HIV Testing & Counseling

APPENDIX NUMBER 12: Rapid HIV Counseling and Testing Guide

(Adapted from the CDC Global AIDS Program, VCT protocol)

Rapid HIV Test Explanation Flesch-Kincaid grade level: 5.9

Action	Content suggestions
Introduce yourself to the client.	Hello, my name is ______________. I’ll be talking to you about HIV and HIV testing.
Describe your roles as counselor.	My role as your counselor is to work together with you to identify risks that increase your risk of getting sexually transmitted infections (STIs) and HIV, and to explore issues related to these risks.
Explain confidential HIV testing	I would like you to know that what we are going to talk about today will be kept private. That means that your personal information will be kept private and will not be discussed with anyone else.
Review the rapid test process and meaning of results.	You will receive a test that may be new to you. This test is an HIV test that detects if you are infected with the virus that causes AIDS.
Accurate, same-day results.	I will do a rapid oral HIV test today. It takes about 20 minutes to get the test result. This type of HIV test is very accurate. I will give you your test result before you leave today.
Discuss the participants’ HIV test history and behavior changes in response to results.	Other than today, how many times have you been tested for HIV? When was the last time that you were tested? What were the results of your last test?
Negative results	If your rapid HIV test is negative, it means that you are very likely not infected with HIV. However, if you were recently exposed to HIV, it may be too soon for the test to show a positive result. In that case, you should be tested for HIV again in 3 months.

Action	Content suggestions
Positive results	If your rapid HIV test is positive, I will do different oral test for HIV to confirm the positive result. I will make an appointment for you to return in 2 weeks for the result of this second HIV test since it has to be sent to a laboratory.
Outline HIV testing and risk discussion plan.	While your rapid oral HIV test is being processed, we will talk about your risk for sexually transmitted infections (STIs) and HIV infection and how you have tried to reduce your risk. We will talk about changes you can make to reduce your risk and develop a plan to do this.

HIV test preparation

Action	Content suggestions
Address participant’s feelings about test for HIV.	OK, let’s talk a little about doing the HIV test. Tell me your feelings about taking the HIV test today.
Discuss the participant’s understanding of the meaning of positive and negative HIV test results.	What will a positive HIV test result mean to you? What will a negative test result mean to you?
Assess participant’s readiness to be tested and to receive the test results.	What test results are you expecting today? Have you thought about how you will deal with each of the possible test results? How will your life change?
Response to negative results.	Will your behavior change if you find out that you are not infected with HIV?
Response to positive results.	How will you deal with an HIV-positive result? How will you reduce the risk of transmitting the virus to your partners?
Assess who will provide support if the participant is infected by HIV.	With whom do you talk about personal issues? Whom will you tell if you find out that you are infected with HIV?
Weigh and discuss the benefits of knowing your serostatus (knowledge is power).	If you have HIV, knowing you are infected can help you prepare for your future (and your children’s future).
Prepare for the future.	It is very important to get HIV medical care if you are infected so that you can be healthier. There are things that you can do to protect others from becoming infected. If you are negative, you will learn how you can do to reduce your risk of getting infected.
Identify and address examples where beliefs and behaviors are at odds or when feelings are mixed about being tested and dealing with the results.	You do not seem prepared to get tested and receive your results today. How can we work together to prepare you?

Perform rapid oral HIV test

Action	Content suggestions
If the participant agrees to proceed with rapid HIV test, describe the test procedure and the interpretation of the test result.	Ok, we’re ready to do the HIV test. I will give you the HIV testing stick to place in your mouth to do the test. It takes about 20 minutes to process and read the test. When the results are ready, we will look at the test result together. If there is only one line on the test stick, then your result is negative. If there are two lines the test stick, then your result is positive. If your test is positive, I will do different oral test for HIV to confirm the positive result. This test sample will be sent to a laboratory. I will make an appointment for you to return in 2 weeks for the result of your second HIV test. Rarely, the two oral test results are different. If this happens, I will take about 2 teaspoons of blood from a vein in your arm and send it to a laboratory for the most accurate test that can be done. As before, I will make an appointment for you to return in 2 weeks for this blood test result.
Perform OraQuick Advance HIV test	Please place the HIV testing pad against your outer gum. Gently rub it on your upper and lower gums only on time around. Do not rub the pad on the roof of your mouth, the inside of your cheek or on your tongue.

Assess risk behavior

Action	Content suggestions
Review “map” of participant stops and activities.	When your result is ready, we will look at it and talk about what it means. Then we will talk about how you can protect yourself and others from HIV. Is this clear?
Address immediate questions and concerns.	Before we go any further, do you have any concerns or questions you want to talk about right now?
Assess participant’s level of concern about having/acquiring HIV.	You may have some HIV risks or concerns like (list them) that we should talk about today. Do you feel you may be at risk of (getting/or having) HIV? Please tell me why.
Explore most recent risk exposure and behavior.	Tell me a little bit about the last time you may have put yourself at risk.
Assess participant’s level of acceptable risk.	What concerns, if any, did you have about this situation or about having sex with this person? Would you have done this if you (knew/thought) this person had HIV? Would knowing have made a difference?
Assess pattern of risk (occurring regularly, occasionally, in an unusual incident).	Let’s look at how often these risk situations happen.
Number of partners?	How many partners have you had in the past 6 months?
Types of partners?	Where do you meet your partners? How well do you know your partners?
Frequency of new or different partners?	Are you in a steady relationship (i.e., married, living as married, have a boyfriend) now?
Condom use?	How often do you use condoms? With which partners are you more likely to use a condom? With which partners are you less likely to use a condom? How do you decide with which partners to use condoms?
Drug injection practices?	Do you ever inject drugs? IF yes: Do you ever share your needle or works? How do you clean your needle and works?
Identify risk circumstances, triggers, and vulnerabilities.	Tell me what may be going on in your life that could be increasing the risks you take.
Assess partners’ risk.	Tell me of your concerns about your partners’ risk. For example, has (have) your partner(s) had sex with anyone else? Do you have any partners who inject drugs or have sex with someone else who injects drugs? What plans for the future do you and your partner(s) have?
Assess communication with partner(s).	What have you and your partner(s) talked about concerning HIV/STI risk?
Assess indicators of increased risk.	Have you ever been diagnosed with a sexually transmitted infection (an STI)? Have you or your partner(s) ever been diagnosed with TB?
Summarize the client’s situation and risk issues.	Here’s how I understand your situation concerning risks for HIV/STIs. (Summarize the key issues provided by the participant. This should not be a checklist.)
Risk pattern.	There are several issues that affect your risk behavior (list specific behavioral, communication, and substance use issues).
Risk triggers and risk vulnerabilities.	Is this how you see your risk behavior? Are there other issues we need to talk about?

Explore options for reducing risk

Action	Content suggestions
Review previous risk-reduction attempts.	What have you done to try to reduce your risk of acquiring/transmitting HIV? How have you tried to protect yourself and your partner(s) from STIs/HIV?
Identify successful experiences with practicing safer sex.	Is there a specific time you remember when you practiced safer sex? Can you tell me about the time and how you felt about it?
Identify obstacles to risk-reduction.	What has been the most difficult part of reducing your risk of HIV?
Explore triggers and situations that increase the likelihood of high-risk behavior.	How does alcohol or drugs affect you having high-risk sexual intercourse? Tell me what makes it more likely you’ll put yourself at risk. In what particular situations or with which partners do you find it difficult to negotiate or ask for safer sex?
Place risk behavior in the larger context of the participant’s life.	Are there times in your life when you feel it is more difficult for you to practice safer sex to protect yourself? What circumstances would cause you to behave in this way? Were you sad, unemployed, going through the pain of ending a relationship?
Assess condom skills.	How well do condoms work for you? Tell me of occasions when you have had problems using condoms. With which partners do you find it most difficult to use a condom?
Review safer drug injection practices and identify drug treatment options. (if applicable)	Let’s talk about how you can be safer when you inject drugs. There are drug treatment options available to you like (list them).
Identify entire range of options for reducing risk.	Tell me what would be easy for you to change and what would be more difficult for you. Why? You have some options for reducing your risk. (list.)
Role-play, build skills, problem solving. Repeat role play for additional partners if needed.	Imagine that I am your partner. What would you say to me about wanting to reduce your risk? Let’s switch roles, I’ll be you and you will play the role of your own partner. I’ll ask you to be tested, and you will respond as you imagine your partner would.
Address examples when the participant/s beliefs and behaviors are at odds or when feelings are mixed about changing behavior.	You have many HIV concerns, but you also don’t like using condoms. What is your alternative? You appear comfortable with having several partners, yet, at the same time you do not want to get HIV. Help me understand this.
Prioritize risk issues and reinforce past successes at avoiding risk.	So, you seem most at risk when you… (prioritize risks). You’ve been able to protect yourself when…(list circumstances that help the participant reduce risk).
Summarize risk-reduction options or discussion.	You have identified several ways of reducing your risk which seem comfortable for you. (List them.) Can you think of any other ways? You have a lot of choices for reducing your risk. We’ll settle on a specific plan later. First, let’s talk about the HIV test. As your plan may change depending on your test result.

Provide HIV-negative test result

Action	Content suggestions
Inform the participant that the test results are available.	Your test results are ready.
Provide results clearly and simply (show the participant the test results).	Let’s look at your test result, and then we’ll talk about how to best understand the result. The test result is negative, which means you have not been infected with HIV.
Explore the client’s reaction to the test results.	What does this result mean to you? How does it feel to hear that it is very likely that you are not infected with HIV?
Review the meaning of the results. Remind the participant of pre-test session.	Let me clarify that this means 3 months ago, which would be before __________, you were not infected with HIV.
Note the need to consider the test result in reference to the most recent risk exposure.	This result does not tell us about an exposure you might have had more recently. I encourage you be tested again in 3 months and that you also encourage your partner(s) to seek testing.
If the participant has ongoing risk, convey concern and urgency about the participant’s risk (as appropriate).	Let’s talk about a plan to reduce your risk.

Post-test Counseling (HIV-negative)

Negotiate risk-reduction plan

Action	Content suggestions
Identify priority risk-reduction behavior	What are the most important issues that we need to address to reduce your risk? Given what we have talked about, what do you think makes it most likely that you will again put yourself at risk of an STI or HIV?
Explore behavior(s) that the participant will be most motivated about or capable of changing.	We talked earlier about some options for reducing your risk. How would you most like to reduce your risk of STIs and HIV?
Identify a reasonable yet challenging incremental step toward changing the identified behavior.	What first step can you think of that you could complete in the next week that would move you closer to reducing your STI/HIV risks?
Break-down the risk-reduction action into specific and concrete steps.	Now that you’ve identified something you would like to do, tell me how you will go about making this happen. When do you think you could do this?
Identify supports or barriers to the risk-reduction step.	What could make it more difficult for you to complete this step? What could make it easier for you? If you are able to complete this step, how will you feel about it?
Problem-solve issues concerning the plan.	If something (specify) gets in the way of carrying out your plan, how will you handle it?
Role-play the plan. Repeat role play for additional partners if needed.	Let’s practice how you might deal with this. Imagine that I am your partner, what would you say? All right, let’s switch roles.

Negotiate disclosure and partner referral (HIV-negative)

Action	Content suggestions
Explore participant’s feelings about telling partner(s) about HIV negative test result.	What are your feelings about talking to your partner(s) about your test result? What are your concerns?
Remind participant that the results do not indicate partners’ HIV status.	It is essential that you understand that your test result does not indicate whether your sex partner(s) is/are infected with HIV. Your partner(s) must be tested to know his/her/their result.
Support participant to suggest that partner(s) seek testing.	Tell me your thoughts about asking your partner(s) to be tested. What would you do if your partner(s) had a positive result?
Anticipate potential partner reactions.	What do you think will be your partners’ reactions when you tell him/her/them your result and ask him/her/them to be tested? How have you and your partner(s) handled difficult conversations in the past?
Practice and role-play different approaches to disclosure. Repeat role play for additional partners if needed.	What would you like to say to your partner(s)? Let’s imagine that I am your partner. Tell me about your results and ask me to also get tested. I’ll pretend I’m your partner. It is good to practice.
End session, providing the participant motivation and encouragement.	You’ve really talked about a lot of issues today. It seems you are ready to make some changes that will protect yourself and your partner(s) from HIV. We hope you will share your experience with others and encourage them to be tested.

Provide HIV-positive test results for newly diagnosed HIV-positive person

Action	Content suggestions
Inform the participant that the test results are available.	Your test results are ready now.
Provide results clearly and simply (show the participant the test results).	Let’s look at your test result, and then we’ll talk about how to best understand the result. The test result is positive, indicating that you are very likely infected with HIV.
Review the meaning of the results.	The result does not mean that you have AIDS and does not show when you may become ill from the virus.
Allow the participant time to absorb the meaning of the result.	Take your time. We have plenty of time to talk about the test result.
Explore the participant’s understanding of the result.	Tell me what this test result means to you?
Acknowledge the challenges of dealing with a positive result.	You need to take time to adjust to learning this result, but in time you will be able to cope with this situation and continue with your life.
Assess how the participant is coping with the result.	It can be difficult dealing with knowing that you are infected with HIV. How are you doing? How are you feeling about the test result?

Perform Confirmatory oral HIV test (new positives)

Action	Content suggestions
Perform confirmatory oral HIV test	The test we did today is very accurate but I need to do a different oral HIV test to be certain the result is correct. I will give you another HIV testing pad to place between your cheek and gum until it is moist, and then hold it in your mouth for about 2 minutes.
Schedule appointment for confirmatory oral HIV test result.	The result of the confirmatory HIV test we just did will be ready in 2 weeks because it must be sent to a lab. Let’s set up an appointment for you to return to see me again then. It is very important for you to come back for this second test result.

Post-Test counseling (HIV-positive)

Identify sources of support and discuss living positively (new positives)

Action	Content suggestions
Assess whom the participant would like to tell about the positive test result.	Who can be supportive of you in dealing with this? You’ll want to tell someone you trust; someone who will keep your confidence. With whom would you like to share your test result?
Identify a family member or friend to help the participant through the process of dealing with HIV.	There are many issues you’ll want to address over time. It is sometimes helpful to have someone to help guide you and assist you as you weigh options and make decisions.
Coping and support.	Who could help you with this?
Planning for the future.	Who could help you as you adjust to living with HIV?
Discuss living positively- staying well, living longer. If the participant is not prepared for this discussion, provide them with a pamphlet.	Many people who are infected with the virus are living well. Do you know anyone who is HIV infected and living well? Have you heard about positive living? Let’s talk about that. Paying attention to your emotional and physical health and your medical care are important elements of living positively. Who will support you in these areas?

Negotiate risk-reduction plan: Prevention with Positives

Action	Content suggestions
Discuss prevention with positives strategies	There are things you can do to avoid getting STIs and other HIV-related infections. Describe ways the participant can protect herself from STIs and other infections. Describe ways the participant can prevent transmitting HIV to others.
Identify priority risk-reduction behavior	What are the most important issues that we need to address to reduce your risk?
Explore behavior(s) that the participant will be most motivated about or capable of changing.	We talked earlier about some options you have for reducing your risk. How would you most like to reduce your risk?
Identify a reasonable yet challenging incremental step toward changing the identified behavior.	What first step can you think of that you could complete in the next week that would move you closer to reducing your risks?
Break-down the risk-reduction action into specific and concrete steps.	Now that you’ve identified something you would like to do, tell me how you will go about making this happen. When do you think you could do this?
Identify supports or barriers to the risk-reduction step.	What could make it more difficult for you to complete this step? What could make it easier for you? If you are able to complete this step, how will you feel about it?
Problem-solve issues concerning the plan.	If something (specify) gets in the way of carrying out your plan, how will you handle it?
Role-play the plan. Repeat role play for additional partners if needed.	Let’s practice how you might deal with this. Imagine that I am your partner, what would you say? All right, let’s switch roles.

Negotiate disclosure and partner referral (new positives)

Action	Content suggestions
Explore participants’ feelings about telling partner(s) about the HIV positive test result.	Have you thought about discussing your test result with your partner(s)? What are your feelings about talking to your partner(s) about your test result? What are your concerns?
Remind the participant that the result does not indicate partners’ HIV status.	It is essential that you understand that your test result does not show what your sex partner’s result will be. Your partner may not yet be infected.
Identify partners that are at risk and need to be informed of their risk of HIV infection.	Who do you believe may need to know about your result? Are there particular partners you are worried about?
Discuss possible approaches to disclosure of serostatus to partner(s).	How will you tell your partner(s) about your test result? What will you say? Will this be difficult for you?
Support client to refer partner(s) for testing.	Your partner(s) must be tested for him/her/them to know their status. Tell me your feelings about asking your partner(s) to be tested? How will you and your partner(s) handle it if your partner is HIV negative?
Anticipate potential partner’s reactions.	How do you think your partner(s) will react when you talk about your HIV status? How have you and your partner(s) handled difficult conversations in the past?
Practice and role-play different approaches to disclosure. Repeat role play for additional partners	Let’s imagine that I am your partner. Tell me about your results and I will respond. It is good to practice.
Provide participant with support.	We have talked about a lot today. It is a challenge to deal with being HIV positive. However, with time and support, you will adjust and will be able to live positively.

Action	Content suggestions
Assess the participant’s plan to reduce risk of transmission to current partners.	Tell me how you/how you plan to protect your partner(s) from getting HIV. How will you be intimate and close without spreading HIV?
Explore the participant’s plan for reducing the risk of transmission to future partners.	When you have a new partner, what are you going to do you protect that partner from getting HIV?
Address disclosure of HIV status to future partners.	How will you tell your new partner(s) about your HIV infection?
Encourage the client to protect others from HIV.	It is important for you to care for yourself and to protect others from HIV. You can do this by making sure you practice safer sex and drug behaviors.

Discuss HIV medical treatment and provide case manager referral (new positives)

Action	Content suggestions
HIV Medical follow-up.	Getting medical care for your HIV is very important so you can stay healthier. Where do you go when you need medical attention?
Identify the participant’s current health-care resources.	When was the last time you received medical care? How difficult is it for you to get access to care (transport, resources, and so on)?
Address the need for health-care providers to know participant’s test result.	It is important that you discuss this test result with your doctor.
Address linkage to HIV medical care	I can help put you in contact with someone who can help you get medical care for your HIV. Would you like to talk with that person?
End session, providing the participant motivation and encouragement.	You’ve really talked about a lot of issues today. It seems you are ready to make some changes that will help you live positively and protect yourself and your partner(s).

Returning for HIV-positive confirmatory test results

Action	Content suggestions
If oral confirmatory test is positive: Provide results clearly and simply (show the participant the test results).	Let’s look at your test result, and then we’ll talk about how to best understand the result. Your second oral HIV test result is positive. This means you are infected with HIV.
Assess how the participant is coping with the result.	It can be difficult dealing with knowing that you are infected with HIV. How are you doing? Review providing HIV-positive test results- if needed.
Review support and positive living.	Have you told anyone that you are HIV-positive? Who did you tell? Review support and positive living discussion.
Review risk reduction.	Last time we talked about things you could do to stay safer. How have you been doing with that plan? Review negotiating a risk reduction plan.
Re-visit disclosure and partner referral.	Have you been able to tell your partner (s) that you have HIV? Review partner notification and referral- if needed.
End session and contact case manager.	We talked about how important it is for you to get medical care for your HIV. Would you like me to call the case manager I/you talked with you before to help you with this?

Returning for HIV-negative confirmatory test results

Action	Content suggestions
If oral confirmatory test is negative: Provide results clearly and simply.	Let’s look at your test result, and then we’ll talk about how to best understand the result. Your second result is negative. Your second oral HIV test did not give us a final result. We are not sure if you have HIV or not. This happens rarely and can be upsetting. How are you doing?
Discuss confirmatory blood test	When one oral HIV test is positive and one is negative, we must do a blood test to check for HIV. We need to wait 2 weeks to do this blood test.
Schedule appointment for confirmatory blood test result.	Let’s make and appointment for you to get your blood test result in 2 weeks. It is very important for you to come back for this HIV blood test result.
Review risk reduction and end session.	Last time we talked about things you could do to stay safer. How have you been doing with that plan? Review negotiating a risk reduction plan.

Returning for indeterminate confirmatory test results

Action	Content suggestions
If oral confirmatory test is indeterminate: Provide results clearly and simply.	Let’s look at your test result, and then we’ll talk about how to best understand the result. Your second result is uncertain. Your second oral HIV test did not give us a final result. We are not sure if you have HIV or not. This happens rarely and can be upsetting. How are you doing?
Discuss confirmatory blood test	When one oral HIV test is positive and one is uncertain, we must do a blood test to check for HIV. We need to wait 2 weeks to do this blood test.
Schedule appointment for confirmatory blood test result.	Let’s make and appointment for you to get your blood test in 2 weeks. It is very important for you to come back for this HIV blood test result.
Review risk reduction and end session.	Last time we talked about things you could do to stay safer. How have you been doing with that plan? Review negotiating a risk reduction plan.