HIV Counselling

Related articles include:

• AIDS (Acquired Immune Deficiency Disease)
• Childhood HIV
• Complications of HIV infection
• Congenital HIV infection and its prevention
• HIV and skin disorders
• HIV virus
• Management of HIV in pregnancy
• Managing HIV positive individuals in Primary Care
• Primary HIV infection
• Post exposure HIV prophylaxis

In theory, everyone should give informed consent before any investigation or procedure but the place of informed consent in HIV counselling is in a different dimension. Before highly active antiretroviral therapy (HAART) was introduced, there were few advantages to knowing one's HIV status except that socially responsible people who were positive would take steps to prevent transmission to others.

Before testing, consent must be obtained and recorded.

Some of the following points may be of value to the patient:

• Sex between men remains the group in the UK at highest risk of acquiring HIV with evidence that transmission is continuing at a substantial rate.
• In 2005, 70% of diagnoses were in people aged 15 to 39 and 73% of heterosexual cases were in people of African origin or were acquired there.¹
• The Health Protection Agency estimates that around 63,500 people in the UK are infected with HIV but a third are not yet diagnosed.¹
• In 2005, 34% of newly diagnosed patients were diagnosed late with serious immunosuppression and 11% had progressed to AIDS.²

Reasons for low testing rates and hence low detection rates include:³

• Concerns about confidentiality, legal and insurance issues
• Self perceptions of low risk in those who would test positive
• Denial
• Dislike of counselling
• Wishing to avoid anxiety when waiting for results

Fear and denial are the commonest obstacles to HIV testing among those acknowledging that they have been at risk.

Not all doctors are aware of the effectiveness of early intervention with modern treatments.⁴ This paper was published in 1998 and hopefully matters have improved since then.

However, the commonest reason is lack of time for pre-test counselling, even in genitourinary medicine clinics.

• Average times for counselling are at least 21 minutes with 18% of people requiring two sessions.
• The longer a person is positive but undiagnosed the longer they have to transmit the disease to others.
• Uptake of voluntary counselling and testing is poor, even in those with high risk sexual practices.
• Many infected people never attend GUM clinics for voluntary counselling and testing even if referred.
• It also seems that pre-test counselling is not dramatically effective in reducing high risk sexual activity.⁵

HIV should now be seen as like any other serious disease in that it can kill but early diagnosis improves prognosis. There are many benefits of early diagnosis to the individual and the community.⁶ It has been argued that the special status of HIV testing should change and doctors should now undertake the test with the same approach as used in any other test with serious implications.⁷ This is a strong argument but it is not yet accepted policy and the Department of Health Guidance remains rooted in the 1990s at the time of writing.⁸

Before undertaking counselling and testing there are a few preliminary enquiries to be made.

• Is there a lifestyle that puts the individual at risk?
• Why do they want the test?
• Do they understand why they are at risk?
• They must understand that irrespective of the result they must address risky behaviour.

There are a number of issues to be discussed. You may be dealing with a very nervous person of very limited intelligence and understanding of medical matters. Ascertain that they do understand what you say.

Nature of HIV Antibody Test and Seroconversion

The test detects antibodies to the virus and not the virus. This is why it takes time to convert. Viraemia occurs at an eary stage and it is this that makes the individual infectious.

Difference between HIV and AIDS

HIV is infection with the virus. AIDS is the full-blown disease with severe immunosuppression.

Without treatment, by 10 years, two thirds have converted to AIDS. This number is reduced by treatment. In countries where people are exposed to tuberculosis and parasitic infection such as malaria, this period is likely to be shorter. It is also shorter for children born with the virus.

• Antibodies do not form immediately after infection but are often forming by 2 or 3 weeks. They may take a month or two to appear and a "window" of 3 months between exposure and testing is often advised.
• Testing can be done earlier but a negative result should be repeated at 3 months.

• It is like cancer. It is a serious disease that can kill but the earlier it is caught the better the prognosis, especially with modern treatments.
• A negative result is reassuring but a positive result means that steps must be taken to protect others from infection.
• Discuss transmission of the virus, safer sex, risk reduction (including injection for drug users).
• Also discuss how it is not transmitted such as hugging, kissing, shaking hands or sharing eating and drinking utensils.

• How would the patient cope if the results are positive?
  • Discuss personal resources, support network of friends and family.
• Who to tell about the test (especially partner)
• What are the implications, if any, for work?
• HIV status of regular partner
• Confidentiality of test
• Does patient need time to consider?
• How results are obtained. They are given in person by the counsellor, and not by telephone or post
• Need for further counselling in those with high risk behaviour (multiple partners, drug injection, HIV symptoms, positive partner)
• Some people are concerned about the implications of having an HIV test on future applications for life insurance or mortgages. Insurance companies now say that a negative test for HIV will not affect their chances of getting life insurance cover, but if they have a high risk lifestyle, such as homosexual men, the premium may be raised
• If the patient is still uncertain about wanting a test, give time to consider and return. They may wish to talk anonymously in confidence to a trained telephone advisor on one of the national helplines. These are the Sexual Health Information Helpline [0800 567123] and the Terrence Higgins Trust Helpline [0845 1221200]

Special Cases

There are also a few special cases that merit discussion.

• Testing in pregnancy poses a challenge.⁹
  • Risk of transmission to baby.¹⁰ Appropriate steps can reduce the risk of mother to baby transmission from around 25% to 2%.¹¹
  • Probably caesarean section and no breast feeding.^12,13
• If a person has been sexually assaulted an immediate test can be useful in that a negative test proves that the victim did not have HIV at the time of the assault. Hence, if it becomes positive in the next 3 months, there is a strong case to blame the attacker.

The target of testing in pregnancy is to achieve an uptake of at least 90%. At booking, the midwife should discuss the various tests that are offered, including HIV testing.¹⁴ For a woman who is not at high risk, this will not require the amount of time and detail as for those who have engaged in risk taking activity and for whom a positive result is a significant possibility. Nevertheless, testing should not be done without some discussion with the woman.

People who donate blood are routinely screened for a number of infections including HIV but they do not receive counselling. In 2005, amongst new donors in the UK there were 24 who tested positive and amongst repeat donors the figure was 15.¹⁵ This represents an incidence of 9.05 and 0.66 respectively of positive results per 100,000 donations. People should be discouraged from seeing blood donation as a "quiet and easy way" of getting an HIV test. They do not have the benefit of counselling and they might donate in the window between viraemia and and seroconversion. Hence they may give the disease to others.

The results should be given simply and in person.

If negative that is reassuring but with some caveats.

• If there has not been at least 3 months since the last possible risk taking event, the test should be repeated. About 1% of people take over 3 months to convert. Over 6 months is most unusual.
• Has there been any more recent risk-taking activity?
• A negative result is not a permit to continue to take risks. Next time may not be so lucky.
• If positive there will be considerable emotional trauma.

The test does not indicate who will convert to AIDS and who will not.

If the result is positive:

• Referral for treatment is required. Attendance is essential as it does make an enormous difference to prognosis.
• The patient is infectious and so must take steps to avoid infecting others, especially a negative partner. Repeat the advice about what is and what is not a risk for transmission.
• Further tests are now required to assess the current state of the immune system.
• Psychological support may be needed.

See separate Post Exposure Prophylaxis article.

Many practices have been reluctant to undertake HIV testing with associated counselling as it is seen as complicated and time-consuming.¹⁶ However, if the uptake of testing is to be increased this needs to change. With the help of the content and references of this article, there is no reason why practices should not write a protocol for counselling and testing that fulfils the various conditions. Practices that treat drug abusers may add this to their services but any practice can offer it to anyone at risk. It may form part of an enhanced service for sexual health. It does not have to be performed by a doctor and in most situations it is a nurse who gives the counselling. The easier it is for the patient to get counselling and testing, the more likely they are to take up the offer.

Denial is a major factor in the spread of AIDS. It may occur at the level of the individual, the community or at a national level. The fact that a person has presented to discuss testing means that the person has faced up to the possibility of infection. Occasionally, testing may seem inappropriate as the activities were such that the person was not truly at risk. If there is any doubt then the safe course is to get a test. With effective treatment now available, prognosis is dependent upon catching the disease early. There is also the need to prevent spread of infection. Hence there can be little justification nowadays for refusing a test where risk exists.

Ignorance and denial are important contributory factors to the spread of HIV in Africa and elsewhere. Young men insist on promiscuity and unprotected sex despite the risk. In some villages in Africa where over half the population has been killed by the disease, there are some who deny that it is really to blame.

At a national level, leaders do not like to admit that their country has a problem like that. Even the great Nelson Mandela denied the problem when he was president of South Africa but at least he has acknowledged his mistake and expended much time and energy to promote awareness of the disease that has so devastated his country. He was succeeded by President Mbeki who denied that HIV was the cause of AIDS.

The Roman Catholic Church has also been strongly criticised for its policy with regard to condoms and contraception.^17,18 Whilst condoms are not 100% effective against preventing infection¹⁹ it has been totally misleading to suggest that they are ineffective and should not be used.²⁰ The dean of Pope John Paul II's influencial Institute for Marriage and Family Studies at the Vatican, said that when one partner of a married couple is positive for AIDS, it is preferable to risk catching the AIDS virus than to use condoms.²¹

This scourge that has killed millions and devastated entire communities cannot be defeated until people face up to the reality of what it is, how it is spread and how it can be curtailed. Some of this requires efforts at the global or national level but for the individual the first step must be the acknowledgement that risk exists. We need more testing at an asymptomatic stage to implement early treatment and to prevent spread.