Counselling Guidelines for HIV Testing
Components of Pretest Counselling
Principles
Pretest counselling is an educational opportunity and should be
viewed as a means to initiate
preventive and continuing care. The decision to be tested should
always be the choice of the
individual patient. More than one pretest counselling session may
be required for patients who
refuse testing or are unprepared for testing.
(See Pointers for
counsellors.)
Assess the person's risk of HIV infection
Assess risk by asking simple, open-ended questions such as:
- To enable you and me to understand your risk of HIV infection
better, may I ask you some
specific questions?
- Has your partner, or anyone who has had sex or used drugs
with your partner, been found
to have HIV infection or AIDS?
- When was the last time you had sex with a woman? With a man?
- What kinds of sexual activities do you have?
- How and when do you use condoms? Spermicides?
- Do you have sex when you are using drugs or alcohol?
- Have any of your partners had problems with alcohol or drugs?
- When was the last time you injected drugs? Anabolic steroids?
- Have you ever injected drugs when you were under the
influence of drugs or alcohol?
- Has someone ever injected them for you?
- When was the last time you shared needles, "cookers"
(syringes) or other drug-injecting equipment?
- Have you ever had a sexually transmitted disease (STD)?
Hepatitis?
- Have you ever had surgery or a blood transfusion?
Assess the window period
The interval following infection and before the appearance of HIV
antibodies is known as the
serologic "window period." After being infected with HIV, 95% of
adults and youth will produce
HIV antibodies within 3 months of infection; 99% will
produce antibodies within 6 months. People
may prefer to be tested at 3 months, 6 months, or both,
after the most recent risk event.
To determine the window period, help identify the most recent
risk event (i.e., potential exposure
to HIV) and plan the appropriate time of testing. If a patient is
believed to be in the window
period, discuss risk reduction to prevent exposure to HIV while
he or she is waiting to be tested.
Provide information
Regardless of whether testing is undertaken, take advantage of
this opportunity to discuss HIV
infection, risk-producing activities and specific ways in which
the person can avoid or reduce risk.
In providing information about HIV, physicians may use
educational materials such as brochures
and videotapes or refer the patient to other sources of
information. Local public health units,
AIDS service organizations and the National AIDS Clearinghouse
can supply material to physicians
for distribution. (See What
the patient should know about HIV
infection.)
Identify testing options available in the region
Anonymous testing
- Usually available through special clinics.
- The patient's only identifier is a code name or number
assigned by clinic staff.
- The identity of the patient does not have to be revealed to
the physician or staff.
- When informed by the patient of a positive test result
obtained from an anonymous test
site, physicians should confirm it with repeat testing and
counselling.
Non-nominal testing
- The patient's name is replaced by a code on the testing
requisition (e.g., billing code,
initials).
- Only the physician and the patient know to whom the code
refers.
- Test results are included in the patient's chart and cannot
be deleted.
Nominal testing
- The name of the patient is written on the testing
requisition.
- Anyone reading these forms will know the identity of the
patient tested and the test result.
- As for non-nominal testing, results are included in the
patient's chart and cannot be deleted.
Discuss record-keeping
Inform the patient that test results and information will be
added to his or her medical record and
will be available to other health professionals on a need-to-know
basis. If the patient objects,
anonymous testing should be discussed.
Unsubstantiated HIV-positive test results should not be recorded
without verification.
Special identification by visual coding or tagging on the outside
of HIV-positive patients' files is
not recommended as it may lead to a breach of confidentiality.
Discuss the implications of testing
Take time to examine and discuss the issues
raised by testing so that the patient has the
opportunity to weigh the advantages and disadvantages of being
tested and prepare for the potential consequences of a positive
or negative test result
(See Advantages, disadvantages and
consequences). Testing
should be carried out only when the patient considers the
advantages to be greater than the
disadvantages.
Discuss the confidentiality of test results in relation to office
or clinic procedures, communication
of results to other health care officials, partner notification
and reporting requirements.
Evaluate the patient's capacity to cope with a positive test
result.
Determine the timing of testing and the post-test visit
Seldom is the need to obtain HIV-test results so urgent that it
must be done immediately. The
patient's concerns should be examined in detail to determine
whether testing is appropriate when
first requested or if it should be deferred.
During the window period, serologic testing for HIV may not be
accurate. Tests should take place
3 months after the most recent risk event. Help identify the
most recent risk event and plan the
appropriate time of testing.
Physicians should contact an experienced colleague or check with
a laboratory to determine time
needed for testing (turnaround time for enzyme-linked
immunosorbent assay [ELISA] and
confirmatory tests).
For patients who have no signs or symptoms of HIV infection and
are willing to wait until the end
of the window period, provide a requisition for testing
3 months after the most recent risk event.
Some patients may request a baseline test for various reasons,
including anxiety, occupational
exposure, requirements of workers' compensation boards or in some
cases of sexual assault.
(When the assault carries a risk of HIV infection, blood can be
drawn during the post-assault visit,
if the patient agrees, to be tested or discarded later at his or
her discretion.) This baseline test,
if negative, cannot accurately reflect the patient's status
vis-à-vis HIV infection
unless a second test is done once the patient is
outside the window period.
Arrange a post-test appointment, allowing enough time for
confirmatory testing should it be
required. Results will usually be available in 2 to 6 weeks.
Obtain and record informed consent
Encourage the person to ask any additional questions to clarify
doubts or fears or to seek
information. Informed consent may be verbal and need not involve
a specific form. Once informed
consent is expressed, it should be recorded
in the
patient's chart [example] (1).
Provide support and follow-up
Test results, whether positive or negative, must be given only in
person, in a face-to-face
interview. Informing patients of their test result by telephone
is unacceptable, even when it is
negative. It places the physician at risk of liability should
disclosure to someone other than the
patient inadvertently occur. Communicating test results
face-to-face permits better appreciation
of the patient's reaction and enables adequate counselling.
Patients should be encouraged to contact the physician, AIDS
service organizations or support
groups if they experience intolerable anxiety between the time
the blood is drawn for testing and
the time they receive their result.
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