HIV Counseling: Its Nature and Purpose
NATIONAL JOURNAL OF HOMOEOPATHY 2001 Sep / Oct VOL III NO 5.
Compiled by:
Dr(Mrs) Rajni. K. Gwalani
Dr Carol Dsouza

In counselling, two people, not related to each other, meet to resolve a crisis, solve a problem, or make decisions involving highly personal and intimate matters. Promoting the well-being and problem solving skills requires continuous gradation between detachment and closeness, within which the counsellor must find the correct balance; of the client. HIV /AIDS counseling has two general objectives: (I) To provide psychological support to those already affected; and (2) to prevent HIV infection by changing lifestyles and life style behaviour.

The Counseling process can:

1. Ensure passing on of correct information
2. Provide support at times of crisis
3. Encourage change when change is needed for the prevention or control of infection.
4. Help clients focus and identify for themselves their immediate and long term needs.
5. Propose realistic action suitably adapted to the different clients and circumstances.
6. Assist clients to accept and act on information on health and well-being; and
7. Help clients to be well-informed and appreciate the technical, social, ethical and legal implication of HIV testing.
8. Give psychological support.

1. Persons and their families, already identified as having AIDS or infected with HIV
2. Those being tested for HIV (pre and post-testing)
3. Those seeking help because of past or current risk behaviour and planning their future.
4. Those not seeking help but who practice high risk behaviour.
5. People with AIDS or other disease related to their HIV infection
6. People experiencing difficulties with employment, housing, finances, family, etc as a result of HIV infection.
7. People considering being tested for HIV.
8. People who have been tested for HIV (whether or not they are infected)
9. The family and friends of people who are infected with HIV
10. People worried that they might have become infected with HIV
11. Health workers and other professionals who come into regular contact with people infected with HIV
12. People who choose not to be tested despite past or present risk behaviour.
13. People who are unaware of the risks of HIV infection involved in specific behaviours they have, or are, engaged in.

In summary, counseling people about HIV infection is important because:

1. Infection with HIV is lifelong
2. A diagnosis of HIV infection can create enormous psychological pressures and anxieties that can delay constructive change or worsen illness, especially as the HIV epidemic has given rise to fear, misunderstanding and discrimination,
3. Behavioural change can prevent a person acquiring HIV infection or transmitting it to others.

Psychological Support
People diagnosed as having HIV infection and HIV-related illness, including AIDS, and those close to them are confronted by a host of problems that call for emotional and /or practical support. Anxiety about having spread infection, physical isolation, hospitalization, discrimination within the community or family, loss of housing, intermission of education, financial problems, the physical effects of illness, disease progression, loss of relationships, bereavement, anger, loneliness and depression are all concerns that may have to be managed.

It is important to remember that counseling incorporates a process of empowerment for the person with HIV. Counselling should help those affected by HIV to live fully and productively by enabling them to resume (or assume) authority over their own lives and decision-making.

Prevention
There are five main steps in situations where prevention of HIV infection is the primary goals of the counseling interaction. These are:

1. Determine whether the behaviour of an individual or group of individuals involves a high risk of HIV infections.
2. Working with the people concerned so that they understand and acknowledge the risks associated with their behaviour.
3. Defining with them how their life, attitudes, values and self images is linked to their behaviour.
4. Helping individuals to define their potential for awaited shifts, behaviour modification and change; and
5. Working with individuals to introduce and sustain the modified behaviour.

Secondary Prevention: For persons known or considered likely to be HIV- infected, counseling should emphasize implications of HIV infection and ways to avoid transmission.

Emphasize the importance of adopting practices that eliminate or minimize the possibility of infecting sex partners. Condom use, low risk sexual practices, alternative ways of seeking gratification and celibacy.

Prevention of transmission through blood or blood products, counseling needs to stress the importance of not donating blood and not sharing syringes, needles or other skin piercing equipment.

Perinatal transmission is also an important concern. In the case of women who are already pregnant, the possibility of interrupting the pregnancy or the desire to do so, will have to be dealt with, taking into account many cultural, familial, emotional and medical factors that can influence such a decision. Prevention of future pregnancies should be discussed.

Content of Counseling
HIV / AIDS counseling should therefore include discussion of the following:

1. the primary need to prevent infection and re-infection;
2. basic information about HIV infection and associated diseases and means of transmission
3. assessment of the level of risk of HIV infection
4. review of possible sources of a client's infection
5. specific information on risk reduction by changing risk behaviour, eg through protected or safer sex
6. exploration of cultural and value obstacles to changing behaviour or adopting safer sexual practices
7. information about what testing can and cannot do, assessment of the
consequences of having the HIV - antibody test
8. follow - up guidance after testing has been done
9. how to tell others that one is HIV - infected and
10. handling hostility, fear and feelings about having HIV infection or being diagnosed as having AIDS

1. supporting the process of anticipatory grief
2. planning for continued involvement of the client in self - care
3. establishing or re-establishing a support network to provide physical and emotional care, during the course of the disease
4. exploring ways of taking care of survivors and
5. accepting fear of death and continuing to provide emotional support

To promote and sustain the behavioural changes needed to prevent HIV transmission. The counsellor needs to work intensively not only with infected or sick persons but also with their families and other people who matter to them. Moreover, the counsellor will have to be sensitive to other people and to attitudes in the social environment, which may inhibit behavioural change or actively promote and support risk behaviour. The people who should be included in the counsellling process will vary in each individual situation and will depend to a certain extent on who the HIV-infected person chooses to be included. Family members, loved ones, friends and colleagues in the workplace all may be involved in the counseling process.

After learning that they are HIV-positive, people may have strong feelings. Most will be shocked. Some people may enter a stage of denial. Many, especially if they feel well, will refuse to accept that they have the disease or that they could harm themselves or other people. HIV infected persons may feel angry and blame themselves or others; some may even want to take revenge by infecting others. Some may enter into a bargain, thinking that they will be cured if they performed a good act. Most will feel lonely and will be afraid of losing their jobs, people rejecting their friendship, their families deserting them, pain, death, etc. Each of the situations mentioned above need counseling. What is likely to move people is concern for spouses or partners and for the children’s well-being. Fear alone may not be a sufficient motivation but counsellor must consistently and patiently keep them well aware of the risks and support their efforts to change their behaviours.

Counseling and Health Education
Psychosocial counseling in relation to HIV infection and health education of the public are the primary ways of:

1. Reducing resistance to behavioural change
2. Helping people adjust to the need to change behaviour
3. Assisting individuals, families and communities to use social, medical, spiritual and economic support systems; and
4. Reinforcing healthy behaviour which may already exist

Effective Counseling Techniques
Qualities of a Good Counsellor

1. Positive regard or respect for people.
2. Open, non-judgmental and help level of acceptance.
3. Caring and empathetic
4. Self awareness and self disciplined
5. Knowledgeable / informed about subject and awareness of resources available within the community
6. Culturally sensitive
7. Patient and a good listener
8. Ability to maintain confidentiality
9. Objective and having clarity.

1. Active attending or listening.
2. Reflection of feeling³. Questioning
3. Paraphrasing
4. Interpretation
5. Repeating
6. Summarizing
7. Confrontation
8. Respecting
9. Structuring or prioritization

Stage Two - Definition and understanding of Roles, Boundaries and Needs: Explaining and making clear to the client the roles and boundaries of the counseling relationship is an essential part of counseling. Establishing and clarifying the client's needs and goals. With most urgent and important ones to be addressed first, followed by more general, long term issues also need to be done before ongoing counseling sessions can begin.

Stage Three - Process of Ongoing, Supportive Counseling:
Encouraging the client to begin a consideration of possible options and assessing possible solutions/ decisions and their implication. Ongoing counsellling focuses on enabling the client to take charge and move towards change. This stage also involves supporting and encouraging the expression of intense emotions like fear and anger by the client. Discussion of the client's plans for informing and involving the family and other close associates in cases of HIV infection and AIDS also occupies a lot of time and attention. Basically, counseling consists of supporting and sustaining work on the selected problems and monitoring of the progress towards the mutually decided goals.

Stage Four - Closure or Ending the Counseling Relationship
After the client has shown willingness to formulate plans and has carried some of them through with a certain degree of success, counseling enters the end stage. The counsellor ends the relationship only when it is certain that the client: (1) is maintaining the necessary changes in behavior; (2) can cope and adequately plan for day-to-day functioning; and (3) has a support system (family, friends, support groups etc.). Also, the client should be assured of being able to return to counseling whenever this is necessary.

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