Module 5

1. Module 5 HIV Testing and Counselling for PMTCT

2. Module Objectives • Discuss the integration of HIV testing and counselling into settings where PMTCT services are provided • Discuss the three guiding principles for testing and counselling in settings where PMTCT services are provided • Explain the difference between provider- and client- initiated approaches to HIV testing PMTCT Generic Training Package Module 5, Slide 2

3. Module Objectives (Continued) • Describe the importance of effective communication and counselling skills when working in settings where PMTCT services are provided • Describe the ways to deliver pre-test information and counselling • Provide pre-test information • Provide an overview of HIV testing of women with unknown status in labour and delivery (L&D) settings PMTCT Generic Training Package Module 5, Slide 3

4. Module Objectives (Continued) • Describe HIV testing processes • Understand the procedures to perform a rapid HIV test correctly • Explain the meaning of positive (reactive) and negative (non-reactive) HIV test results • Describe the steps involved in post-test counselling • Discuss the disclosure process for women who are HIV-infected PMTCT Generic Training Package Module 5, Slide 4

5. Session 1 Overview of HIV Testing and Counselling for PMTCT

6. Session 1 Objectives • Discuss the integration of HIV testing and counselling into settings where PMTCT services are provided • Discuss the three guiding principles for testing and counselling in settings where PMTCT services are provided • Explain the difference between provider- and client- initiated approaches to HIV testing PMTCT Generic Training Package Module 5, Slide 6

7. HIV Testing and Counselling • HIV testing provides: • Information about HIV status • Opportunity to identify women with HIV and empower them to make decisions to prevent MTCT • Opportunity to identify women who are HIV negative and empower them to remain negative PMTCT Generic Training Package Module 5, Slide 7

8. HIV Testing and Counselling (continued) WHO recommends provider-initiated HIV testing and counselling as a standard part of antenatal care (ANC), labour and delivery and post-delivery care PMTCT Generic Training Package Module 5, Slide 8

9. Definitions • HIV testing:process of determining if client is infected with HIV • HIV counselling: confidential dialogue between an individual or a couple and a healthcare worker (HCW) to help clients examine their risk of acquiring or transmitting HIV • HIV counselling is tailored to the risk behaviour, circumstances and special needs of the client PMTCT Generic Training Package Module 5, Slide 9

10. Advantages of Testing and Counselling • HIV testing and counselling provides clients with an opportunity to learn their HIV status • For HIV-negative women, advantages include: • Information and support to remain uninfected • Information and support to exclusively breastfeed for six months PMTCT Generic Training Package Module 5, Slide 10

11. Advantages of Testing and Counselling (Continued) • For HIV-infected women, advantages include: • PMTCT interventions (ARVs, safer delivery, infant feeding, referrals) • Discuss partner testing and prevention (discordance, disclosure) • Receive information on treatment, care, nutrition, family planning and support services • Learn about importance of continuous health care • Learn about needs of HIV-exposed children (testing, co-trimoxazole) • Make informed decisions about their pregnancy PMTCT Generic Training Package Module 5, Slide 11

12. Guiding Principles • Confidentiality • Informed consent • Post-test support and services PMTCT Generic Training Package Module 5, Slide 12

13. Guiding Principles (Continued) • Confidentiality • Important responsibility of all HCWs • Essential to establishing and maintaining client trust • Information shared between HCWs and clients must be kept private PMTCT Generic Training Package Module 5, Slide 13

14. Guiding Principles (Continued) • Confidentiality, continued • Personal and medical information may be disclosed to other HCWs only to ensure client receives appropriate medical care • Only those directly involved in client's care will have access to medical records—and only on “need-to-know” basis • Anyone not directly involved in a client’s care (e.g., receptionist at ANC clinic), should not have access to client medical records PMTCT Generic Training Package Module 5, Slide 14

15. Guiding Principles (Continued) • Confidentiality, continued • All medical records and registers, whether or not they include HIV-related information, should be kept private and stored in a safe, secure place PMTCT Generic Training Package Module 5, Slide 15

16. Guiding Principles (Continued) • Informed Consent • Process during which clients receive clear and accurate information about HIV testing to make an informed decision about whether to accept or decline testing The client must give informed consent before being tested PMTCT Generic Training Package Module 5, Slide 16

17. Guiding Principles (Continued) • Elements of informed consent: • An understanding of the purpose and benefits of testing, counselling and PMTCT services • An understanding of the testing and counselling process • Respect for the client’s testing decision PMTCT Generic Training Package Module 5, Slide 17

18. Guiding Principles (Continued) • Informed consent: • Where HIV testing is offered routinely (e.g. in a “provider-initiated approach”), written informed consent may not be required PMTCT Generic Training Package Module 5, Slide 18

19. Guiding Principles (Continued) • Post-test counselling support and services • HIV test result should be offered in person as part of an individual (or couple) post-test counselling session • Provide both HIV-negative and HIV-positive women with test results and counselling PMTCT Generic Training Package Module 5, Slide 19

20. Guiding Principles (Continued) • Post-test counselling support and services • Ensure privacy when providing HIV test results • Reassure client you will keep the conversation and test results confidential • Inform client that follow-up treatment, care, support are available, including support for disclosure when needed PMTCT Generic Training Package Module 5, Slide 20

21. Exercise 5.1 Confidentiality Role Play: Large Group Discussion

22. Provider- and Client-Initiated Approaches to HIV Testing • Two basic approaches to HIV testing: • Provider-initiated • Client-initiated • Both approaches include • Basic information about providing HIV testing • Risks and benefits of testing PMTCT Generic Training Package Module 5, Slide 22

23. Provider-Initiated Approach • HIV testing is a routine, expected part of standard care • Also referred to as “opt-out” • All women provided with pre-test information • All women are tested for HIV and provided with post-test counselling unless they decline testing • Testing is still voluntary under the provider-initiated approach PMTCT Generic Training Package Module 5, Slide 23

24. Client-Initiated Approach • Client specifically requests HIV test • Also referred to as “opt-in” • Clients provided with pre-test information • Only clients who specifically request to be tested are provided with HIV testing • Client gives verbal or written consent PMTCT Generic Training Package Module 5, Slide 24

25. Provider- vs. Client-Initiated Approaches to HIV Testing PMTCT Generic Training Package Module 5, Slide 25

26. Preferred Testing Strategy: Provider-Initiated • Recommended for HIV testing and counselling in ANC, L&D, post-delivery settings • Helps normalize HIV testing • Likely to increase the number of women who get tested for HIV PMTCT Generic Training Package Module 5, Slide 26

27. Provider- and Client-Initiated Approaches to HIV Testing • Whether provider- or client-initiated, adhere to the guiding principles of testing and counselling: • Informed consent • Confidentiality • Provision of post-test services PMTCT Generic Training Package Module 5, Slide 27

28. Session 2 Counselling Skills

29. Session 2 Objectives • Describe the importance of effective communication and counselling skills when working in settings where PMTCT services are provided PMTCT Generic Training Package Module 5, Slide 29

30. Role of the HCW in Counselling What client counselling do you currently undertake in your work? PMTCT Generic Training Package Module 5, Slide 30

31. Role of the HCW in Counselling • Role of HCW during counselling: support and assist client’s decision-making process by: • Listening to client • Understanding the choices client needs to make • Helping client explore her/his circumstances and options • Helping client develop self-confidence to carry out her/his decision about testing PMTCT Generic Training Package Module 5, Slide 31

32. Role of the HCW in Counselling(Continued) • HCW is not responsible for: • Solving all of the client’s problems • The client’s decisions PMTCT Generic Training Package Module 5, Slide 32

33. Counselling Skills: Active Listening Active listening helps establish a trusting relationship with the client • It involves: • Listening to and understanding the client • Taking note of client’s non-verbal behaviour • Listening for client’s social and cultural context • Listening to client’s negative comments or feelings—make note of things that may have to be challenged PMTCT Generic Training Package Module 5, Slide 33

34. Counselling Skills: Self-Awareness • HCWs needs to be aware of their • Strengths and weaknesses • Fears or anxiety about HIV PMTCT Generic Training Package Module 5, Slide 34

35. Counselling Skills: Self-Awareness (Continued) • Consider your responses to these questions: • What are my expectations of my clients? • How do I feel about discussing HIV infection and AIDS? • What are my feelings about people with HIV infection or AIDS? • What are my feelings about people whose behaviour has placed them at risk? PMTCT Generic Training Package Module 5, Slide 35

36. Counselling Skills: Self-Awareness (Continued) • Consider your responses to these questions: • Which sexual practices would I find most difficult to talk about? • Will I be judgemental of clients whose values, beliefs, attitudes, fears and views differ from mine? • Am I ready to let clients make their own decisions? PMTCT Generic Training Package Module 5, Slide 36

37. Listening and Learning Skills Skill 1: Use helpful non-verbal communication • Includes all aspects of message not conveyed by literal meaning of the words • It includes the Impact of gestures, gaze, posture and expressions that convey information • Reflects attitude • Helpful non-verbal communication encourages client to feel HCW is interested in her PMTCT Generic Training Package Module 5, Slide 37

38. Non-Verbal Communication PMTCT Generic Training Package Module 5, Slide 38

39. Listening and Learning Skills Skill 1: Use helpful non-verbal communication • Demonstration PMTCT Generic Training Package Module 5, Slide 39

40. Listening and Learning Skills (Continued) Skill 2: Ask open-ended questions • Open-ended questions begin with “how?” “what?” “when?” “where?” or “why?” • Encourages responses that lead to further discussion • Try to avoid questions with a “yes” or “no” answer PMTCT Generic Training Package Module 5, Slide 40

41. Listening and Learning Skills (Continued) Skill 2: Ask open-ended questions, examples of closed-ended questions: • You know what HIV is, don’t you? • Do you have any other questions about MTCT? • Are you going to tell your partner that you tested for HIV today? • Is your husband your only partner? • Do you plan to replacement feed? • How would you revise these questions so that they are open-ended? PMTCT Generic Training Package Module 5, Slide 41

42. Listening and Learning Skills (Continued) PMTCT Generic Training Package Module 5, Slide 42

43. Listening and Learning Skills (Continued) Skill 2: Ask open-ended questions • Demonstration PMTCT Generic Training Package Module 5, Slide 43

44. Listening and Learning Skills (Continued) Skill 3: Use gestures and responses that show interest • Gestures: nodding and smiling • Responses: “Mmm,” “Aha” • Attending skills: clarifying and summarizing—invite client to relax, talk about herself and her problems PMTCT Generic Training Package Module 5, Slide 44

45. Listening and Learning Skills (Continued) • Clarifying • Prevents misunderstanding • Helps sort out what has been said, e.g., if client says, “I can’t exclusively breastfeed my baby,” HCW may ask, “In what way is exclusive breastfeeding a concern for you?” • Summarizing • Helps ensure client and HCW understand each other • Summarizing can offer support and encouragement to clients to help them carry out decisions they have made PMTCT Generic Training Package Module 5, Slide 45

46. Listening and Learning Skills (Continued) Skill 3: Use gestures and responses that show interest • Demonstration PMTCT Generic Training Package Module 5, Slide 46

47. Listening and Learning Skills (Continued) Skill 4: Reflect back what the mother says • Encourages her to say more • Shows HCW is actively listening, encourages dialogue, gives HCW opportunity to better understand client’s feelings • Say what client said in a slightly different way • If client says, “I don’t know what to give my child; she refuses everything,” HCW might reflect back by saying: “Your child is refusing all the food you offer her?” PMTCT Generic Training Package Module 5, Slide 47

48. Listening and Learning Skills (Continued) Skill 4: Reflect back what the mother says • Demonstration PMTCT Generic Training Package Module 5, Slide 48

49. Listening and Learning Skills (Continued) Skill 5: Empathize—show you understand how she feels • Used in response to an emotional statement • Encourages mother to discuss the issue further • If client says, “I just can’t tell my partner that I have HIV,” HCW could respond with “You sound like you are afraid to tell your partner your HIV test result” • HCW is not empathizing if she responds with a question that has a factual answer PMTCT Generic Training Package Module 5, Slide 49

50. Listening and Learning Skills (Continued) Skill 5: Empathize—show you understand how she feels • Demonstration PMTCT Generic Training Package Module 5, Slide 50