Components of Post-Test Counselling

Post-test counselling involves working with the patient to understand the test result, address psychological reactions to it, promote behaviour changes and assess the need for follow-up and care.

Communicate the test result

When the patient is a child who is not able to understand the meaning of the test result, parents or legal guardians should be told first. Disclosure of test results to a child is a complex process and consultation should be sought from an expert in this field.

Assess the person's understanding of the test result

Indeterminate result
Patients with an indeterminate result must face another distressing period of uncertainty. True status can usually be clarified over several months. While serologic status is being confirmed, physicians should be available for support and they should identify AIDS service organizations and resources in their region.

Positive result
After diagnosis, an HIV-positive patient usually cannot absorb much more information. The first post-test visit may be mainly supportive in nature (see Breaking bad news).

Over several visits, counselling of patients whose test result was positive should:

• stress that the patient can remain healthy and productive for a long time
• emphasize the importance of medical follow-up, referral when appropriate, and health promotion and stress-reduction in general (2)
• include discussion of the reproductive consequences of HIV infection for both men and women, including intervention to reduce mother-to-child transmission (3)
• arrange psychological and social support services as needed
• encourage self-education on care and treatment and be available to discuss new developments in the management of HIV infection.

Discuss risk-reduction strategies

Any activity that deposits blood, semen or vaginal fluid on intact skin or in a condom carries a low risk.

Exposure to HIV can be avoided by abstinence, monogamy of uninfected sexual partners and refusing to share equipment for injecting drugs. If these options are not realistic, risk- and harm-reduction strategies should be explored periodically, as behaviour of all patients may change over time.

Alcohol and other drugs may impair a person's judgement or cause impulsive behaviour, increasing the risk of acquiring or transmitting HIV.

Counselling safer sex
A complete and regularly updated history of the person's sexual activity should describe risk-producing activities, including current and past sexual partners, specific sexual practices and history of STDs and of sexual assault.

The risk from specific sexual practices can be reduced by the use of barriers (e.g., latex condoms and dental dams) that prevent potentially infectious body fluids from entering the partner's body.

Dental dams are square sheets of latex used by dentists to isolate a tooth and control infection. They are available from pharmacies, medical supply stores and sex-equipment or condom shops. Some people cut open an unused, unlubricated condom or latex glove to use as a substitute for dental dams.

Condoms should be used consistently by monogamous partners until both have established that they are not infected with HIV or have other STDs.

Repeated unprotected exposure to HIV should be avoided. If both partners are HIV-positive, the couple may reduce the risk of transmission of different types of HIV and other infections between them by practising safer sex. If one partner is HIV-positive, the couple should minimize unprotected sexual activity.

Counselling safer drug use
A complete history of nonmedical drug use, including anabolic steroids, should enable the physician to determine the possibility of HIV transmission by this means. Risk associated with drug use arises from sharing injection equipment, i.e., needles and syringes.

Discuss current and past drug use, frequency of use, routes of administration, effects of drug use on sexual activity, and any illnesses resulting from drug use.

Counsel patients to make choices that will reduce their risk of acquiring HIV and other blood-borne infections; for example, adopting safer injection practices or switching to safer modes of drug use such as smoking, "snorting" or ingesting.

Reducing other risk
Contaminated instruments and trauma to skin: Any skin-piercing instrument that is contaminated with someone else's blood can transmit HIV. Activities such as tattooing, ear and body piercing, acupuncture and scarification are considered to be risk-producing when equipment is not sterilized.

Artificial insemination by HIV-positive donors: Since 1988, Canadian guidelines have recommended that only semen that has been tested for HIV 6 months after donation be used for artificial insemination (5). Explain these procedures to the inseminated patient and help her find out if guidelines were followed.

Receiving contaminated blood, blood products, tissue and organs: Medical care in countries where the blood supply is not secure or where instruments are not sterilized may carry a risk of HIV exposure. Since November 1985 in Canada, only blood that does not contain HIV-1 (and more recently HIV-2) has been used for treatment. In addition, all preparations for blood coagulation are treated to inactivate any HIV that may be present (5).

Although recombinant factor VIII is now safe, people with hemophilia may continue to be at risk through other modes of HIV transmission. Counselling should be directed at reducing risk of acquisition or transmission of HIV, including emphasis on safer sexual practices.

Recipients of blood transfusions may be unaware of their serologic status and experience significant anxiety about their risk of HIV infection.

Occupational exposure: Transmission of HIV through occupational exposure (particularly in health care settings) is rare in Canada. The greatest and most common risk has been associated with injuries from hollow-bore needles; the risk of infection as a result of injury from a needle used on an HIV-positive person does not exceed 0.3%. Needles should never be recapped and should be disposed of promptly in rigid prescribed containers (6).

Partner notification
Address the HIV-positive patient's feelings of guilt or anxiety about exposing and possibly infecting others by discussing partner notification.

The patient and physician should determine who will inform the patient's partners (the patient alone or the patient with the assistance of the physician or a public health officer or nurse) and what information should be given to them.

If the physician notifies the partners, the patient's identity should not be disclosed. The physician should be prepared to answer questions. Public health authorities never disclose the identity of an infected person.

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