1.pdf 11/6/09 10:26:08 P ounselling and Testing for HIV in the Pacific HIV PRE-TEST OUNSELING SESSION FLIPHART Protect ourself, our Baby and our Family from HIV/AIDS
2.pdf 11/6/09 10:26:56 P Acknowledgements Developed in 2008 by Alistair acdonald on behalf of the Secretariat of the Pacific ommunity (SP) and the Oceania Society for HIV and Sexual Health edicine (OSSHH), this flipchart was adapted from Antenatal pre-test session flipchart, published by the enters for Disease ontrol and Prevention in conjunction with the World Health Organisation (accessed from www.womenchildrenhiv.org/pdf/p05-vc/vc-10-00/pretest11x13-l.pdf on the 29 July 2008). For this publication, the following OSSHH members have reviewed the flipchart: Arvin haudhary, Griffith Harrison, Jason itchell, Sereima Vatuvatu and Zachaias Zacharaias. The members of the Pilot Test Group were the following: Alan Garvez, Alita Waqabaca (Pacific ounselling and Social Services), Sereima Vatuvatu, Pablo Romakin, Sophaganine Ty-Ali, Tenneth Dalipanda, Toakase Ratu and Robyn Drysdale (SP). For further information, contact: STI and HIV Section Public Health Division Secretariat of the Pacific ommunity Private ail Bag Nabua, Suva Fiji Islands The Executive Officer c/o Secretariat of the Pacific ommunity Private ail Bag Suva, Fiji Islands E-mail: jasonm@spc.int Website: http://www.spc.int/hiv/osshhm All reasonable precautions have been taken by OSSHH to verify the information contained in this flipchart. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies in the reader. In no event shall OSSHH be liable for damages arising from its use.
3.pdf 11/6/09 10:19:53 P Table of ontents ii Introduction Purpose of the Flipchart How to Use the Flipchart v v vi Pre-Test Session Help the client understand HIV & AIDS, the importance of HIV testing, and how testing is relevant to her/his situation. harts 1 3 > HIV can affect anyone. > How can I get or pass on HIV? > If I have HIV, can I pass it to my baby? (ante or prenatal setting) Explain the benefits of HIV testing. hart 4 > Why should I test for HIV? Explain HIV testing procedures. hart 5 > How will the HIV test be done? Explain importance of sexual partner testing. harts 6 7 > y partner s test result could be different from mine. > Why should my partner test for HIV? Explain risk reduction and available services. harts 8 10 > How can I protect myself from HIV? > If I have HIV, how do I protect my baby? (ante or prenatal setting) > If I have HIV, what help can I get? Explain the importance of returning for results and follow-up. harts 11 12 > Why is it important to return for my results or continue with my healthcare visits? > Testing for HIV - a positive choice. HIV Test Declined Address barriers to testing. hart 13 Review risk reduction. hart 14 Explain exclusive breastfeeding, review antenatal care and encourage testing. (ante or prenatal setting) hart 15
4.pdf 11/6/09 10:21:35 P Introduction iii The HIV Pre test ounselling Session Flipchart contains illustrated steps for HIV and STI testing and counselling. The flipchart is designed to support quality counselling and testing messages for clients accessing an HIV and/or STI test by providing scripted guidance and illustrations. It may be used by: > Health are Workers who have been trained in HIV/STI counselling and testing. > Health are Workers who have had minimal or no specific training in HIV/STI counselling and testing, including medical doctors, nurses, mid-wives and other HWs. > lients who present for HIV/STI counselling and testing. The Flip chart is designed to be used in all health and social service setting including > Antenatal or prenatal clinics > HUB centres > Blood banks > On wards > In emergency rooms, and > TB clinics > Other dedicated STI or HIV testing and counselling centres This Flipchart was designed to compliment as much as it is possible the varied information brochures available in the Pacific region. Purpose of the Flipchart For Health are Workers, the flipchart: > Is a reference on essential topics to cover for the pre-test sessions > Outlines the counselling objectives > ontains scripted messages and open-ended questions to facilitate the sessions The flipchart also helps clients understand: > The importance and benefits of HIV and STI testing > The benefits of partner testing > The services available for those who test positive or negative The picture and caption on the front of each card help clients understand the key points, reinforce messages and serve as a visual focus.
5.pdf 11/6/09 10:23:04 P How to Use the Flipchart v ou can use this flipchart for pre-test sessions with an individual or a couple. The illustrated charts should be used as a step-by-step guide. Be sure to tailor all messages to your clients circumstances and level of understanding, using words they understand. Respond to a client or couples concerns and questions as they arise. > To become familiar with the content, read through and study all the illustrated charts and scripts before using them. Review the Probing Questions matched to the illustrated charts: know which questions are appropriate for individuals or couples. > When using the flipchart, try to place the entire binder on a flat surface such as a desk or table. If you don t have a table or desk, hold it on your lap. Ensure that the client(s) can see each illustration and that the Health are Worker can read the matching step-by-step objectives and script. > The Steps: Use illustrations 1 12 and their matched scripts to guide the pre-test information session. Use illustrations 13 15 and their matched scripts to guide the HIV test declined scenario. Position the illustration side of the Flipchart to face the client(s). Show one illustration at a time, giving clients a few moments to look at each picture. Position the back of the illustration (the side with the objectives and script), so that it faces the Health are Worker. Use the script to guide your explanation of each illustration and topic. Use the Probing Questions near the bottom of each card to facilitate discussion. Allow time for client(s) to answer and ask questions, and provide further information and/or support when necessary. > When you have finished presenting an illustrated chart topic, ask if the clients have any more questions on this particular stage, and if the answer is no then go on to the next illustrated chart. PLEASE NOTE: Prior to using this flipchart, add country or clinic-specific information as indicated on some pages. Specific scripted messages are provided to assist those working in ante/prenatal or prevention of mother to child transmission settings. For further assistance in adapting the Flipchart to a specific setting please contact details are provided on page ii.
6.pdf 11/6/09 10:04:23 P HIV can affect anyone.
7.pdf 11/6/09 10:09:14 P hart 01 HIV can affect anyone. Objectives Introduce yourself to client(s). Script Welcome, my name is. I am a ( title ) here at the clinic. Explain purpose of the discussion. Address HIV/AIDS as a community issue. Address general benefits of knowing HIV status. Today, we will be discussing HIV and HIV testing, and ways you can protect your health, and the health of your family. (If in an antenatal setting add: Ways you can protect your health, and the health of your baby and your family). HIV affects individuals, couples, families and our community. HIV is an infection that can lead to a range of serious illnesses which are often collectively called AIDS. As you can see in this picture, you cannot tell who has HIV. ost people who have HIV do not feel or look sick. Everyone should know if he/she has HIV. (If in an ante or prenatal setting add: It s important for a pregnant women to know if she has HIV as she can pass it to her baby). The only way to know if you have HIV is to be tested. If you are tested and do not have HIV, you can learn how to protect yourself from getting HIV. If you are tested and have HIV, you can learn how to reduce the risk of infecting a sexual partner with HIV and how to get care and treatment for yourself and your family so you can live healthy lives. (If in an ante or prenatal setting add: How to reduce the chance of passing HIV to your baby).
8.pdf 11/6/09 10:01:55 P How can I get or pass HIV?
9.pdf 11/6/09 9:57:36 P hart 02 How can I get or pass HIV? Objectives Explain the main ways that HIV is transmitted in the Pacific. Explain that HIV can also be transmitted through blood transfusions. Explain that HIV can be transmitted through blood-to-blood contact. Dispel myths about HIV transmission. Script The main way most people in the Pacific get HIV is by having unprotected vaginal or anal sex (sex without a condom) with someone who has HIV. (Ante or prenatal setting: All pregnant women have had unprotected sex and are therefore at potential risk of HIV infection.) A person can also get HIV when receiving a blood transfusion, if the blood has not been tested for HIV. A person can also get or pass on HIV by sharing sharp objects such tattoo equipment, razor blades or piercing equipment that puncture or cut the skin. It can also be transmitted by sharing needles and syringes, to inject drugs or any other substance. If a person has been infected with HIV, their body develops a special response to the HIV and it can take up to 3 months for the response, called antibodies to show up in their blood. The 3 months is called the window period. This means that when a test is done in this period, an infected person can test negative even if they actually have the virus and can pass it on to other people. So, if a person has unsafe sex (sex without using a condom) in the 3 months before having a test and the test result is negative, they should have another test 3 months later, and not have unsafe sex in the meantime, to be sure. HIV cannot be passed on in the following ways: 1. osquito bites 2. Sharing food, cups, plates, spoons and forks 3. Hugging and kissing 4. Shaking hands 5. Using toilets 6. Drinking kava with an infected person Probing Questions: > What do you know about how HIV is passed from one person to another? > What questions do you have about how HIV is passed? > Do you have some HIV risks or concerns you would like to talk about today?
10.pdf 11/6/09 10:00:12 P Optional (for ante or prenatal setting) If I have HIV, can I pass it to my baby? Pregnancy Delivery Breastfeeding
11.pdf 11/6/09 9:59:02 P hart 03 If I have HIV, can I pass it to my baby? For Ante and prenatal clients or settings Objectives Explain HIV transmission from mother to baby. Script A woman with HIV can pass HIV to her baby at any stage during the pregnancy, labour, delivery and breastfeeding. Probing Question: > What questions do you have about how HIV is passed from a mother to her baby?
12.pdf 11/6/09 9:11:49 P Why should I test for HIV?
13.pdf 11/6/09 9:08:46 P hart 04 Why should I test for HIV? Objectives Explain the benefits of HIV testing. (In Ante or prenatal setting) Explain the risk of mother-to-child HIV transmission (TT). Script There are many benefits to testing. > ost people who are tested will not have HIV BUT you can only know if you have HIV or not by having a test. > To feel confident that you know your HIV status (whether you have HIV (HIV positive) or do not have HIV (HIV negative). > If you do not have HIV infection (HIV negative) you can obtain support and information to remain negative and to also avoid other STIs. > If you have HIV infection (HIV positive) you can obtain support and information to understand and cope with the diagnosis, and work together with your health care worker to look after your health and think about whether any treatment would be helpful. > nowing your HIV status, positive or negative can help you to make the right choices about sex and reducing your risk of other STIs and helps stop the spread of HIV in other ways. (In Ante and prenatal setting) If you test and you do not have HIV, you will learn how to protect yourself and your baby from getting HIV. If you test and you are diagnosed as having HIV, you will learn how to lower the chance of passing it to your baby and how to get treatment and care services so you and your baby can both live healthy lives. (In Ante and prenatal setting) Not all women who have HIV will pass it to their babies. Without care, 1 out of 3 women with HIV will pass HIV to her baby. This is why it is important to get tested for HIV and receive medical care: to lower the chance of passing HIV to your baby at different stages; during the pregnancy, delivery and when the child is born.
14.pdf 11/6/09 9:15:07 P How will the HIV test be done? Gloves
15.pdf 11/6/09 9:16:32 P hart 05 How will the HIV test be done? Objectives Explain availability of HIV testing services. Explain confidentiality. Explain that HIV testing is routinely recommended and he or she has the right to refuse. Script ou may have requested HIV testing or been offered HIV testing as part of the other services you are to receive today. HIV testing is private. This means that only healthcare workers who are caring for you will know your HIV test result. While we strongly recommend you consider being tested for HIV the final decision is yours and you have the right to refuse HIV testing. This will not affect the usual care you will receive. Only describe the method of testing used by the clinic. Read only the option below that applies. As shown in the first poster, the HIV test will be done by drawing blood. OR As shown in the second poster, the HIV test will be done by a simple finger prick. Only describe the process for testing and receiving results used by the clinic. Read only the option below that applies. ou will be tested here and get your result today. OR ou will be tested (state when and where). ou will get your result (state date). Explain the meaning of the test results. > If your HIV test result is negative, it means you do not have HIV (or that you are in the window period we discussed earlier in this session and you should consider testing again outside of the 3 month period). > If your HIV test result is reactive, your blood will be retested for confirmation. If this second test is positive then it means you have HIV. Probing Question: > Before we go any further, what concerns or other questions do you have about HIV testing?
16.pdf 11/6/09 9:14:17 P y partner s test result could be different from mine. HIV HIV NO HIV HIV HIV NO HIV NO HIV NO HIV
17.pdf 11/6/09 9:23:18 P hart 06 y partner s test result could be different from mine. Objectives Define discordance and the risk to the uninfected partner of acquiring HIV. Script Regardless of your HIV test result, it is very important for your partner to get tested for HIV. In couples, it is common for one person to have HIV (i.e. HIV-positive) while the other person does not have HIV (i.e. HIV-negative). In this picture, there are four couples: 1. In one couple, both partners are HIV-positive. 2. In another, both partners are HIV-negative. 3. In the other two couples, the partners results are different: one partner is HIV-negative and the other is HIV-positive. When couples have different test results, the HIV-negative partner is at high risk of getting HIV. If an HIV-negative partner continues to have unprotected sex with a partner who is HIV-positive, then he or she is very likely to get HIV. Probing Questions: > Do you understand how one partner can have HIV and the other not have it? Suggested Response: Similar to how a person may not get pregnant every time they have sex, HIV transmission may not happen every time a person has sex with an HIV-positive person. It is not possible to know when HIV will be passed, but every time a person has sex with an HIV-positive person there is a chance that they could become infected. > What questions or concerns do you have?
18.pdf 11/6/09 9:20:51 P Why should my partner test for HIV?
19.pdf 11/6/09 9:19:08 P ard 07 Why should my partner test for HIV? Objectives Encourage sexual partner testing. (In ante or prenatal setting or to a woman/couple) Explain the increased risk of TT if infected during pregnancy or while breastfeeding. Inform the person where he/she and his/her partner can be tested for HIV. Script The only way to know whether your sexual partner has HIV is for him or her to get tested for HIV. our partner should be tested so you can protect each other from HIV. (In ante or prenatal settings: you can protect each other and your baby from HIV) Another important reason why your partner should get tested is because if you are HIV-negative now and become pregnant and get HIV later in your pregnancy, or while you are breastfeeding, the risk of passing the virus to your baby is very high. If you prefer to be counselled and tested as a couple, you can be tested together at (name of site). our partner can also be tested at (name of site). Probing Questions: > Are you comfortable asking your sexual partner to be tested for HIV? How do you believe he/ she will react? > What do you think about receiving HIV counselling and testing with your partner? > What questions or concerns do you have?
20.pdf 11/6/09 9:25:18 P How can I protect myself from HIV?
21.pdf 11/6/09 9:24:29 P hart 08 How can I protect myself from HIV? Objectives Introduce HIV prevention methods. Define and describe being sexually faithful (both people sticking to having sex with each other). Define and describe condom use. Describe abstinence. Describe non-penetrative sexual activities. Script There are 4 main ways to protect yourself and your partner from HIV. If you and your partner have both tested for HIV, have got the results and are both HIV-negative, you can protect each other from HIV by being sexually faithful, which means both of you only having sex with one another. If either of you has sex with anyone else, you could become infected with HIV and pass it to your partner. The window period which we have already discussed is important to remember when a couple both test for HIV Another way to protect yourself is by using condoms. When used correctly and every time you have penetrative sex (sex that involved the penis being in the vagina or the penis being in the anus), and condoms are highly effective protection against HIV. It is particularly important to use condoms if your partner is HIV-positive, if you don t know if your partner has HIV, if they haven t been tested or they haven t got the results, are in the window period, or if your partner has other partners. Remember that you cannot tell by just looking at someone if they have HIV (or another STI). We can provide you with condoms and information and demonstrations on how to use a condom correctly. Another option is not to have sex, particularly until your partner is tested for HIV. This can be difficult and not a suitable option for everyone. Another option is not to have penetrative sex (penis in vagina or penis in anus sex) but to do other sexual activities which are either no risk or much less risky for HIV transmission including rubbing, kissing, masturbation, fingering, body rubbing without penetration, breast fondling, nipple sucking where no semen, vaginal fluid or blood passes from one person in to the body of another. Probing Questions: > Have you taken steps to protect yourself from getting HIV? What methods have you used? > What questions or concerns do you have?
22.pdf 11/6/09 9:26:03 P If I have HIV, how do I protect my baby?
23.pdf 11/6/09 9:30:20 P ard 09 If I have HIV, how do I protect my baby? Objectives Inform woman that there are medications and infant feeding choices for preventing mother to child transmission. Script If you are diagnosed HIV-positive, there are medicines that we will offer you and your baby to take to reduce the risk of passing HIV to your baby. our healthcare provider will discuss with you when you need to take medicines for HIV (called antiretroviral), which can help protect you from becoming ill and can help you live a long and healthy life. We will also discuss ways to safely feed your baby so you can choose which one is suitable for you and reduce the chance of passing HIV to your baby. We will give you more information after the test result to help you make these choices. Probing Question: > Before we continue, what questions do you have about how to protect your baby from HIV?
24.pdf 11/6/09 9:28:52 P If I have HIV, what help can I get?
25.pdf 11/6/09 9:29:28 P hart 10 If I have HIV, what help can I get? Objectives Explain that someone diagnosed HIV-positive will receive referrals for care and treatment. (Optional) Inform person that referrals for support services are also available. Script ore and more services are becoming available to help HIV-positive people and their families stay healthy. If you are diagnosed HIV-positive, there are medicines available to help you live a long and healthy life. Not everyone needs to start taking medications immediately after they are diagnosed and more information would be provided about this after the test result. any people who are diagnosed HIV positive find it helpful to talk about issues that develop when they are diagnosed. Additional counselling, prevention, nutrition and support services are also available to help clients who have been diagnosed HIV positive. After the test, we will give you more information about the support services available to help you.
26.pdf 11/6/09 9:32:47 P Why is it important to continue with my healthcare visits?
27.pdf 11/6/09 9:40:32 P hart 11 Why is it important to return for my results or continue with my healthcare visits? Objectives Encourage client to return for their results and continue receiving health care. Encourage women to deliver in a health facility. Script It is important that you come back to receive your test result. ou may be nervous or worried about what your test result is but as we have discussed, if you know your HIV status then you can take steps to either remain HIV negative, or if HIV positive we can discuss treatment, care and support suited to your situation. (In ante or prenatal settings) It is important that you come back to receive your test results as these will guide the ante or prenatal care provided to you and your unborn baby. ou should also plan to deliver your baby in a health facility, where there are skilled providers who can help in case of problems. This is especially important for women who are diagnosed HIV-positive because there are steps we can take at the health facility to maintain the health of the HIV positive mother and protect the baby from HIV. These steps may not be available if you delivery your baby outside of a health facility. Probing Questions: > Do you plan to continue ante or prenatal care? > What are some of the issues you would face in coming back for your results or other follow-up? > Are you currently intending to deliver your baby in a health facility?
28.pdf 11/6/09 9:38:55 P Testing for HIV, a positive choice. Gloves
29.pdf 11/6/09 9:45:39 P hart 12 Testing for HIV - a positive choice. Objectives Summarise services. Provide motivation and support for receiving HIV test. Offer individual counselling. Script We have talked about five main points today: 1. How HIV is and is not transmitted and the activities that can place you at risk of HIV infection 2. Why it is beneficial and important that you test for HIV. 3. If your test result is HIV-negative; ways for you to stay HIV-negative. 4. If your test result is HIV-positive, how you and your health care worker can keep a close eye on your health and think about whether any treatment is needed. 5. If your test result is positive or negative, why it is important for your partner to be tested for HIV - since your result could be different from his/ hers. In ante or prenatal setting: 1. If you are HIV-positive, plan to deliver in a health facility, and there are medicines and ways to feed your baby to lower the chance of passing HIV to your baby. 2. ou should continue with your ante or prenatal care during pregnancy. Remember, by taking the HIV test, you can protect yourself and your family from HIV and you can stay healthy. If you have specific questions or concerns, you can discuss them in private with the counsellor/nurse after this. ou will also have the opportunity to answer some questions that will help you assess yourself for any risk of exposure to HIV. (Direct them to individual rooms for risk assessment before seeking their consent for the HIV test) (instructions)
30.pdf 11/6/09 9:47:37 P Self assessment of Risk Factors, an opportunity for self awareness.
31.pdf 11/6/09 9:44:19 P hart 14 Address barriers to testing. Objectives For Individual Session: Determine reason(s) for declining the HIV test and problem-solve. Note: Explore safety issues such as fear or experience of violence and or other forms of abuse from partners, family or community members. Restate reasons for taking HIV test. Ask again if she/he would like to be tested for HIV. If ES, stop and refer or perform HIV test according to clinic policy. If NO, continue to harts 14 & 15. Note:14 &15 are to assist client(s) to understand personal transmission risk - not to pressure client in to testing. Script What are some of your reasons for not wanting to have an HIV test today? (Acknowledge and discuss issues and concerns). How could we help you with your concerns? What would help you to be ready for an HIV test? There are many benefits to testing. ou can only tell if you are HIV positive or HIV negative by having a test. To feel confident that you know your HIV status (whether you are negative or positive). So that, if you are positive, you and your health care worker can keep a close eye on your health and think about whether any treatment would be helpful. To help you to make the right choices towards your sex life. To help stop the spread of HIV. (If ante or prenatal setting) It is very important that you get tested for HIV with every pregnancy. If you are tested and do not have HIV, you will learn how to protect yourself and your baby from getting HIV. If you are tested and have HIV, there are medicines for you and your baby, and ways to feed your baby, to lower the chance of passing HIV to your baby. ou and your family can also receive prevention, treatment, care and support services to stay healthy. Would you like to test for HIV today?
32.pdf 11/6/09 9:51:14 P Barriers to Testing.
33.pdf 11/6/09 9:56:09 P hart 15 Review risk reduction. Objectives Review prevention of sexual transmission of HIV. Declining lient(s) Thank client(s) for their time and reassure them of: 1. Their privacy and confidentiality. 2. That you would welcome any further contact or questions from them. Script Without knowing if you have HIV, there are still some steps you can take to protect yourself and your partner from getting or passing HIV. > ou and your partner should use condoms. When used correctly every time you have penetrative sex (penis in vagina or penis in anus sex), condoms help protect against HIV. It is particularly important to use condoms if your partner is HIV-positive, if you don t know if your partner has HIV, if they haven t been tested or they haven t got the results or if your partner has other partners. > We can provide you with condoms and information and/or demonstrations on how to use a condom correctly. ou and your partner can also get additional information about condoms from (name of site if appropriate). > Another option is to not have sex, particularly until you and your partner are tested for HIV. > Another option is not to have penetrative sex (penis in vagina or penis in anus sex) but to do other sexual activities which are either no risk or low risk for HIV transmission including rubbing, kissing, masturbation, fingering, body rubbing without penetration, breast fondling, nipple sucking where no semen, vaginal fluid or blood passes from one person to another. > If you and your partner have both tested for HIV, have got the results and are both HIV-negative, you can protect each other from HIV by being faithful, meaning both of you only having sex with one another. If either of you has sex with anyone else, you could become infected with HIV and pass it to your partner. > What questions or concerns do you have about any of these choices for preventing HIV? Which choice do you think will be best for you and your partner?
34.pdf 11/6/09 9:50:07 P IN ANTE OR PRENATAL SETTING hart 15 Explain exclusive breastfeeding, review ante or prenatal care and encourage testing. Objectives Inform woman there are steps she can take to protect her baby from HIV: > Encourage AN attendance > Encourage delivery in a clinical facility > Encourage exclusive breastfeeding > Encourage use of family planning Script Without knowing if you have HIV, there are some steps you can take to protect your health and the health of your baby. 1. Exclusively breastfeed your baby. Give your baby only breast milk and no other liquids or foods, not even water. However, you may give your baby drops or syrups consisting of vitamins, mineral supplements or medicine. Breastfeeding has many benefits. It provides all of the nutrients a baby needs and protects the baby from illnesses such as diarrhoea. 2. Attend all of your ante or prenatal care appointments so you have a healthy pregnancy, and so we can help you and your partner make good decisions. 3. Plan to deliver your baby in a health facility because there are steps we can take to help you through labour and to have a safe birth. 4. After you deliver your baby, you should continue with HIV prevention services to reduce your risk of acquiring HIV and get family planning to help plan future pregnancies. Provide final encouragement for woman to be tested for HIV. Remember, we strongly encourage you and your partner to test for HIV. If you know you have HIV, you can lower the chances of passing HIV to your baby. ou can also get care and treatment for yourself and your baby so you can both live healthy lives. Would you like to be tested for HIV today? If NO, develop plan to return or provide referral for partner or couple testing. Provide encouragement and support. We would like you to continue thinking about being tested. When do you think you will be able to come back and take the HIV test? What questions do you have? If you have any further concerns, please contact us so we can help you.