How this Course Works

This online course provides the information that forms the foundation for the
HIV Counselor Training you will be attending soon. Both trainings build on
almost 30 years of experience talking with people about stopping the
transmission of HIV.

This online course is separated into reading modules, followed by a 34-

question quiz. There is no time limit to complete the reading or quiz. Once you
begin the quiz, you may go back to the readings. However, you may only
submit your quiz answers once. Your quiz will be scored by a training
administrator, and you will receive an email with your score. You need at least
80 percent of correct responses in order to be eligible to sign up for the
training. If you do not pass on the first try, you will receive an email notification
and then can re-take the quiz one more time after reading the material again.
HIV/HCV/STI Test Counselor
Pre-Training Materials

2022
 Training Modules
1 – HIV, the Basics
2 – HIV Transmission Continuum & HIV Toolkit
3 – What is HIV Testing and Counseling
4 – Things to know before you become a counselor
5 – Hepatitis C, a brief overview
6 – The Counseling Session
 Module 1: HIV, the Basics…
Goal:
This module will present an overview of the basics of how HIV passes from
person to person, and a brief description of who is at risk for HIV in
California and San Francisco.
Learning Objectives:
At the end of this module participants will be able to:
1.Differentiate basic HIV concepts, such as: exposure, infection,
modes of transmission, replication, infectious/non-infectious body
fluids
2.Explain the effects of HIV in the human body
3.Express basic HIV Stage 3 concepts such as diagnosis and
opportunistic infections
4.Evaluate basic local HIV epidemiology
 H uman
I mmunodeficiency
What are HIV and AIDS?
V irus

A cquired
I mmuno
D eficiency
Syndrome
 What is HIV?
➢A retrovirus transmitted only between humans

➢Multiplies inside specific cells of the immune system

➢Destroys immune system cells

➢Causes inflammation of arteries and of the heart

➢Causes a condition called HIV Stage 3 (formerly AIDS)

HIV Invades CD4+ Cells
➢HIV invades CD4+ cells, also
known as T-cells, which play a
critical role in our immune system.

➢Once inside a CD4+ cell, the virus

uses the cell to create more virus.
In the process, HIV destroys the
original cell.

➢As more and more immune system

cells are destroyed, the body has a
harder time fighting off both HIV
and other illnesses.
 Stages of HIV
➢Stage 1 – Acute Infection
Within 2-4 weeks after infection, people may experience a flu-like
illness, which may last for a few weeks. This is the body’s natural
response to infection. People have large amount of virus in their blood
and are very contagious. Sometimes, people don’t get sick at all. To
know whether someone has an acute infection, either a fourth-
generation or nucleic acid test (NAT) is necessary.
➢Stage 2 – Asymptomatic or Chronic Infection
HIV is active but reproduces at very low levels. For people not taking
HIV medicine, this period can last a decade or longer but some
progress through this stage faster. People on HIV medication may be in
this stage for decades. People can still transmit HIV to others during
this phase, although people who stay virally suppressed are much less
likely to transmit HIV.
➢Stage 3 – formerly Acquired Immunodeficiency Syndrome (AIDS)
The immune system is damaged so badly people get an increasing
number of severe, opportunistic illnesses. People with Stage 3 HIV can
have high viral loads and be very infectious.
Source: www.CDC.gov/actagainstaids/basics/whatishiv.html
 Opportunistic Infections (OIs)
OIs are illnesses that take advantage of a
person’s weakened immune system. OIs
do not normally appear in persons with
healthy immune systems.

The Centers for Disease Control and

Prevention (CDC) have generated a list of
40 OIs, which includes: Kaposi’s sarcoma,
pneumocystis jirovecii pneumonia,
Toxoplasmosis, Cryptococcal Meningitis,
Mycobacterium Avium Complex (MAC),
Cytomegalovirus retinitis, among others.
 What Gives an
HIV Stage 3 (AIDS) Diagnosis?

➢ HIV positive, AND

➢ CD4+ (T-cell) count below 200

➢ And/orpresence of one or
more opportunistic infections
 Viral Load (VL)
Viral load is the amount of HIV in a
sample of blood. HIV medications
fight HIV and work to keep the virus
from making copies of itself. VL tests
are used along with the CD4+ cell
count to monitor the status of HIV
disease, guide recommendations for
therapy, and predict the future
course of HIV. It is important to keep
VL at an undetectable level.
 Undetectable Viral Load?
What is that?
It means that:
➢the level of HIV is below the threshold needed for detection
➢the risk of transmitting HIV has decreased but has not been eliminated

It does not mean a person’s HIV infection is gone.

The CDC has confirmed that recent published research shows that
“people who take ART [antiretroviral therapy] daily as prescribed and
achieve and maintain an undetectable viral load have effectively no
risk of sexually transmitting the virus to an HIV-negative partner."

*McCray, Eugene. Mermin, Jonathan. “Dear Colleague.” 27 Sept. 2017. Dear Colleague Letters. CDC
 Exposure vs. Infection
➢ HIV exposure happens
when infected body
exposure fluids come in contact
with a person (see
transmission slide)

➢ HIV infection happens

when the virus enters a
infection human cell and
multiplies, creating more
viruses

Not every case of exposure will result in HIV infection.

 Infectious Bodily Fluids
Body fluids containing HIV at levels high enough to infect someone else include:

➢ Blood
➢ Semen

➢ Pre-ejaculate

➢ Vaginal

Secretions
➢ Breast Milk

(for infants)
 Non-Infectious Bodily Fluids
➢ Saliva
➢ Tears

➢ Sweat

➢ Urine

➢ Sputum

➢ Nasal secretion

➢ Feces

Small traces of HIV have been found in some of the body fluids mentioned
above. However, the amount of virus present is so small that these body
fluids are not able to transmit HIV. These fluids only present a risk for HIV
transmission if they are mixed with blood.
 Requirements for Infection
The following three factors need to happen in order for HIV to cause infection:

1. HIV must be present,

2. In sufficient quantities to cause infection,
➢ Ex: Blood, Sexual fluids, Breast milk

3. And be able to get into the bloodstream

➢ Directly through damaged skin or through
injection
➢ Absorption through mucous membranes

If you remove one of these factors, infection cannot take place.

 HIV is transmitted through….

Unprotected anal Vertical Sharing Contact with

and vaginal sex transmission needles and infected blood
with an HIV from HIV equipment with during health
positive partner. infected mother an HIV positive care or other
or birthing person. occupational
parent to child. exposure.
How to explain HIV & oral sex
The risk of HIV transmission from
oral sex is extremely low. Though
the presence of cuts, bleeding
gums, or STIs can elevate the
risk. Options for lowering the risk
of transmission during oral sex
include using a barrier like a
condom. If a client does not want
to use condoms, not allowing
partners to ejaculate into the
mouth offers some protection.
 HIV is NOT transmitted by:
➢ Hugging ➢ Swimming pools or hot tubs
➢ Kissing ➢ Casual contact with
➢ Massage someone who has HIV
➢ Shaking hands (sharing dishes, food,
showers or toilets, phone)
➢ Insect bites
➢ Casual contact with saliva,
➢ Pets
tears, sweat, or urine
➢ Donating blood

The U.S. National Institutes of Health and the U.S. Centers for Disease Control and
Prevention have found that none of the above are ways that people contract the virus.
What does HIV look like in SF?
Note: the identity words used in this slide were the original identity categories listed in the study.

➢ 70% of those who newly diagnosed with HIV infection

are men who have sex with men (MSM) including
MSM who inject drugs (MSM-PWID, 9%)

➢ 28% are between ages 18 and 29

➢ 31% are between ages 30 and 39
➢ 19% are between ages 40 and 49

➢ 21% are Black/African American (5.7% of SF residents

are African American)

➢ 37% are Latinx (15.7% of SF residents are Latinx)

➢ Transgender women make up 4% of those living with

HIV in San Francisco
Source: SFDPH HIV Epidemiology Annual Report 2020
 What does HIV look like in SF?

Source: SFDPH HIV Epidemiology Annual Report 2020 (to view the entire report, please visit bit.ly/3yDgkgy)
Module 2: HIV Transmission
Continuum and HIV Toolbox
Goal:
This module will present the HIV transmission continuum
and some ways to reduce the chance of sexual and
substance use transmission of HIV and the concept of
harm reduction.

Learning Objectives:
At the end of this module, participants will be able to:
1. Apply the continuum in HIV counseling
2. Convey different options that might lessen the chance
of infection
3. Explain the concept of harm reduction
 HIV Transmission
Continuum
Different sexual and substance use activities pose different risks for HIV
transmission. It may be easier to think of risk in terms of a continuum where
some activities carry more HIV risk than others. As a counselor, you might rely
on this continuum to help clients think of small, incremental steps to reduce
the chance of infection. For example, if a client is not going to use a condom,
substituting oral sex for anal intercourse is a step that dramatically reduces the
client’s chance of contracting or transmitting the virus.
 HIV Transmission
Continuum
No Transmission High Transmission

Mutual Masturbation Insertive vaginal Receptive anal sex

sex without a (bottoming) without a
Receptive Performing condom with a condom with a positive
oral sex unprotected positive partner partner
oral sex Sharing of used
Using a new Insertive anal
unused needle needle with positive
sex (topping)
partner
Kissing Oral-Anal without a
contact condom with a
Oral sex with a Receptive vaginal sex
(Rimming) positive partner
condom without a condom
with a positive partner

Note: If either partner has an STI or if there is blood present, activities listed as no to low transmission can become higher modes of transmission.
If a condom, either external or internal condom, is used properly with any of the activities, the risk is decreased to almost none.
 HIV Prevention Tool Kit
There are many tools we use as HIV test counselors to
help reduce the transmission of HIV. In the next slides we
will talk about these in greater detail.
How to Prevent HIV During Sex
People can prevent HIV infection
during sex by not taking blood,
semen, pre-ejaculate, or vaginal
secretions into the mouth, vagina,
or anus. The following slides offer HIV
other options that might lessen
the chance of infection during
sex:
 Condoms
When used properly, external
condoms and internal condoms (for
example, FC2 brand), and other
latex barriers are effective
prevention methods. Condoms
nearly eliminate the risk of HIV
transmission during anal and
vaginal intercourse. Make sure to
check the expiration date on the
condom as well as use the
appropriate lubrication for the
product (see lube slide).
 FC2 for Rectal Use
Hold the pouch with the open end hanging
down. Squeeze the inner ring with your
thumb and middle finger.
Gently insert the inner ring Until you and
into the anal opening. as your partner
shown in image. become
Take your time. If the FC2 is comfortable
slippery to insert, let it go using the FC2, With your index finger
use your hand inside the condom, push
and start over.
to guide the the inner ring up the anal
penis into the canal. For maximum
anus. protection, insert it past
the sphincter muscle.
To take out the
FC2, squeeze and
twist the outer ring
to keep the sperm
inside the pouch.
Pull out gently and
throw away. http://www.sfcityclinic.org/providers/FC2AnalSexENGL.pdf
 Use Lube for
Vaginal and Anal Sex
Lubrication can help to
prevent tears in mucous
membranes, which could
lower the risk of transmission.
Make sure to use lubricants
that are compatible with any
latex product you are using.
Water-based and silicone
lubricants are always safe to
use with any kind of condom.
Test and Treat STIs
Individuals who are infected with STIs are at
least two to five times more likely than
uninfected individuals to acquire HIV
infection if they are exposed to the virus
through sexual contact. In addition, if an
HIV-infected individual is also infected with
another STI, that person is more likely to
transmit HIV through sexual contact than
other HIV-infected persons (Wasserheit,
1992). This is why screening or referring to
STI testing and treatment during a session
is important.
 Pre-Exposure Prophylaxis
Pre = before
Exposure = coming into contact with HIV
Prophylaxis = treatment to prevent an infection from happening

PrEP is an HIV prevention strategy where HIV-negative individuals take anti-

HIV medications before coming into contact with HIV to reduce their risk of
becoming infected. The medication works to prevent HIV from establishing
infection inside the body.

It has been shown to reduce the risk of HIV infection through sex for gay and
bisexual men, transgender women, and heterosexual men and women, as well
as among people who inject drugs. It does not protect against STIs.
PrEP Should be Discussed with…
PrEP should be discussed for anyone who has a sexual partner who is HIV positive, someone
who is sharing injection equipment on a regular basis with someone who is HIV positive, or
someone who is inquiring about PrEP.
MSM / Gay or Bisexual Men / Trans & Gender Nonconforming (GNC) Persons
❑ Anal sex without condoms ❑ Multiple sexual partners
❑ History of STI: STI (Rectal ❑ HIV+ sex partner
Gonorrhea/Chlamydia or Syphilis) ❑ Anticipated risk (we will cover in
in the last six months Mod 4)
People who Inject Drugs (PWID) Heterosexual Women and Men
❑ Sharing injection equipment ❑ Sex with MSM
❑ Recent drug treatment ❑ Doing commercial sex work
❑ Risk of sexual acquisition ❑ Sex without condoms with partners
of unknown HIV status at risk for HIV

Anyone who asks for PrEP!

* Adapted from SFCC and CDC current guidelines.
 Pre-Exposure Prophylaxis
PrEP is a powerful HIV prevention tool. However, for sexually active people, no prevention
strategy is 100% effective. Therefore, individuals who use PrEP should use it along with
other effective HIV prevention strategies. These include:
➢Using condoms consistently and correctly
➢Getting HIV testing with your partners
➢Getting STI testing with your partners
➢Choosing less risky sexual behaviors, such as oral sex
➢If you inject drugs, participating in a drug treatment program or using sterile drug
injection equipment.

Also, PrEP is only for people who are at ongoing substantial risk of HIV infection. For
people who need to prevent HIV after a single high-risk event of
potential HIV exposure – such as sex without a condom,
needle-sharing injection drug use, or sexual assault
- there is another option called postexposure prophylaxis
(PEP) as explained in the next slides.
Post-Exposure Prophylaxis (PEP)
Post = after
Exposure = coming into contact with HIV
Prophylaxis = treatment to prevent an infection from happening

Post-exposure prophylaxis (PEP) is an HIV prevention strategy where

HIV-negative individuals take HIV medications after coming into
contact with HIV to reduce their risk of becoming infected. PEP is a
month-long course of drugs and must be started within 72 hours (three
days) after possible exposure.

These medications keep HIV from making copies of itself and

spreading through your body. PEP consists of 2-3 antiretroviral
medications and should be taken for 28 days. A doctor will determine
what treatment is right based on how the client was exposed to HIV.
 Is PEP Safe?

PEP is safe but may cause side effects like

nausea in some people. These side effects can
be treated and are not life-threatening. PEP is
not 100% effective; it does not guarantee that
someone exposed to HIV will not become
infected with HIV.
 Linkage and Retention in
Care and Treatment
As we learn more about how early access to
treatment and how retention in care help HIV
positive people stay healthy longer, we also
start to see how this helps reduce people’s viral
loads and reduce transmission. For people
found to be in the acute stage, it is important
that they start treatment within 24 hours of
diagnosis.
 What does Sero mean?

Sero = the Latin prefix meaning “blood

serum”

Example:
Serostatus = status of the blood
 Serosorting

Some people make a practice of only

having sex with people of a specific HIV
status. This could be the same as or the
opposite of their HIV status. This is called
serosorting. The advantages and
limitations of serosorting can be a rich
topic of conversation during a counseling
session.
Seropositioning
Strategic positioning, also known as
seropositioning, is the act of choosing a
different sexual position or practice
depending on the serostatus of one’s
partner.
While strategic positioning does not
eliminate the risk of HIV transmission, it is
practiced based on evidence that there is
a lower relative risk for HIV acquisition
per-contact when HIV-negative partners
engage in insertive anal sex, compared to
receptive anal sex with a HIV-positive
partners.
 Substance Using Activities
and HIV Transmission
People can prevent HIV infection during
substance using activities by not
sharing any equipment that has come
into contact with blood. The following HIV
slides offer other options that might
lessen the chance of infection during
these activities.
 Injection Drug Use
Some substance using populations are at risk for
HIV transmission based on the way they are
using substances. Injection Drug Use (IDU) is at
the highest end of that continuum as HIV and
Hep C can live in the barrel of a needle.

In San Francisco, a network of community based

organizations, in partnership with the health
department, provide safe and accessible
locations where people can safely dispose of
and retrieve new unused syringes and supplies
across the city.
Syringe Access and Disposal
Syringe access is an essential component of
prevention activities. Programs not only provide people
access to sterile equipment and reduce HIV
transmission and acquisition, but also promote safe
disposal of syringes and lead to fewer syringes found
on the streets, as compared to cities without syringe
access.

These programs ensure that PWID (people who inject

drugs) populations have access to sterile injection
equipment to prevent the transmission of HIV and viral
hepatitis. These programs can also connect clients to a
wide range of community and health services.
 Naloxone (Narcan®)
Naloxone, also often referred to as Narcan®
(brand name), is the antidote that reverses an
opioid overdose. It's legal and has been
approved by the Food and Drug Administration
(FDA). It works by neutralizing the opioids in the
system and helping the person breathe again.
Naloxone only works if a person has opioids in
their system; the medication doesn't work on
other drugs.

It has been used in programs all over the world

to effectively reverse opioid overdoses. There
are two kinds of naloxone, one that you can
squirt up someone's nose and another that can
be injected through clothing into a muscle.
 Concept of Harm Reduction
Harm reduction is both a public health
philosophy and behavioral practice. Harm
reduction promotes methods of reducing
the physical, social, emotional, and
economic harms associated with drug and
alcohol use, sexual activity, and other risk
behaviors on individuals and their
community.

Harm reduction methods and treatment

goals are free of judgment or blame and
directly involve the client in setting their
own goals.
 Harm Reduction
➢ Meet people “where they’re at,” but don’t leave
them there

➢ Support clients in making any positive change

➢ Although the concept of harm reduction was

developed by substance users and their
counselors, the principles are applicable to
many other kinds of activities.
– Example of harm reduction: switching to

more oral sex and less anal sex reduces

the risk of HIV transmission
Harm Reduction Approaches
Here are some suggestions adapted from the Harm Reduction
Coalition and Training Institute for working with clients on harm
reduction:
➢ Maintaina policy of respect for all clients: Recognize and set aside
judgments about drug use and sexual behaviors
➢ Focus on a client’s strengths and abilities
➢ Support all positive changes
➢ Let people identify and set their own priorities
➢ When asked, provide accurate and honest information about the
possible harm of drug use and sexual behaviors, both in general
and specifically in terms of the client’s life
Module 3: HIV Testing & Counseling

Goal:
This module will describe 2 different types of HIV tests and
present the principles of HIV counseling.

Objectives:
At the end of this module participants will be able to:
1.Understand the goal and characteristics of HIV test
counseling
 What is HIV Testing?
➢ HIV testing is a health tool people use to
find out if they are infected with HIV

➢ Conventional HIV tests are designed to

detect HIV antibodies*

➢ Other more specific tests can detect

antigens**, or even the virus itself (RNA)

*Antibodies are proteins produced by the body's immune system in response to harmful or
foreign substances.
**Antigens are pathogens that stimulate the production of an antibody when introduced into
the body. Antigens include toxins, bacteria, viruses, and other foreign substances.
 Antigens & Testing
➢ Antigens - pathogens or parts of a pathogen
(virus, bacteria, fungi and parasites) that
cause the body to produce antibodies

➢ One HIV antigen is a protein called p24

which is found in the core structure of the
human immunodeficiency virus

➢ Conventional HIV rapid tests are designed to

detect HIV antibodies

➢ New antigen rapid tests can detect the p24

antigen
 Testing - Antigen & Antibody
➢ Antigens are detectable within approximately the first 6 weeks
of a new infection, possibly as soon as 12 days (see next slide)

➢ Antigen testing can detect acute infections (a time when people

could be most infectious) sooner than antibody testing

➢ Antibody testing detects chronic infections after

the presence of antigens are no longer detectable

➢ Antigen testing will not detect infections in “late testers” (people

who develop AIDS within a year of testing positive for HIV) or
in people who test more than 6 or 7 weeks after becoming
infected
Markers for HIV infection vary over
time
• Viral RNA is first
detectable marker
• 4th generation P24
Antigen (Ag) rapid
test is second
• 3rd generation
antibody rapid test is
third
The 1st and 2nd generation
antibody laboratory tests of
years ago would take a
4th Gen Ag
matter of months before
Modified after Busch et al. Am J Med. 1997 detecting antibodies
 What Is Counseling?
➢ Counseling is a two-way communication
process that helps individuals:
➢ Examine personal issues

➢ Make decisions

➢ Make plans for taking action

➢ In HIV counseling and testing the focus is to

help clients come up with ways to reduce
their exposure to HIV/STIs
 HIV Counseling Involves
➢ Active listening

➢ Being client focused

➢ Maintaining confidentiality

➢ Asking questions

➢ Supporting clients in making their own

decisions

➢ Helping
clients find other services they
may need
 HIV Counseling is NOT
➢ Advising clients what to do
➢ Criticizing clients
➢ Forcing ideas or values on clients

➢ Fixing anything for the client

➢ Internalizing clients’ resistance or ambivalence to change

The purpose of counseling is to help clients come up with their own

plans for reducing risk. As counselors, we can give some queues
regarding the possible pros and cons to a decision, but we are not to
give advice, pass judgment, or force our ideas as to what we believe
the client should decide.
People are the experts in regards to their lives!
Module 4: Things to Know Before
You Become a Counselor
Goal:
This module will present the basic concepts of the stages of
change, the window period, and clients’ context
Learning Objectives:
At the end of this module participants will be able to:
1. Name the 5 Stages of Change
2. Identify appropriate interventions for each stage of
change
3. Understand and explain the “Window Period”
4. Apply the concept of context when counseling clients
 The Stages of Change
If you have ever tried to stop smoking, you know how hard it is. Going through
this process, you probably went through several stages, starting with not
wanting to change at all. Maybe later you considered the pros and cons of
changing for a long time. Perhaps you had a few unsuccessful attempts before
you succeeded in making a change, or maybe you’re still thinking about
whether you want to try. That is totally normal.

Two researchers, James Prochaska and Carlo DiClemente, discovered that

there is a series of Stages of Change that almost everyone goes through when
faced with changing an ingrained behavior.

As HIV test counselors, understanding the Stages of Change is important. The

more we adapt our discussion with a client to the client’s stage, the more likely
we are to be effective. Let’s look at those stages.
The Stages of Change
According to Prochaska
and DiClemente, there are
five stages of change:

➢ Precontemplation
➢ Contemplation
➢ Preparation (Ready for
Action)
➢ Action
➢ Maintenance
 Stages of Change:
Characteristics
➢ It is not realistic to expect change
after a single intervention
➢ Once clients initiate behavior
change, they are susceptible to
reverting to a previous stage at any
time
➢ Clients may go forward and
backward through stages
repeatedly
➢ Successful change involves not
only restructuring patterns of
behavior, but also restructuring
thoughts about oneself and one’s
actions
 Staging Interventions
➢ When counseling clients around changing behaviors, it can be most
helpful to match an intervention with their stage of change

➢ Intervention: An action by the counselor that results in a change in

the client’s thinking or understanding of themselves or their
behaviors in relation to HIV

On the following screens, we’ll look at each stage

one at a time.
Read the following slides carefully!
 People in the
Precontemplation Stage…
➢ Have no intentions to change their
behavior, they have difficulty in seeing
that a problem exists in the first place

➢ Areunaware of their HIV risk or deny

the adverse outcome that could
happen to them or others

➢ Have made a decision not to change

behavior, which can be due to
personal safety or other survival
issues
Precontemplation: Appropriate Interventions
➢ Establish rapport and build trust
➢ Follow the client’s lead to get a sense if they want to talk about their risks
➢ Get a reaction, either cognitive or emotional
➢ Help them think about their risk taking behavior patterns by:
➢ Offering factual information about the risks of having unprotected sex and needle sharing
(keep to a minimum as information alone rarely changes behavior)
➢ Exploring the meaning of events that brought the client to testing
➢ Eliciting the client’s perceptions of the problem
➢ Exploring the pros and cons of risk taking behaviors
➢ Examining discrepancies between the client’s and others perceptions of the problem
behavior
➢ Express concern and keep the door open
People in the Contemplation Stage…
➢ Recognize that a problem exists and seriously think
about changing a behavior but have not yet
committed to action. The contemplation stage can
last for long periods of time.

➢ Know where they want to go but are not ready to do

what is necessary to get there.

➢ Spend considerable effort weighing the pros and

cons of the problem and its solutions. However, they
can’t maintain the change and sustain the new
behaviors that change requires.
Contemplation: Appropriate Interventions
➢ Normalize ambivalence

➢ Help the client “tip the decisional balance scales” toward change by:
➢ Eliciting and weighing pros and cons of engaging in risk behaviors and
change
➢ Changing from external to internal motivation
➢ Examining client’s personal values in relation to change

➢ Emphasizing client’s free choice, responsibility, and self-efficacy for change

➢ Elicit self-motivational statements of intent and commitment from client

➢ Elicit ideas regarding client’s perceived self-efficacy and expectations regarding

change

➢ Summarize self-motivational statements

 People in the Preparation Stage…

➢ Bringtogether the intention to change and

the preliminary behavioral efforts to make
the change.

➢ Need work on strengthening commitment.

Preparation:
Appropriate Interventions
➢ Clarify the client’s own goals and strategies for change
➢ Consider and lower barriers to change
➢ Help the client enlist social support
➢ Elicit from the client what has worked in the past either
for them or others who they know
 People in the Action Stage…

➢ Make adaptations in order to change their

attitudes, behaviors, or environment.
➢ Try new behaviors, but these are not yet stable.
➢ Have spent a considerable time and energy
altering their behavior and their change is
notable
➢ Are particularly susceptible to returning to an
earlier stage
Action: Appropriate Interventions
➢ Engage the client in talking about new behaviors and
reinforce the importance of maintaining them
➢ Support a realistic view of change through small steps
➢ Acknowledge difficulties for the client in early stages of
change
➢ Help the client identify high-risk situations and develop
appropriate coping strategies to overcome these
➢ Assist client in finding new motivations for positive
change
➢ Help client assess support networks
People in the Maintenance Stage…

➢ Focus on sustaining a change in behavior,

preventing a return to previous behavior, and
consolidating the gains of the action stage.

➢ Maintenance was once considered static. It is

now viewed as the continuation of change, rather
than its absence. “Once you’re there, there is still
plenty of work to do.” Returning to an earlier
stage is always possible.
 Maintenance:
Appropriate Interventions
➢ Acknowledge the client’s resolve to maintain lower risk
behaviors
➢ Support lifestyle changes
➢ Affirm the client’s resolve and self-efficacy
➢ Help client practice and use new coping strategies to avoid a
return to previous behaviors
➢ Review long-term goals with the client
 Revisiting old behaviors…

➢ Sometimes, people experience

a recurrence of their risk
behavior(s) and must now cope
with the reality and decide what
to do next.
➢ This may be a sustained return
to a previous behavior(s) or a
brief episode.
Return to old behavior(s): Appropriate Interventions
➢ Normalize returning to old behavior(s)

➢ Help the client reenter the change cycle and commend

any willingness to reconsider positive change

➢ Explore the meaning and reality of the recurrence as a

learning opportunity

➢ Assist the client in finding alternative coping strategies

➢ Maintain supportive contact

 In Summary…
➢ Assessing a client’s stage of change and negotiating a stage
appropriate intervention can help clients make decisions to reduce
their risk for HIV.

➢ Participants who revisit previous behavior(s) or revert to a previous

stage tried to do something different. They didn’t fail. It just didn’t
work and they need to revisit their steps, amend them, and try again.
Each time a person goes through the cycle, they learn from each
time they return to old behavior(s) and grow stronger.
 HIV Window Period

The time it takes for a

test to detect the
presence of antibodies,
antigens or virus.

NOTE: The window period will vary depending on the testing technology you are using.
 HIV Window Period
Date of the last 1 2 3 4 5 6
time you may month later months later months later months later months later months later
have been at risk

June 1st July 1st Sept 1st Dec 1st

Sometimes Most people Most people You may

antibodies develop develop want to
will be antigens by antibodies by retest to
detected in the end of 4 the end of 3 close the
as early as weeks months (13 window
2 weeks weeks)

As testing technologies advance, this window period becomes shorter.

Module 5: Hepatitis C Brief Overview
Goal:
This module will present a basic overview of hepatitis C.

Learning Objectives:
At the end of this module participants will be able to:
1. Describe what is hepatitis C
2. Asses who should be tested for hepatitis C
3. Identify the different types of hepatitis C testing
4. Provide appropriate counseling based on the clients
test result
 What is Hepatitis C (HCV)?

➢ RNA virus
➢ Transmitted primarily by blood (mostly IDU)
➢ Approximately 4 million with HCV in U.S.
➢ 50-75% unaware of infection

➢ Causes chronic infection in 3 out of 4 people

➢ Can cause liver disease, liver cancer, death
➢ Can be treated and, in some cases, cured
➢ There is no preventable vaccine for Hepatitis C
HCV is transmitted through...

Sharing Contact with Unprotected

needles and infected blood anal and
equipment during health vaginal sex
with an HCV care or other with an HCV
positive occupational positive
person. exposure. partner.
Hepatitis C: Who Should be Tested?*

➢ Ever injected drugs, even once, years ago

➢ HIV-positive MSM and trans women who have sex
with men
➢ Have used intranasal drugs
➢ Have smoked stimulants
➢ Ever snorted drugs

*Priority groups for hepatitis C testing in non-healthcare settings

 Types of Hepatitis C Tests
➢ Hepatitis C antibody (conventional and rapid testing)
➢ Used to detect the presence of the hepatitis C antibodies

➢ It confirms there was an infection but it does not tell us if there is a current

or chronic infection
➢ About one in four people who have acute hepatitis C clear the virus

naturally without treatment. These people will have antibodies but no

virus
➢ Unlike HIV, this is not a diagnostic test

➢ Hepatitis C nucleic acid test (NAAT) (confirmation)

➢ Used to detect the presence of the hepatitis C virus

➢ This tests confirms current infection

Hepatitis C Window Period
 What Happens After Someone is
Tested?
Hepatitis C antibody Hepatitis C antibody Hepatitis C NAAT
non-reactive reactive reactive

▪Conduct or refer to
▪Discuss window period ▪Referral to primary care
diagnostic testing
(2 wks to 6 mths) provider
▪Discuss social
▪Risk reduction ▪Discuss social support
support
▪Referrals ▪Make plan until follow-
▪Make plan until follow-
up testing
up testing
Module 6: The Counseling Session
Goal:
This module will present what HIV test counselors do and
introduce you to the nuts and bolts of a counseling session.

Objectives:
At the end of this module participants will be able to:
1. Differentiate each of the steps of an HIV counseling
session
Welcome,
Framing,
Consenting

Sample
Collection
Assessing
and
Prevention
Counseling
Yes? No? Results and
Counseling

Referrals
Close
 Welcome,
Framing
and
Consenting Greeting the Client
The first few minutes of the counseling session
might be the most important. This is your chance
to make sure that your client feels comfortable
and respected.

Basically, the goals in greeting a client are to:

➢ Establish rapport
➢ Explain the counseling and testing process
➢ Ask for questions
➢ Get informed consent in writing from the client
 Welcome,

Establish Rapport
Framing
and
Consenting

Your clients have shown tremendous

courage in testing for HIV. For some
people, it is uncomfortable talking about
sexual health and substance use activities.
Make them feel as much at ease as
possible by:
▪ Providing a private, quiet counseling area
▪ Introducing yourself in a warm, friendly
manner
Welcome,

Framing the Process

Framing
and
Consenting

▪ Explain what will happen during the session

and when the client will receive test results

▪ For rapid tests, make sure the client knows

that a reactive result requires a confirmatory
blood test

▪ Check for questions and concerns

 Welcome,

Written Consent
Framing
and
Consenting

➢ Consent means that the client understands what is going to happen

and agrees to the procedure.
1. The test is an antibody and/or antigen test
2. The client understands the window period for the test
being ran
3. If reactive, a confirmatory test must be performed
4. All confirmed reactive tests must be reported to the
state health department
➢ Have client give written consent to test
 The Rapid Test
Sample
Collection

➢ Is sometimes performed on an oral sample but most often performed on a

blood sample, usually from a finger stick
➢ Takes between 1 to 20 minutes to develop a result depending on the brand
of rapid test being used and the result of the test (Determine takes 20
minutes for the result to come back)
➢ Looks for the antibodies that the body creates to fight HIV infection (4th
generation rapid tests look for antigens also)
➢ Is a “screening” test and not intended to diagnose an illness
➢ Is over 99% accurate
➢ Most can detect antibodies for both HIV 1 and HIV 2 (less infectious and
less common in the United States)
 Assessing
and
Prevention
Counseling The Counseling Session
Part of the session involves gathering
contextual information. This includes:
➢ environmental factors
➢ sexual and drug use behaviors
➢ personal beliefs and feelings
With this information we can help clients
explore activities in their lives that could result
in HIV transmission. Part of the session
involves helping the client come up with a plan
to reduce their level of harm.
 Assessing
and
Prevention
Counseling
Using the Word “Risk”

Sometimes the word “risk” can be ambiguous. What is risky to one

person can be not risky to another.

Instead of asking “What is your risk for HIV?”, try being more direct:
➢ “Tell me about the kinds of sex you have.”
➢ “What are your concerns about HIV transmission?”
➢ “Have you ever injected substances?”
 Rapid Test Results
Results and
Counseling

There are three possible rapid test results:

1. Reactive test result: the test very likely detected HIV antibodies and/or antigens and a
second test will be run to verify the results of the first test. The individual is very likely
infected with HIV. Reactive results must be confirmed by an outside laboratory. If the
confirmatory test is also reactive, it is considered a positive result and the client could
pass HIV to others. NOTE: With 4th generation testing, there can also be antigen reactive
and antigen/antibody results.

1. Negative test result means that no antibodies and/or antigens to HIV were detected in
the sample. The person is either not infected with HIV, or the person is infected but has
not yet produced enough HIV antibodies/antigens to show up in the test.

1. Invalid test result is very rare. If it occurs, the test must be redone with a new sample.
Results and
Disclosing
Non-Reactive Results
Counseling

➢ State results in a direct, neutral tone

➢ Help clients make sense of their result
➢ What does it mean for them?
➢ Revisit the window period (difference between Ab & Ag)
➢ Support them in protecting themselves from HIV
➢ Give referrals to help with HIV prevention in the future
➢ Continue the prevention counseling conversation, revisit
their plan
➢ Explore re-testing
Results and
Counseling Disclosing Reactive Results
➢ State results in a direct, neutral tone
➢ Help clients make sense of their result…what does it mean for them?
➢ Provide a supportive environment for the client to express feelings about the
result
➢ Provide linkage to medical care
➢ Work with client to go through their options for medical care. If the client
does not have insurance discuss the LINCS services provided by SFDPH
(See LINCS slide)
➢ Discuss disclosure and partner services
➢ Help them consider their next steps
 Results and
Counseling Key Points for Antibody Reactive
➢ Linkage to medical care
We strive to connect individuals to primary medical care as early as possible after
their diagnosis. This is because early HIV treatment both greatly benefit the health of
the individual, and also reduces the risk of transmitting HIV to partners. Work with
client to go through their options for medical care. If the client does not have
insurance discuss the LINCS services provided by SFDPH (see LINCS slide).

➢ Partner services
Discuss that the local health departments provide confidential HIV Partner Services
which helps people with HIV who may want to inform sex and needle-sharing
partners they should be tested for HIV and other STIs. These models are designed as
confidential and voluntary assistance by trained health professionals. During the
process the staff does not reveal HIV information about the person to the partners.
Results and
Counseling Key Points for Antigen Reactive
➢ Linkage to medical care
We strive to connect acutely infected individuals to primary medical care as early as
possible after their diagnosis, with in 24 hours. This is because early HIV treatment both
greatly benefit the health of the individual, and also reduces the risk of transmitting HIV to
partners. Work with client to go through their options for medical care. If the client does
not have insurance discuss the LINCS services provided by SFDPH. (See LINCS slide)

➢ Partner services
Discuss that the local health departments provide confidential HIV Partner Services which
helps people with HIV who may want to inform sex and needle-sharing partners they
should be tested for HIV and other STIs. During the acute stage this becomes more
important as partners may be unaware of their HIV status. These models are designed as
confidential and voluntary assistance by trained health professionals. During the process
the staff does not reveal HIV information about the person to the partners.
 Results and
Linkage, Integration, Navigation
and Comprehensive Services
Counseling

The goal of LINCS is to provide and coordinate comprehensive linkage to care, partner services and
navigation for people who test positive for HIV and syphilis.

Linkage to care:
➢Assist clients in making initial medical appointments
➢Help clients gain a better understanding of the individual options for treatment and the importance of early
treatment for HIV
Partner Services:
➢Assist people in notifying partners that may have been exposed to HIV and STI and would benefit from
the specialized support services that are offered
Navigation:
➢Assist people living with HIV re-enter and remain in HIV medical Care
➢Improve health outcomes for people living with HIV, reduce HIV health disparities, and prevent new
infections in San Francisco by supporting HIV infected patients to stay in medical care.
 Close the Session
Close &
Referrals

When closing your session, thank your clients for

coming in and remind them to test again in six
months if their result was negative (only if relevant
to them and their behaviors).
CLOSE THE
At the end of your session, all of the participants’ SESSION,
issues will not be resolved. An HIV test counselor BUT NOT
ensures that participants leave knowing they have THE DOOR!
specific and appropriate steps to take in the
present, and options for further follow-up in the
future.

Let’s review what makes a referral a good referral.

 Close &
Referrals Giving a Good Referral
1. APPROPRIATE: The referral is appropriate for the client: the service is
needed, the service will be accessible, the client will feel comfortable in the
setting, etc.

2. WRITTEN: The information is written down in easy-to-read fashion. Clients

should be given the name, phone number, and address of the referral.

3. PURPOSE IS CLEAR: The purpose of the referral is clearly stated to the

participant. For example, ―This is a place where you can talk to someone
regularly about your plans to reduce your substance use.
 Close &
Referrals Giving a Good Referral
4. GIVE A NAME : Whenever possible give the name of a contact person to the
participant. If you can add something about what this person has to offer, it may
help clients feel more comfortable following through on the referral.

5. EXPLORE OBSTACLES AND SOURCES OF SUPPORT FOR FOLLOW-

THROUGH: Many people do not follow through on referrals. Discuss this frankly
with clients and problem-solve ways to overcome obstacles, if they exist.

6. INVITE FEEDBACK: Ask clients to let you know if the referral does not work out
for any reason. Such feedback can alert you early on to changes in or
misunderstandings about your referral resources.

Regardless of HIV status, clients should be referred to STI testing!

 Thank you for all your hard work!
We have covered a lot of material in this online pre-training course. By now you are well
prepared for the HIV Counselor Training.

The HIV Counselor Training is an intense, hands-on learning experience. It includes

opportunities to discuss counseling issues and practice skills. You will watch experienced
counselors model the Assessing, Prevention Counseling, and Disclosure portions of the HIV
counseling session. You will have opportunities to practice specific sections of the counseling
session and to get feedback. You will be trained and certified to administer and read the Stat-
Pak Rapid HIV-1/HIV-2 Antibody Test and to perform fingersticks to collect test samples.

This online training, and the observations and trainings you have experienced at your sites has
given you the background to be a knowledgeable and engaged participant in the live training.
We hope you feel confident and committed to participating actively in that training. It will help
you be an effective HIV test counselor.

You have now completed the training and are ready for your exam. This test will reflect
important information you have learned throughout this training. You must score at least 80
percent on this test to be eligible to take the HIV Counselor Training.