HIV & You
Counselling Guidelines for HIV Testing
 

Emerging Issues

Rapid, simple testing for HIV

New methods for testing for the presence of HIV provide a patient with a definite negative or preliminary positive result in 10 minutes or less. As of April 1995, none of these tests has been approved for sale in Canada. Such tests may be available for research purposes but they cannot be used in the diagnosis of HIV infection.

Rapid, simple testing for HIV may have advantages over current protocols in specific settings, such as remote areas, developing countries or outreach test sites.

The advent of these tests, which do not require complex laboratory equipment or advanced technical training to perform, raises significant scientific, technical, epidemiologic, cost and ethical issues.

The use of these tests would affect the content of counselling information provided. As a result, their introduction will have to be accompanied by changes to counselling guidelines. However, it would not, in any way, abbreviate counselling protocols.

The introduction of rapid, simple testing does not decrease the need for quality assurance in the testing methods and the training of those carrying out counselling and testing.

Screening for insurance purposes

Insurance companies may use urine or saliva tests for HIV as part of their screening procedures. Patients who have obtained positive results in this manner should be retested according to the testing and counselling protocol recommended in these guidelines.

Continuing unsafe behaviour

An ethical dilemma arises when a physician knows that an HIV-positive person is exposing drug-using or sexual partners through risk-producing behaviour. Fortunately, continuing unsafe behaviour among people with HIV is not frequently encountered.

The physician should intervene to motivate the patient to disclose or stop unsafe behaviours. The following steps should be taken in order:

  • Counsel the patient by exploring impediments to risk-reduction strategies. These may include partner's refusal to use condoms, inaccurate information about risks for HIV infection, poor social or economic living situation, psychological or emotional state, or fear of disclosure to partner(s).
  • Inform the patient of the physician's ethical requirement to safeguard others.
  • Report the situation to public health authorities.

Patients who do not return for test results

Controversy exists as to what steps should be taken if a patient does not return for results of tests for HIV. Seek consultation from an expert colleague in the field of HIV infection to determine the most effective intervention for such people.

Specific counselling issues

People infected and affected by HIV come from varying backgrounds and living situations. In dealing with people who are alienated from society, have special needs that "mainstream" health care addresses poorly or lack influence owing to poverty, low self-esteem or other reasons, physicians must be flexible and sensitive to each person's unique circumstances.

Ethnic communities
Be sensitive to cultural issues that may affect vulnerability to HIV infection and understanding of the HIV epidemic, including:

  • different interpretations of medicine, illness, sexuality, death, shame and reputation,
  • monogamy, homosexuality, bisexuality, commercial sex, alcohol and drug use
  • cultural beliefs about AIDS and HIV infection
  • disparity in male-female roles.
Aboriginal peoples
Be aware of cultural, social, geographic and language issues specific to aboriginal communities. Many urban aboriginal peoples are estranged from their communities of origin and need to be informed of the resources available to them, such as outreach, repatriation and traditional healing.

Street-involved people
Young people and adults who spend time on the street are often confronted with difficulties that place them at high risk for HIV infection. They may use drugs; exchange sex for money, drugs, shelter or food; and feel rejected. They may often be non-compliant with medical care until trust is established with a physician. Being identified as HIV-positive may place these people at risk of physical violence.

Adolescents
Assess cognitive and emotional development of an adolescent; it may not be in step with his or her physical development or chronological age. Normal adolescent rebellion against parental and societal norms may include both sexual and drug exploration; education and preventive counselling on these issues are needed. Explore local support systems for adolescents.

Gay and bisexual adolescents may have difficulty in disclosing their sexual orientation; physicians must provide a safe, non-judgemental atmosphere in which these issues can be discussed.

Commercial sex workers
The personal life and sexual behaviour of those who trade sex for money (men, women and children) are often quite distinct from their "working" identity; physicians should inquire about both. Some patients are more vulnerable to exploitation and HIV infection because of past or ongoing history of physical or sexual abuse, drug use and social isolation. Injecting drugs and drug dependence may undermine the patient's ability to protect him- or herself and others against HIV.

Provide ongoing education about safer sex and safer drug use, including how to deal with partners who refuse to implement risk-reduction strategies.

Men who have sex with men
Some men who have sex with men do not identify themselves as either gay or bisexual. Be sensitive to the fact that many gay or bisexual men may be hostile or distrustful because of previous encounters with homophobic health care professionals.

Prisoners
Risk-producing activities, such as unprotected sex, sexual assault and sharing of drug-injecting equipment, may occur in correctional facilities. Discuss behaviours openly with a recognition that the inmate, parolee or previously incarcerated person may fear retribution for his or her frankness. Appropriate print material can be obtained from the National AIDS Clearinghouse to support counselling.

Physicians working with inmates should be particularly aware of a need for confidentiality in a setting that tends to deny privacy. Knowing institutional requirements for disclosure of a positive test for HIV before counselling inmates on testing is essential.

Psychiatric patients and the mentally challenged
Those whose insight, impulse control or capacity to perceive risk is impaired by psychiatric or neurological disorders are at increased risk of acquiring and transmitting HIV. These people may also be poor or marginalized, lack basic sex education, have multiple diagnoses and have a history of past or ongoing sexual abuse.

In counselling such people, use audiovisual material and identify any underlying thought process or cognitive distortion that could interfere with risk-reduction strategies.

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