Session 4:

Counselling Skills in Providing Health

Care Services to HIV Clients

Facilitator Beatrice Mahay

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 4.1 Learning tasks
At the end of this session, students are expected
to be able to:
• Demonstrate effective communication.
• Establish rapport or relationship of trust
• Assess client’s knowledge about HIV, STI, TB
and ARVs
• Identify risk factors and risk behaviors
• Discuss with client/patient about risk
reduction plan
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 4.1 Learning tasks….
• Perform HIV test
• Conduct post-test counselling
• Link HIV infected care for continuum of care

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 Activity : Brainstorming

• What are types of communication?

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 4.2 Types of communication
There are two types of communication:
• Verbal: through spoken words 7-11%
• Non-verbal (89-93%):which includes
o Gestures (smiling, leaning forward, nodding)
o The way we stand
o The way we sit
o Facial expressions
o Silence
o Eye contact
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 4.3 Recognize and interpret non-
verbal communication
Examples of Non-Verbal Gestures:
• Body position- Tense, relaxed, leaning
toward or away from
• Eyes- Teary, open, closed, excessive
blinking, twitching
• Eye contact -Steady, avoiding, shifty
• Body posture- Stooped shoulders,
drooping body, legs crossed, rigid, relaxed
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 4.4 Recognize and interpret non-
verbal communication …
• Body posture- Stooped shoulders,
slouching, legs crossed, rigid, relaxed
• Mouth -Smiling, lip biting, licking lips, tight
lips, loose lips, shaking lips,grinding jaws
• Body movement- Knee jerks, taps, hand
and leg gestures, fidgeting, head nodding
pointing fingers, dependence on arms and
hands for expressing message, touching

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 4.5 Recognize and interpret non-
verbal communication …
• Facial expression- Animated, bland,
distracting, frowning, puckers, grimaces
• Skin -Goose flesh, perspiration, paleness
and colour change
• General appearance- Clean, neat, sloppy,
well groomed.
• Voice -Fast, slow, jerky, high pitched,
whispers
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 4.2 Prepare Environment for Counseling

Activity: Brainstorming

• What is environment in counselling?

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4.2 Prepare Environment for Counseling

• The counselling environment is made up of

three components: Physical preparation,
Social and Psychological /emotional
• The counsellor should ensure privacy when
providing HIV test results
• Test results should be provided in a private
area or room.

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4.2 Prepare Environment for Counseling….

• The counsellor should reassure the client that

the pre-test conversation and the test results
will be kept confidential.
• During the post-test counselling session, The
counsellor should inform the client that
follow-up treatment, care, and support are
available, including support for disclosure
when needed.

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 4.3 Establish rapport for counseling or
Relationship Building

The first step in counselling is for the counsellor

to establish a relationship with a client. This
trusting relationship is an important
prerequisite to effective counselling.
 4.3 Establish rapport for counseling or
Relationship Building
Important issues to be covered in this stage
include:
• A warm genuine welcome(i.e. self
introduction and clarification of her/his role)
• Ensure that client is comfortable
• Ice-breaking (start with non-threatening
issues/comments)
• Discuss confidentiality
 4.3 Establish rapport for counseling or
Relationship Building ….
• Find out why client has sought help
• Give information on the duration of the
sessions
• If client talks about requiring HIV test, find
out:
o Why the client wants to test for HIV
o For how long he/she thought about it
 4.3 Establish rapport for counseling or
Relationship Building ...

• Another component of establishing rapport is

explaining to clients that they might be
working with a different counsellor at the next
appointment - so they need to be aware of
that from the beginning.
 4.3 Establish rapport for counseling or
Relationship Building ...

• Get to know your clients better. In order to be

in a helping position, first the counsellor gets
consent from the client to know her/him
better, and gently gather demographic
information from your client. What kind of
information would you collect from your client
in the first meeting?
 4.4 Assess Client’s Knowledge On HIV, STI AND TB

• Find out what the client knows about HIV and

AIDS, TB, STI (Syphilis), and ARVs interms of:
o Routes of transmission
o What it means being HIV-negative, HIV-
positive or suffering from AIDS
o Family Planning
o TB and its relationship with HIV
4.4 Assess Client’s Knowledge On HIV, STI
AND TB ...
o Methods of prevention
o General outcome of infections/medication
o Any misconceptions

2.Clarify any questions the client may have

3. Dispel any myths and misconceptions that
might come up
 4.5 Identify Risk Behaviours
When identifying the risk behaviours
 Take sexual history to ascertain risk for
HIV/Syphilis.
 Gather history of blood transfusion and
exposure to non sterile invasive procedures
like injections, scarification, tattooing, and non
medical circumcision.
 4.5 Identify Risk Behaviours
 Ask if client has had contact with a TB patient,
taken non-boiled milk, or had prolonged
exposures in overcrowded environments.
 History of taking alcohol or drugs can affect
safe sex practice.
4.5.1 Risky Behaviours (Factors) that Facilitate HIV Transmission

• Unprotected sexual behaviour, particularly

among mobile population with multiple sexual
partners
• Use of alcohol and/or drugs that impair
decision making and negotiation skills
 This leads to taking greater risks.
 Impaired judgement can lead to causal sexual
contact.
 4.5.1 Risky Behaviours (Factors) that
Facilitate HIV Transmission…
Sharing of needles and equipment
• Lack of awareness of one’s own sero-status
 A person might not take steps to prevent
transmitting HIV if he/she does not know
his/her sero-status
 4.5.1 Risky Behaviours (Factors) that
Facilitate HIV Transmission ...
 When taking a sexual history counsellors
would ask clients about the current and past
sexual history to ascertain risk of HIV and
Syphilis, including:
• First sexual contact
• Number of sexual partners in the last 3
months and 12 months
• History of STI infection
 4.5.1 Risky Behaviours (Factors) that
Facilitate HIV Transmission ...
• Having had an ulcer which later disappeared
without treatment
• Generalized body rashes
• Use of condoms
• History of getting sex for favours or rewards
Note: While taking a sexual history, it is important
to highlight the relationship between HIV and
STIs, as well as to discuss risk factors for HIV,
STIs, and TB.
 4.6 Risk Reduction Plan

Individualized Risk Assessment

• Help the client identify and recognize the
connection between the modes of
transmission and his/her own particular
behaviours that may put him/her at risk of
acquiring or transmitting HIV.
• This will facilitate client to think to what extent
they are at risk of being infected and therefore
the necessity of the test.
 4.6.1 Facilitate Risk Reduction Plan

Explore ways of sexual living after results:

• Ask the client to propose the method that
he/she will use to reduce his/ her risk of HIV
exposure
• Discuss chosen plan by client to minimize risk:
• Lead a discussion concerning the chosen
method- How realistic is it; and how doable
For each risk-reduction behavior.
 4.6.1 Facilitate Risk Reduction Plan…

The counsellor assesses internal and external

obstacles to change, perceived efficacy in
enacting the new behaviour, readiness to
change and availability of resources to support
the change.
 4.6.2 Steps in Risk Reduction Plan

• Get commitment from client (By referring to

previous ways of coping)
• Inform that you will demonstrate correct use of
condom (if chosen as a method of prevention
by client).
• Ask the client to explain what he or she knows
about condoms and practice putting a condom
on a penis/vagina model before the counsellor
conducts the condom demonstration.
 4.6.2 Steps in Risk Reduction Plan…
• If the client does not mention condom as one
of his/her means of risk reduction plan, the
counsellor may introduce the subject whether
or not the client is planning to use them. Then
the client’s response will be taken care of
during the discussion.

• Clarify any pending questions/misconceptions

on use of condom.
 4.6.2 Steps in Risk Reduction Plan…
• If the client shows signs and symptoms of syphilis
and TB infection -Facilitate him/her to plan for
behaviour change as well.
• In supporting the client to enact his or her
personalized risk-reduction plan, the counsellor
acknowledges and supports the client’s strengths
(e.g., social support, self-efficacy,previous success
in changing behaviour) and assists in problem
solving in areas of concern or expected difficulty.
 4.6.3 Correct Use of a Condom

Handout 4.1 How to Use a Male Condom

Handout 4. 2 Correct use of a female condom

 4.7 Assess Knowledge Of Clients On HIV testing process

• Find out what the client knows about the test

• Explain procedure behind HIV test and the
meaning of the test results
• Discuss benefits of testing with the client
 4.8 HIV Testing Process, Possible Results
And Possible Interventions
Explain step by step how test will be conducted
and time frame involved as well as:
 Negative test result: need to remain negative
and adopt precautionary behaviors.
Window period: need for re-testing in 3
months if client has had recent exposure to
HIV within past 6 weeks.
 4.8 HIV Testing Process, Possible Results
And Possible Interventions …
• Positive test result: being infected (can
transmit the virus, will need medical care, and
could still live for many more years depending
on the progress of the infection).

• Handout 4.3 Counselling and Testing

Algorithm Recommended for HIV Testing and
Counselling Services in Tanzania
 4.9 Testing Process

If patient agrees to testing, then:

• Draw blood
• Perform test according to national algorithm
• Interpret results
 4.10 Reporting HIV Testing and Counselling (HTC) Data

All data are collected and compiled at a site

level in the site monthly summary form.
• HTC data for the health facility are then
reported to the district level.
• The district compiles all site reports, and then
sends the report to the regional level.
• The district HTC data are finally compiled at
the regional level and report is sent to NACP.
 4.10 Reporting HIV Testing and Counselling (HTC) Data

Note: Usually the counsellor performs the test

themselves. In some clinics however, the
blood is collected and specimen is labelled
with a code number and sent to the
laboratory.
 4.11 General Counselling Skills and
Techniques
Establish a relationship of trust:
• Greet the client warmly.
• Start with non-threatening issues.
• Discuss confidentiality
• Find out why the client has come for testing.
• Explain what will be covered in the pre test
session and confirm that client is ready to
proceed with the session.
 4.11 General Counselling Skills and
Techniques…
Get to know the client better in terms of : Age,
Education status, Marital status, Pregnancy,
Number of children, Children under 18 years
old, Any children still breastfeeding,
Employment status, Religion, Tribe, How did
the client know about this service, If they have
been tested for HIV, TB, syphilis before – if so
where and what were the results, Client’s
knowledge about partner’s status.
 4.11 General Counselling Skills and
Techniques…
Find out what the client knows about HIV and AIDS
, TB, syphilis, ARVs in terms of:
• routes of transmission
• methods of prevention
• general outcome of infections/medication
• any misconceptions
• Clarify any questions the client may have.
• Dispel any myths and misconceptions that might
come up.
 4.11 General Counselling Skills and
Techniques…
Identify risk behaviours:
• Sexual history
• H/o blood transfusions etc
• Contact with TB
• Help client identify and recognize the
connection between the modes of transmission
and his/her own particular behaviours that may
put him/her at risk of acquiring or transmitting
HIV.
 4.11 General Counselling Skills and
Techniques…
Facilitate risk reduction plan:
• Explore ways of sexual living after results.
• Discuss chosen plan by client to minimize risk.
• Get commitment from client (refer to previous
ways of coping).
• Demonstrate use of condoms if necessary.
 4.11 General Counselling Skills and
Techniques…
Assess knowledge of HIV test:
• Procedure
• Possible test results
• Understanding of what the different test
results mean – negative, indeterminate,
positive
• Discuss benefits of testing
 4.11 General Counselling Skills and
Techniques…
Discuss HIV Test and Possible Interventions:
• Negative test result
• Window period
• Positive test result
• Indeterminate result
 4.11 General Counselling Skills and
Techniques…
Discuss likely reactions to test results:
• Emotional state
• Coping
• Disclosure
 4.11 General Counselling Skills and
Techniques…
Prepare client for HIV testing:
• Ask client if he or she has any questions – and
provide any clarifications.
• Allow time for client to think through what has
been discussed.
• Check if ready to proceed with the test
• Take informed consent
• Schedule a visit for post test counselling
 Key points
• Pre test counselling is provided before the HIV
test and consists of many steps such as:
o Relationship building
o Assessing HIV knowledge
o Risk and risk reduction plan
• The process of the testing, possible outcomes
and interventions are discussed before drawing
blood and getting informed consent from the
client.
 Key points
• Personalized risk reduction plan chosen by the
client is a key element of behaviour change.
• The counsellor assists the client in developing
a specific personalized risk reduction plan.
 Review Questions
1. What are the benefits of HIV testing?
2. What are the factors that are likely to affect
client’s emotional state during provision of
test results?
3. How would you lead a client to form a doable
personalized risk reduction plan?
 References
• MOHSW (2005). National Guidelines for
Voluntary Counselling and Testing. Dar es
Salaam, Tanzania: Ministry of Health and
Social Welfare, National AIDS Control
Programme.
• MOHSW (2007). IMAI: Chronic HIV and TB
Basic Care with ARV Therapy. Dar es Salaam,
Tanzania: Ministry of Health and Social
Welfare