Couples Voluntary Counseling and Testing

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					Couples Voluntary
Counseling and Testing
(CVCT) Counselor
Overall CVCT Counselor Training
By the end of the training
 participants should be able to:
 Define couples counseling
 Explain the process and the
 objectives of couples counseling
 Begin the practice of counseling (pre-
 test, post-test, follow-up, etc.)
 Explain HIV-discordance in couples
 and be able to give appropriate
What is a couple?
 Man and woman married or cohabiting
 (living together) or in a serious relationship
 Engaged or plan to be married
 Gay, lesbian or same-sex
 May be sexual or pre-sexual
 Some sort of interdependence: sexually,
 economically, emotionally and/or socially
Why Should New Start Focus on
 To promote behavior change of Both
 Partners in a Couple
   It helps couples to change their sexual
       Couples represent the largest
       HIV/AIDS risk group
       Sub-Saharan Africa has over 80% of
       the World’s HIV infections.
       70% of the infections in African cities
       are a result of transmission between
       married couples.
Why should New Start focus on
couples, cont.?
    20-45% of couples in Sub Saharan
    Africa have one or both partners
    infected with HIV.
    Roughly 60% of new HIV infections are
    acquired from a spouse.
    As a result, there are already thousands
    of orphans in many African countries
    due to parental deaths from HIV/AIDS.
    However, only 1% of all couples in
    Africa have been counseled and tested
Objectives of HIV couple’s
 Propose realistic strategies adapted to the
 situation of the couple
 Help the couple to acquire knowledge in
 the subject of HIV/AIDS
 Help the couple put in practice information
 regarding the health and well-being of the
 two partners
 Encourage behavior change to prevent and
 control infection
 Help facilitate access to other treatment
 services and assistance if necessary
 Help the couple accept their situation
Some basic principles of couples
 Should be a voluntary, confidential interaction
 between counselor and each of the clients
 Encourage couples to protect their sexual
 health including preventing transmission of
 HIV and STIs with correct and consistent use
 of condoms
 Provide counseling, emotional support and
 social service referral as needed for couples
 with positive partners;
 Reducing the stigma associated with
 Provides a starting point for talking about
 sexual issues such as STIs, condoms,
 pregnancy, HIV and the sexual act itself
The benefits of CVCT therefore
include the following:
 It helps the couple plan for the future
 It reduces the problem of partner
 Encourages consistently and correct
 implementation of risk reduction
 plans, especially among discordant
What can we do to encourage
couples VCT?
How is couples counseling different
from individuals?
The Particularities of Couples:
     Feelings of guilt
     Fear of rejection by the partner
     Arguments within the couple
  The shame of having an infection that is often
  associated with extra-marital sex
  Negotiation of behavior to reduce risks
  (understanding of condom use)
  The mutual responsibility needed to prevent
CVCT Scenarios:
Scenario 1: A couple comes in for
 CVCT and the woman is currently
 The wife is HIV positive and as a result of your
 counseling, you are able to get her referred to a
 prenatal clinic to receive appropriate care to
 prevent mother-to-child transmission.
 The woman is negative and the man is positive.
 You are able to discuss risk reduction in order to
 prevent her from acquiring HIV during this
Scenarios, cont.
 Scenario 2:
 A married couple comes in for VCT. In the
 pretest session, it becomes clear that there
 is a significant amount of conflict between
 the two partners and the communication is
 very strained. The counselor decides to
 separate them briefly to talk with them
 individually in order to get a better
 assessment of the situation. In the
 individual session, the woman reveals that
 her husband forced her to come for VCT.
Scenario 2, cont.
 The counselor should use his/her
 judgment to determine whether it is
 appropriate for the couple to be tested
 and receive their results together. If
 after pre-test counseling either
 partner is not certain that they are
 ready for the test, then the counselor
 should suggest that the couple talk
 about it together more and to come
 back another day.
Scenarios, cont.
 Scenario 3: A couple receives
 discordant results, with the male
 positive and the female is negative.
 The male refuses to believe these
 results. He insists that the test is
 wrong and that he wants to get tested
 elsewhere to prove that he is
 negative. Because he is convinced
 he is HIV negative, he refuses to use
VCT Process:
Focus on Couples
VCT Process: Focus on the Couple

   Each individual must consent to receive
   counseling as well as testing.
Couple Counselor Skills:
Additional counselor skills may also include the
  ability to:
  Acknowledge various
  feelings/emotions in couples,
  individually and together
  Know how to take time to respond to
  couples’ reactions
  Make use of silences
  Know when to listen and when to
  Be aware of how your own feelings
  may influence your interactions with
  the couple, and their view of you may
  also affect those interactions
Couples Counseling Skills, cont.
 Deal with anger (in individual and in
 Build couples’ assertiveness/confidence
 Deal with a dominant partner
 Deal with irrational beliefs without offending
 Help couple establish goals (e.g.
 prevention of transmission in discordant
 couples, ‘living positively’)
 Know when to abandon CVCT protocol
 (protocols are not just for ‘reading out’)
Pre-Test: Focus on the couple:
Pre-test guidelines:
 Same guidelines as individual counseling,
 but counselor needs to concentrate on the
   Explore their reasons for seeking testing
   Review each partner’s basic understanding of
   HIV/AIDS and modes of transmission, correct
   misinformation and myths.
   Do risk assessment for each of them
   Discuss possible risk reduction issues given the
   information they have on transmission
   Identify partners’ history of HIV testing
Pre-test: Focus on the couple:
 Discuss the couple’s understanding of the
 meaning of different HIV test results, including
 concordant negative, discordant and concordant
 Clarify misunderstandings of the meanings of
 Explore how each would react if :
   Both test negative (concordant negative)
   Both test positive (concordant positive)
   One tests positive and the other tests negative
 Discuss implications of results with regard to
 pregnancy and explore options
 Explore couple’s feelings about taking an HIV test
 and receiving results together Make it clear how
 the couple will receive results
 Explore whether they would like to have their
 results separately or together
Pre-Test: Focus on the couple,
 Discuss advantages/disadvantages of
 knowing their serostatus
 Help the couple identify sources of support
 Discuss disclosure issues,
 The counselor must assess the couple’s
 readiness to be tested and receive results
 Determine couple’s decision to test (‘yes’
 or ‘no’)
 Describe the HIV test process
Pre-test counseling: TIPS

   Do not assume individuals in the
   couple perceive their problem in the
   same way
   Avoid getting used as a
   battleground or switchboard
   Align with person you talk to and
   shift alliance, don’t align yourself
   with one person
Post-test: Focus on the Couple:
 Reconnect with couple
 Check if they still want to get their
 results together or as individuals
 depending on their agreement in the
 pre-test counseling session.
 Where they prefer to have them
 separately, ask the other one to wait
 However, counselor cannot disclose
 an individual’s results without their
Post-test -/- couple:
 Attend to the couples feelings and
 concerns according to the procedure
 followed with individuals
 How do they feel about each others
 Explore the impact on:
   Their reason for testing
   Their relationship
   Their families
Pre-test -/- couple, cont.
 Revisit issue of window period
 Remind the couple of the need to maintain
 their negative status
 Time for questions and honest answers
 Encourage the couple to come back
 whenever they feel they need help
Post-test counseling: +/+ couple
 Ask who would like to receive results first
 Give the person according to their choice
 and observe reaction
 Give the other one as well and observe
 reaction again
 Help the couple deal with feelings arising
 from getting positive results
 As soon as they seemed settled, explore
 how each one feels about the other’s
 Explore concerns arising from their results
 and help them deal with those
Post-test +/+ couple:
 Emphasize the importance of avoiding re-
 In case of pregnancy, explore what the
 couple plans to do with the pregnancy
 (PMTCT referrals)
 Counsel about family planning services to
 avoid unplanned pregnancy
 Discuss living positively
   Post test clubs or support groups
   Medical care,
   Give them a referral for other relevant services
Post-test +/+ couple:
 Give them the opportunity to ask questions
 and answer these honestly
 Make an appointment for the next session
 Find out what each one is going to do after
 this session as individuals and as a couple
Post-test +/- couple:
   After each partner understands their
   results, give them time to internalize
   their results and react
   Help them to express their
   Assess short-term and long term
   Provide and reinforce the necessary
   information for positive living.
Post-test +/- couple:
 Inform couple that the negative partner is
 not immune or protected against HIV
 Stress the importance of avoiding
 infecting the negative partner
 You can infect your unborn children; avoid
 having more children by using family
 Try to support and understand positive
 partner; don’t judge him/her.
 Discuss how to avoid other high-risk
 contacts in the future.
 Teach each individual how to use condoms
Understanding Discordancy:
 How is counseling of discordant couples different?
 Negotiating behavior change that protects the negative
 Not notifying partner about their serostatus continually
 exposes negative partner to the virus
 Monogamy and fidelity are not enough in a discordant
 couple - they do not protect the negative partner
 No explanation could lead to inequality in the couple
 Social status of the woman may not allow her to
 change her sexual behavior or to control her
 reproductive health
 Fear of living with a sero+ person:
    To live together and continue to have sexual
    relations (fear of the strength of condoms)
    Fear of stigmatization of the family
Understanding Discordancy, cont.
 Some of the issues/difficulties involved in
 counseling a discordant couple may include:
   Possible secrets not disclosed at beginning of
   Confusion about how to go forth with their
   Anxiety about putting each other at risk
   Decision about a fool-proof safer sex method
   Making decisions about marriage
   Decision on having babies in future
   Disclosure to other people
   Abuse of the spouse if woman +
   + Partner depressed/feels disproportionate guilt
   Counselors are the first ‘shock absorber’
Beliefs about discordancy:

 Couples may also have some
 questionable or unfounded beliefs
 about discordance, such as:
   The ones who ‘misbehave’ are more
   likely to become infected
   People can be immune to the virus
   ‘Special protection’ from God
Steps that the counselor can take:
 Encourage open communication
 as much as possible in and out
 of the sessions
 Explore how each person feels
 about the situation
 Discuss in depth concerns put
 forward by both parties
 Give relevant information where
 they need knowledge about
 certain issues
 Explore how they think their
 relationship may be affected and
 help them deal with that
 Discuss future plans and explore
 how these can still be achieved
 despite their discordant results
Counseling steps for discordant
couples, cont.
 Give couple sufficient time to think things through
 Answer questions honestly and sensibly
 Have frequent sessions with them immediately
 and gradually tail them off to give them space to
 grow in their relationship
 Leave your door open for them to come back
 whenever they feel the need to do so
 Make relevant referrals for example in case of
 complex marital problems or health problems.
 There may be organizations that care for
 discordant couples in your area.
Making Referrals: CVCT and
 Get permission from
 the couple to do so
 Cases include:
   Complicated multi-
   problem families
   Cases of spouse abuse
   Cases of rape within
   the couple
   Marital Problems
   Discordant couples
   Medical referrals (for
   one or both partners)
   Pregnancy/ PMTCT
   Family planning
Role Plays: Each person
take a question from a man or
woman in a couple and be
prepared to act your part as
that individual in a couple.
Do you have any questions or
concerns about Couples VCT?

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