Reproductive health support

Module 5

8

11

Health facilities Friends and family Post-test couples clubs Religious institutions NGOs/CBOs/AIDS Support Organizations

Module 5

12

39

Sources of Support for Couples in the Community Place for Support

Type of Support

Benefits

Questions to Consider When Forming a Post-Test Club for Couples

Limitations

Health facilities

Medical, psychosocial

Improved care, prevention of OIs

Accessibility, cost, quality of services

Family and friends

Psychosocial, physical

Constant source of support, reduced stigma

Lack of information, requires disclosure, involuntary disclosure

Couples’ clubs

Psychosocial, experience sharing

Coping mechanisms, sense of belonging

Few in existence, requires public disclosure, time constraints

Religious institutions

Spiritual, Psychosocial

Coping mechanisms, sense of belonging, hope

Lack of information, stigma, involuntary disclosure, belief in miraculous healing

NGOs, CBOs, ASOs

Material, Medical, Psychosocial

Improved medical care and treatment, information

Unstable, inadequate services, may have limited forms of support

Module 5

13

• What is the provider’s agenda in forming the club? • What are the benefits and limitations of forming a posttest club for all couples, versus post-test clubs for HIV positive concordant, HIV negative concordant, and HIV discordant couples separately? • What resources does the formation of the club require? • Do the couples appreciate the need for the club? • How do couples expect to benefit from the club? • How might couples lose by being part of the club? • How often will the club meet? • Where and when will they meet? • What will they do when they gather? Module 5

14

Sample Activities for Post-Test Couples Clubs • • • • • • • • • •

Couple meetings Expert panels Plenary discussions Testimonies On-going counseling Role models Video shows Income generating activities Exchange visits Provision of IEC materials Module 5

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Practicum • Counselors will put their skills into practice by counseling real couples in an actual counseling and testing setting • Each counselor should lead one full couples HCT session • Each session will be supervised using the observation checklists • Counselor’s will need to seek a couple’s consent before conducting a sit-in session • Assure clients that both persons are trained counselors

Practicum Guidelines Couples HIV Counseling and Testing Training

Practicum Guidelines

Practicum

Practicum Debrief

• Supervisors will not interrupt sessions unless invited by the participant or couple, or if wrong/harmful information is conveyed • Supervisors will provide feedback to the counselor immediately after the session ends • We will also debrief in plenary Practicum Guidelines

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• What went well? • What were your biggest challenges? • How did you handle those challenges?

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Practicum Guidelines

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