42 Ann Ist super sAnItà 2010 | Vol. 46, no. 1: 42-50
criteria for standardising counselling
reseArch from anImAl testIng to clInIcAl experIence
for HIV testing
Anna Maria Luzi(a), Barbara De Mei(b), Anna Colucci(a) and Pietro Gallo(a)
Centro Operativo AIDS, Dipartimento di Malattie Infettive, Parassitarie ed Immunomediate;
Centro di Epidemiologia, Sorveglianza e Promozione della Salute,
Istituto Superiore di Sanità, Rome, Italy
Summary. In the present work, we outline basic health counselling skills, specifically, those for per-
forming pre-test and post-test counselling for HIV infection. the ultimate goal is to propose that
counselling be performed in facilities that carry out screening for anti-HIV antibodies, following
standardised (and thus replicable) criteria, with consistent focus on the quality of the relationship
between the healthcare professional and the individual undergoing testing and on the individual’s
Key words: HIV infections, counselling, pre-post test.
Riassunto (Criteri di standardizzazione dell’intervento di counselling nella diagnosi di infezione da HIV).
Il presente lavoro intende delineare gli aspetti peculiari dell’applicazione delle competenze di base del
counselling in ambito sanitario, con particolare riferimento all’ intervento effettuato nel pre e post test
HIV. La finalità principale è quella di proporre l’applicazione dell’intervento di counselling nei Servizi
dove si effettua lo screening per la ricerca degli anticorpi anti-HIV, secondo criteri standardizzati e,
pertanto, replicabili, mantenendo costantemente l’attenzione alla qualità della relazione e alle specifi-
che esigenze del singolo individuo.
Parole chiave: infezioni da HIV, counselling, pre-post test.
IntRoDuCtIon In this relational process, counselling represents a
In the present work, we outline basic health coun- fundamental tool. In 1989, the World Health organ-
selling skills, specifically, those for performing pre-test ization (WHo) defined counselling as “a decision-
and post-test counselling for HIV infection. the ulti- making and problem-solving process which involves
mate goal is to propose that counselling be performed a counsellor and a client. the client is in need of help,
in facilities that carry out screening for anti-HIV an- and the counsellor is an impartial person who is not
tibodies, following standardised (and thus replicable) attached to the client and who has the capacity to
criteria, with consistent focus on the quality of the listen and to provide guidance and support. through
relationship between the healthcare professional and dialogue and interaction, counselling helps persons
the individual undergoing testing and on the individu- to resolve or control their problems, to understand
al’s specific needs. to this regard, it should be stressed them, and to face psychosocial difficulties and needs
that all healthcare professionals can be trained to per- in the most rational way possible. counselling is in-
form standardised basic counselling. tense, focussed, limited in time, and specific” .
thus health counselling can be defined as a well-
structured intervention that is particularly effective
HEALtH CounSELLInG in helping a person to use his or her own resources
For healthcare professionals, counselling skills are to actively face important difficulties and changes
fundamental for creating effective relationships with for maintaining health. counselling focuses on the
clients, in diverse areas of healthcare (e.g., health pro- individual, the specific experiences recounted, and
motion, disease prevention, communicating diagnosis, the problems posed; it also focuses on the resources
developing a therapeutic plan, crisis management, and and opportunities that emerge from the individual’s
functional adaptation to a pathology). an effective re- narration. In performing counselling, the healthcare
lationship cannot be improvised, and the healthcare worker applies the knowledge specific to his/her
professional must apply cognitive and relational skills profession and uses his/her personal qualities to fa-
and individual qualities, with the objective of activat- cilitate the communication process; the counsellor
ing the clients’ resources, so that they can choose solu- must also control personal communication styles
tions that are consistent with their needs. and traits that can hinder counselling.
Address for correspondence: anna Maria Luzi, Unità operativa “telefono Verde aIDS”, Dipartimento di Malattie Infettive,
Parassitarie ed Immunomediate, Istituto Superiore di Sanità, Viale regina elena 299, 00161 rome, Italy. e-mail: firstname.lastname@example.org.
counsellIng for hIV testIng 43
of particular importance are the knowledge and - awareness of and capacity to apply relational
application of the basics of verbal, non-verbal, and skills (active listening, empathy, self-awareness)
paraverbal communication, relational skills, and and the specific communication strategies used
communication strategies [2-4]. in counselling, in particular:
the objective of counselling is to activate and reor- - informative counselling, for providing per-
ganise a person’s resources, to make possible choices sonalised information;
and changes in situations that the individual per- - problem-solving counselling, for facilitating
ceives as complex or to actively confront problems solutions to problems;
and difficulties through empowerment, consistently - crisis counselling, for providing support
respecting the individual’s values and capacity for during crises;
self-determination . - decision-making counselling, for facilitating
as mentioned, counselling is a process that has the decision making;
following qualities: - knowledge of the procedures necessary for struc-
- intense, in that the relationship between the turing counselling.
healthcare worker and the individual must be
conducted in a climate of acceptance and total
mutual respect, which is a prerequisite for a rela- RELAtIonAL SKILLS
tionship of trust and collaboration; relational skills (empathy, self-awareness, active
- focussed, in that counselling must concentrate on listening) are an integral part of counselling, and
the “here and now” of the individual’s current given that these are actual skills, they can be learned
and emerging problems; and perfected with specific training.
- limited in time, in that counselling must be per- • Empathy is the ability to know how to enter into
formed within a certain time frame; another person’s scheme of reference, the capacity
- specific, in that, based on the individual’s emerg- to see the world through the other person’s eyes
ing problem, a specific and realistic objective is and have information from his/her rational and
gradually identified and agreed upon; emotional point of view (thoughts, experiences,
- active, in that both the healthcare worker and the emotions, and meanings), so as to be able to un-
individual play an active role in the relationship; derstand the person’s requests and needs. empathy
in fact, through listening, the healthcare worker is the ability to open oneself to another’s experi-
remains focussed on the needs and experiences of ence, to follow, grasp, and understand as fully as
the individual, thus facilitating the process of be- possible the subjective experience of the “person”,
coming aware, which is indispensable for facing from that person’s point of view. In other words,
the problem and for autonomously and responsi- the healthcare worker lives as if he/she were the
bly activating choices. other person. empathetic healthcare workers
- integrated, in that counselling can be learned must, however, remain separate from the other
by all healthcare workers, favouring integration person’s world, given that they would no longer
among diverse professional figures and thus fa- be able to help the person and thus not meet that
cilitating teamwork . person’s needs.
all healthcare workers, regardless of their specific • Self-awareness is an essential skill in the profession-
profession or area of expertise, must learn and per- al relationship. For communication to be effective,
fect their basic counselling skills, so that they clearly the healthcare worker must be aware of his/her
understand the main characteristics of the interven- own cultural reference scheme, motivations, value
tion and how it is performed [7-9]. system, prejudices, perceptions, emotions in the
to this regard, some basic qualities that healthcare “here and now”, and personal conceptual maps. It
workers should possess to perform counselling are is very important that the healthcare professional
listed below: be very familiar with his/her “inner world”, so as
- knowledge of the scope of counselling, which to be able to constantly contact, control, and dis-
does not consist of “giving advice” or “quick so- tinguish it from that of the other person. It is also
lutions to the problem” or providing “additional important to be aware of the context that is at the
generic information” but instead focuses on ac- foundation of every relationship. the capacity for
tivating an individual’s resources, so that he/she self-observation and self-monitoring in the rela-
can responsibly face problems and difficulties tionship is also essential, as is knowledge of non-
and make conscious choices; verbal and paraverbal language, which express the
- self-awareness of qualities that can favour com- emotional states underlying the verbal content. In
munication (e.g., acceptance of others, sensitiv- actuating self-awareness skills, it is important to
ity, authenticity, spontaneity, warmth, consisten- analyse in-depth the setting of counselling. the
cy, availability, creativity, and respect), and of the setting is the framework in which the relationship
qualities that could hinder the relationship (e.g., develops, and it plays a fundamental role in the
sarcasm, short temperedness, pity, antipathy, and success of counselling. In particular, relationships
aggressiveness), as well as self-awareness of per- between a healthcare worker and an individual re-
sonal communication style in relationships; quire a specific “external” and “internal” setting.
44 Anna Maria Luzi, Barbara De Mei, Anna Colucci, et al.
the external setting is a well-defined time-frame individual recognises him/herself in the reformu-
and space, whereas the internal setting is that of lation, he/she is certain of having been listened to
the healthcare worker, that is, “disposition”, “lis- and understood and is encouraged to continue to
tening”, and “openness” towards the given indi- communicate and collaborate. this also helps the
vidual, in a given moment, in a given place. even individual to remain focused on the problem and
when the external setting is not ideal, a good in- on how it is experienced.
ternal setting can facilitate the entire counselling clarification facilities self-understanding, also
process. Particular importance must be placed on stressing the experiences that accompany the
the specific attitude and behavioural style of the verbal content. Much can be understood from
healthcare worker, who should not be judgmental both verbal and non-verbal communication, as
or demanding, but open, welcoming, authorita- well as from paraverbal communication (“From
tive, clear, confident, and respectful of the other the look on your face you seem to be worried”
person as an autonomous individual who is able “From the tone of your voice, I have the impres-
to communicate the resources that he/she pos- sion that you’re confused regarding …”).
sesses and to use them. Investigative skill consists of knowing how to ask
• Activity listening is a communication skill based questions, which depends on the specific phase
on empathy and acceptance and on the develop- of the relationship. at first, open questions are
ment of a positive relationship and a non-judg- preferable because they leave ample possibility
mental climate. It is the first step in a relationship. for answers; they tend to expand and deepen the
Its purpose is to create a relationship of trust and relationship; and they stimulate the individual
collaboration, which is necessary for developing to express opinions and thoughts. closed-ended
an alliance, demonstrating interest, and helping questions (When?, Where?, Who?) are circum-
the individual to communicate, with the objective scribed; they demand a single specific response;
of better understanding his/her needs. When a they narrow down and focus communication, re-
healthcare worker knows how to listen, the indi- quiring only objective facts, and at times they can
vidual perceives him/herself to be the focus of at- seem limiting and hindering. When questions be-
tention and is thus encouraged to continue com- gin with “Why?”, the individual may feel that he/
municating and is more willing to reveal his/her she is being blamed or accused and should thus
experiences and provide more detailed informa- be avoided.
tion on his/her current health status. The use of messages in the first person helps to
What is listened to distinguish between that which the healthcare
- contents: that which the individual says with worker thinks and feels and that which regards
words (verbal) and silences, the tone of voice, the individual, allowing conflictual interpreta-
how something is said (paraverbal), listening/ tions and situations to be avoided and favour-
observation of facial expressions, gestures (non- ing a non-judgemental and positive climate (“I
verbal), and how the individual presents him/ think that...”;“In my opinion...”). It should also
herself and moves; be considered that some conditions, whether
- context in which the individual lives: family, so- mental, verbal, visual, aural, olfactory, or spa-
cial, work, school, experiences, cultural reference tial, hinder listening and become actual barriers.
schemes, and values, and “his/her narration”; counselling allows the professional relationship
- self-listening: listening to oneself in the here and to be structured into well-defined, though not
now, to one’s own context of reference, to the rigid, phases, which over the course of the rela-
extent to which one attributes what belongs to tionship vary in terms of importance and dura-
him/her to the other (self-awareness). tion, based on the specific situation, the emerging
How to listen problem, and the individual’s experiences. this
For active listening, it is necessary to adopt em- structuring is the common denominator with re-
pathic mirroring, a basic active-listening tech- spect to the variability of the intermediaries with
nique which consists of: reformulation, clarifica- whom the healthcare worker comes into contact,
tion, investigative skill, and use of messages in the specific characteristics of each specialised
the first person. environment, and the socio-cultural context of
reformulation is a communication technique reference [2, 10].
that consists of repeating that which the individ-
ual just said, using the same words or paraphras-
ing, without additional content. In this way, the CounSELLInG FoR HIV tEStInG
healthcare worker can obtain the individual’s counselling takes on particular importance for
consent, and the individual is ensured that the dealing with issues regarding HIV infection and
healthcare worker has been listening. When the aIDS, in that it allows healthcare workers to address
individual finishes a sentence, the healthcare the complex problems inherent to the prevention of
worker can repeat that which was just said (“So at-risk behaviours and to diagnosis and treatment.
you’re saying that …”, “You mean that …”, “In In this context, basic counselling skills are an es-
other words …”, “So in your opinion …”). If the sential tool, in that they ensure that the relationship
counsellIng for hIV testIng 45
between the healthcare worker and the individual is are the characteristics of the modes of transmission,
not improvised and is instead based on principles the infection, and the disease, which require specific
and strategies that focus on the individual’s needs behavioural choices to avoid becoming infected, as
and requests, as well as on his/her specific resources well as physical, psycho-social, sanitary, legal, and
and potential. economic implications, which require that infected
the importance of HIV counselling was already persons constantly adapt to the diverse needs that
stressed by the major international organisations distinguish their complex condition. Nonetheless,
early in the epidemic. In fact, as early as 1989, the the general objective of counselling remains the cre-
Global Programme on aIDS (GPa) of WHo indi- ation of a professional and structured relationship,
cated counselling as a tool for offering both practical which is at the same time flexible and personalized,
and psychological support, in order to provide ac- between a healthcare worker and an individual,
curate and personalised information geared towards aimed at stimulating the individual’s resources to
preventing further transmission of HIV . In 1990, consciously face emerging problems and activate au-
WHo developed guidelines on HIV/aIDS counsel- tonomous decision-making processes. It should also
ling, specifying its nature, role, and principles . be stressed that the counselling skills applied in this
In 1993, the GPa included counselling, together relationship do not constitute an added or isolated
with clinical treatment, nursing care, and social sup- intervention but are instead an integral part of the
port as one of the main components of an integrated relational process and that for communication to be
care continuum, with the intention of strengthening effective the healthcare worker’s involvement in the
the capacity and resources of the health system for relationship must be authentic and empathetic, ac-
facing problems caused by aIDS and aIDS-related cepting the individual and all of his/her anxieties,
pathologies . In 1994, the GPa reaffirmed the doubts, and convictions .
usefulness of counselling as a vital component of today, 30 years after the first reported cases of
care in HIV/aIDS and as a fundamental part of aIDS, despite the changes in clinical history and in
good clinical management, as well as “an important infected persons’ needs, HIV/aIDS continues to be
means of prevention”. the following eight objec- a fundamental tool for reaching the goals of pre-
tives of counselling were also developed: vention and support, which are intertwined in ef-
- to provide support in times of crisis; forts aimed at primary and secondary prevention
- to propose realistic actions adapted to diverse (pre-and post-test phase) and in the condition of
persons and circumstances; seropositivity and full-blown aIDS. Moreover, the
- to help persons to accept health information and objective of HIV/aIDS counselling correspond to
act in accordance with this information, for main- the eight general objectives of health counselling
taining health; in general of WHo/GPa, listed above, which must
- to communicate, in a comprehensible and cultur- gradually be integrated with the specific objectives
ally suitable and acceptable manner, the need to agreed upon with the individual, based upon his/her
change unsafe behaviours and thus prevent infec- needs and resources .
- to encourage change when necessary for the pre- Main objective of HIV/AIDS counselling
vention and control of infection; the main objective of HIV/aIDS counselling is
- to reduce the risk of infected persons’ transmit- to provide personalised information (informative
ting the virus to others; counselling), in order to activate processes of aware-
- to contribute to maintaining the best possible ness and empowerment, so as to encourage the indi-
state of emotional and physical health and to pro- vidual to make autonomous and responsible choices
vide social support to persons with HIV infection regarding at-risk behaviours or the suitability of
and those who care for them; undergoing HIV testing (decision-making counsel-
- to ensure to the greatest extent possible the main- ling). It is also aimed at strengthening an individu-
tenance of productivity of HIV-infected persons al’s resources so that he/she can live with the disease
and their integration in society. (WHo/GPa (coping) and improve adherence to therapy, facing
1994) . emerging problems (problem-solving counselling)
Finally, in 1995, the GPa defined HIV/aIDS coun- and crises (crisis counselling). the choice of specific
selling as a confidential dialogue between a client strategies is made by the healthcare worker based
and a counsellor geared towards putting the client on the specific individual and condition in the “here
in a condition to face stressful situations and make and now” that emerges during counselling.
autonomous decisions regarding HIV infection and HIV/aIDS counselling for testing takes place dur-
aIDS . ing two or more interviews, pre-test counselling
It is evident that the diverse definitions of HIV/ (before the test is performed) and post-test coun-
aIDS counselling reported above are consistent selling (when the result is provided), conducted by
with the 1989 WHo indications on health counsel- adequately trained healthcare workers, who are
ling in general and with that which was proposed capable of structuring the professional relation-
by the British association for counselling in 1992 ship based on the principles and phases of counsel-
[1, 15]. What distinguishes HIV/aIDS counselling ling and who can integrate specific knowledge and
46 Anna Maria Luzi, Barbara De Mei, Anna Colucci, et al.
skills, personal qualities, and relational capabilities - to control the individual’s anxiety and support
such as self-awareness, active listening, and empa- him/her in actively facing the problem that he/she
thy [17-20]. is experiencing.
the healthcare worker must be constantly aware
that the objectives of pre-test counselling be gradu-
PRE-tESt CounSELLInG ally modified and focussed on the characteristics of
Pre-test counselling consists of a brief interview the specific individual and situation and that they
between a healthcare worker and an individual who be flexible, so that they can be modified based on
is considering undergoing testing. Its goal is to de- the specific, concrete, and realistic objectives agreed
termine whether or not the individual has engaged upon with the individual.
in at-risk behaviour, allowing him/her, if necessary, In performing counselling, the healthcare work-
to make a conscious, autonomous, and responsible er can refer to a structured model which consists
decision to undergo testing (accepting and signing of phases or steps, which provides him/her with a
the informed consent form) and preparing him/her conceptual and operational reference map, so that
for the test result (article 5 of Law 135/1990. Piano counselling is both flexible, taking into considera-
degli interventi urgenti in materia e prevenzione e lot- tion the specific individual and situation, and ho-
ta all’AIDS and Decreto marzo 2008) . In fact, mogenous among different healthcare workers.
individuals can request testing for different reasons, thus pre-test counselling consists of well-defined
which are often accompanied by psychological re- steps whose importance and duration change over
percussions which begin when the persons starts to the course of the relationship, depending on the
think about the need to be tested. For this reason specific situations and the individual. the qualities
the healthcare worker, together with the individual, and skills that can be developed at different times
through an effective professional relationship, must can be differentiated. the outline provided below
evaluate the specific risk and the actual need to un- must absolutely not replace the strongly relational
dergo testing. nature of counselling but instead serve as an impor-
thus pre-test counselling constitutes an important tant reference protocol based on which the health-
opportunity for primary prevention aimed at the indi- care worker can comfortably manage the diverse
vidual’s acquiring personalised information and indica- factors of the individual and the context that affect
tions for adopting safe behaviours. It is also important the relationship and can elicit emotional reactions,
for secondary prevention, encouraging the individual to depending on the individual’s personality and the
carefully reflect upon the risks taken, the suitability of problem being faced in that particular moment.
changing his/her habits, and the necessity of undergoing
testing, specifying that the test for anti-HIV antibodies Steps of pre-test counselling
must be performed after a window period . testing Greeting
for persons with at-risk behaviour is important because • Preparing the external and internal setting
it allows for early diagnosis, which is fundamental for – counselling should take place in a welcoming
interrupting the chain of transmission . Moreover, and silent atmosphere, with no distractions, and
it allows infection to be adequately monitored and ap- the healthcare worker should prepare him/herself
propriate anti-retroviral therapy to be started. emotionally, preparing his/her internal space for
another integral part of pre-test counselling is that each new meeting.
of facing, together with the individual, the wait for, and • Adequately introducing oneself – the healthcare
the concerns regarding, the test result, which can elicit worker should provide his/her last name and pro-
emotional reactions and thoughts that require opti- fessional qualifications. the first words (verbal
mal management skills on the part of the healthcare communication), tone and pitch of voice (paraver-
worker, which is made possible by acquiring counsel- bal communication), gestures, looks, and posture
ling skills [2, 3]. (non-verbal communication) used by the health-
the general objectives of pre-test counselling are: care worker are important for creating a comfort-
- to allow an individual to describe his/her situation able environment, which allows the individual to
and the potentially at-risk behaviours; feel at ease and to begin discussing his/her prob-
- to identify an individual’s risk factors and his/her lem. the ultimate goal is to establish a relation-
perception of them; ship based on collaboration, trust, and empathy
- to provide personalised information on HIV infec- (alliance).
tion, with particular reference to the modes of trans- Active listening
mission and ways of preventing it; It is important to clarify the reasons for which the
- to provide indications on testing for anti-HIV an- individual wishes to undergo testing. the individual’s
tibodies and on the window period required for specific experiences, problems, and requests can only
the specific test; be understood through careful attention and active
- to prepare the individual for facing the test result; listening, demonstrating cognitive and emotional em-
- to facilitate the individual’s ability to make a pathy, attempting to enter the individual’s scheme of
conscious decision on whether or not to undergo reference “as if” it were the healthcare worker’s own.
testing; In this way the healthcare worker begins to explore
counsellIng for hIV testIng 47
and defined the individual’s “true” problem or request, and motivated, it is necessary to assume personal
which is not always expressed clearly, identifying the responsibility, which must be shared and elaborated
actual reasons for wanting to undergo testing. upon with a healthcare worker who possesses the
In this phase, the use of active listening techniques skills for doing so, who the individual trusts, and
(messages in the first person, reformulation, clarifi- with whom the individual can collaborate and form
cation, and investigation) allow the healthcare work- an alliance. During this process it may be necessary
er to understand the individual’s concerns regarding to provide emotional support and evaluate the inter-
his/her behaviour and the possible consequences of nal resources that the individual is capable of using
this behaviour and, if necessary, to provide emo- in this particular moment (crisis counselling).
tional support. Summarising, verifying, and saying goodbye
Clarifying the problem, identifying a shared objec- at the end of the interview, it is useful to summarise
tive and agreeing upon alternative solutions what emerged and was agreed upon and to determine
If based on the individual’s behaviour it is deemed the extent to which the indications have been un-
that testing is not necessary, the actual problem that derstood and whether the individual has additional
led the individual to consider him/herself at-risk doubts or concerns. the healthcare worker should
must be clarified. this can be the result of misin- express his/her availability for additional contact, say
formation or lack of knowledge regarding HIV in- goodbye in a suitable manner, and conclude the meet-
fection and aIDS. In this case, the individual must ing by immediately making an appointment for pick-
be provided with accurate, updated, complete, and ing up the test result, stressing the importance of do-
personalised information, so that he/she can adopt ing so. appointments for post-test counselling should
behaviours or make decisions that would allow not be made right before the weekend .
him/her to decrease anxiety (informative counsel-
ling). Individuals may also request testing because
of great apprehension regarding the possibility of PoSt-tESt CounSELLInG
becoming infected and emotional suffering. In this Post-test counselling consists of an interview be-
phase it is important to continue focussing on the tween a healthcare worker and an individual who has
relational process, avoiding false reassurances and undergone testing, to provide the test result. It consti-
helping the individual to contain his/her anxiety. tutes a continuation of pre-test counselling and when
clarifying the problem is crucial for developing a possible should be conducted by the same healthcare
shared objective that is both concrete and feasible worker. During post-test counselling, more than one
and based on which diverse alternatives for solutions interview may be necessary, for example, when the
can be proposed and agreed upon. at this point the test result is undetermined .
individual may consciously decide to not undergo If the test result is negative, post-test counselling fo-
testing, given the absence of risk, or to take to time cuses on prevention and on helping the individual to
reflect or to undergo testing nonetheless. identify reasons for discontinuing at-risk behaviour,
It is important that the healthcare worker be able by activating “life skills”. If the test result is positive,
to stimulate the individual’s own resources, so that post-test counselling focuses on providing support
he/she can make an informed and anonymous deci- to the individual and on either providing care at the
sion regarding the best solution to the problem at- healthcare facility or referring him/her to a special-
hand (problem solving counselling / decision mak- ised facility. Finally, if the test result is undetermined,
ing counselling). post-test counselling focuses on containing the indi-
In cases in which the individual has engaged in vidual’s anxiety, managing his/her feelings of uncer-
at-risk behaviour and should undergo testing, the tainty, and repeating the test. Diverse interviews may
healthcare worker must determine the individual’s be necessary while waiting for the test result.
knowledge of infection, provide information where although the objectives of post-test counselling
lacking, evaluate the individual’s perception of the differ depending on the test result, some general and
risk, and propose testing, providing information on share objectives exist:
testing and discussing the possible individual and - to provide the test result immediately after the
social implications, agreeing upon strategies for individual has been greeted;
modifying at-risk behaviour. - to recognise the individual’s emotions and pro-
Moreover, in this phase it is important to provide vide support;
adequate support for favouring the decision-making - to address the significance and immediate and
process (decision making counselling). Informed future implications of the test result;
consent is proposed, and the individual is encour- - to help the individual to activate suitable strate-
aged to return for the test result and prepared to gies for confronting the situation and modifying
face this result. at-risk behaviours.
any decision or choice regarding the solution to a as with pre-test counselling, during post-test coun-
problem or change is possible only if the individual selling the healthcare worker must be able to modify
him/herself comes up with proposals for change the objectives of counselling based on the individual’s
and finds within him/herself the reasons for actuat- characteristics, personalising these objectives accord-
ing these changes. For a decision to be autonomous ing to the specific, concrete, and feasible objectives
48 Anna Maria Luzi, Barbara De Mei, Anna Colucci, et al.
agreed upon with the individual. again, the health- that the individual can notify current and past sexual
care can refer to a standardised model structured partners or persons with whom he/she shared syringes.
into well-defined steps, which would allow him/her to For contact tracing, the healthcare worker directly at-
feel more at-ease in this complex relational context. tempts to identify, trace, and contact partners who had
However, for post-test counselling, the steps differ de- engaged in at-risk behaviour with the seropositive in-
pending on the test result. dividual, to inform that person of the risk and of the
need to undergo testing. Both partner notification and
Post-test counselling if the test result is negative contact tracing require the consent and collaboration
If the test result is negative, post-test counselling fo- of the individual and must respect privacy.
cuses on prevention by helping the person to change
those behaviours that led him/her to undergo testing. Post-test counselling if the test result is undetermined
If the test result is undetermined, post-test
Steps of post-test counselling in cases in which counselling focuses on containing the emotions
the test result is negative related to the uncertainness and helping the
- greeting the individual; individual to undergo another test, containing the
- immediately communicating or explaining the anxiety caused by the wait .
test result; the steps of post-test counselling if the test result
- helping the individual to express his/her feelings; is undetermined are:
- determining whether the person has understood - greeting the individual;
what he/she has been told; - immediately communicating the test result;
- discussing the implications of a negative test result; - explaining the significance of the test and deter-
- agreeing upon prevention strategies for modify- mining whether the individual has understood;
ing at-risk behaviours; - recognising the individual’s worries and provid-
- concluding the meeting, expressing availability ing support;
for further contact. - analysing the implications of the result;
- managing the individual’s uncertainty;
Post-test counselling if the test result is positive - agreeing upon prevention strategies;
If the test result is positive, post-test counselling fo- - concluding the meeting.
cuses on providing support, helping the individual to the above considerations demonstrate the evi-
deal with the emotional impact (crisis counselling), dent complexity of the issues related to testing for
providing clear information on the condition of serop- anti-HIV antibodies. to this regard, certain aspects
ositivity and on treatment and care options (informa- regarding the performance of rapid tests should be
tive counselling), as well as helping the individual to mentioned, and these aspects should be communi-
identify, plan, and manage the most urgent issues re- cated during pre-test counselling. In general, pre-
lated to this situation (problem-solving and decision- test counselling for rapid tests is performed in the
making counselling). the steps of post-test counsel- same way as that for the test for anti-HIV antibod-
ling in cases in which the test result is positive are: ies. Nonetheless, during pre-test counselling the indi-
- greeting the individual (importance of the exter- vidual must be informed of the method used and its
nal and internal setting); reliability, and, if the result is positive, of the need
- immediately communicating or explaining the test for a second-level confirmation test . It should be
result; stressed that for all relationships, regardless of the
- ensuring that the individual has a realistic per- specific test used and the test result, it is necessary to
ception of the situation; take into consideration the specific individual, his/her
- helping the individual to express emotions and age, the emerging problem and how it is experienced,
providing support; as well as his/her socio-cultural background, which is
- stimulating the individual’s resources (empower- particularly important for non-nationals.
ment); another approach, known as “opt out”, should
- strengthening cognitive restructuring (regaining also be mentioned . In 2006, the US centers for
control of the situation); Disease control and Prevention developed guidelines
- evaluating and favouring social support; for the opt out approach. In this case, the healthcare
- providing information, only if the person is capa- worker informs the individual that HIV testing is one
ble of absorbing it; of the routine tests performed. Informed consent
- developing a care plan and promoting safe be- is not necessary, and the individual is only asked to
haviour; sign if explicitly refusing to undergo HIV testing. In
- providing information on Partner Notification the opt out approach, there is no pre-test counsel-
and contact tracing; ling for evaluating risks or for favouring awareness
- making additional appointments to meet or re- in the choice to undergo testing. However, in 1997,
ferring the individual to specialised facilities; this approach was reevaluated, given that some stud-
- concluding the meeting. ies showed that the need to undergo testing should
regarding partner notification, the healthcare work- always be accompanied by informed consent, confi-
er makes him/herself available for providing support so dentiality, and counselling .
counsellIng for hIV testIng 49
tRAInInG oF HEALtHCARE WoRKERS ness. this focus is fundamental for managing the
InVoLVED In PERFoRMInG HIV tEStInG internal setting, so that thoughts, prejudices, convic-
the acquisition and/or improvement of counsel- tions, and personal emotions can be recognised and
ling skills for healthcare workers in HIV-testing managed. Self-awareness, including that of one’s own
facilities can constitute fundamental training for conceptual maps, individual limits and needs, and the
being able to effectively communicate, so as to ad- ability to confront one’s own cultural prejudices and
dress the needs of individuals who are directly or those of the individual, are the foundation of effec-
indirectly affected by HIV infection and aIDS [7-9, tive counselling. It is difficult to be empathetic and
26]. training can be done through courses that are engage in active listening if not in touch with one’s
structured based on the specific objectives and the emotions or recognising those personal aspects that
teaching methodology used. In the initial phase, the can be elicited by another’s feelings, situation, experi-
objective is to provide basic training in counselling ence, and ethic and moral convictions.
skills by teaching the principles and scope of coun- Moreover, in addition to learning, of great impor-
selling, the procedures, and the necessary relational tance is the application of the counselling interven-
skills. this objective can be reached with a 24-hour tion, that is, the reference scheme. In fact, after initial
course for diverse professionals, using classroom training, additional in-depth training is needed, using
training which includes, in addition to providing blended training, characterised by classroom train-
information, brief lessons, above all didactic experi- ing and remote training, together with supervised
ences: small-group exercises, accompanied by obser- field training. Finally, this training methodology can
vations, evaluation of behaviours in analogue role provide good opportunities to test tools for evaluat-
playing and case studies. ing HIV counselling based on previously established
the teaching method used is interactive and is indicators [7-9, 26].
based on the principles and criteria of the andra-
gogical model (geared towards adult education) of
the american scholar Malcolm Knowles , who ConCLuSIonS
places at the centre of training the experience of the In conclusion, 20 years after the first guidelines on
individual healthcare worker, who becomes the cen- HIV counselling were written by WHo, we have at-
tral element as a person, as the subject of learning, tempted to focus attention on the need for healthcare
and as a professional. the objective is to stimulate workers involved in testing for anti-HIV antibodies to
in the participant new cognitive schemes, concep- commit to the rigorous application of the methodol-
tual elaborations, and links to practical experience, ogy used for pre- and post-test counselling. the goal
aimed at allowing not only rapid and accurate re- is to stimulate healthcare workers to reflect upon the
sponses to the demands of individuals undergoing need to follow a reference protocol, so that counselling
HIV testing but also specific interventions in relation is not inappropriately performed or not performed at
to the complexity of pre- and post-test HIV coun- all. In fact, it is well known that there are numerous
selling. the basic prerequisite of training activities and complex implications for persons deciding to un-
in this specific environment is the actual willingness dergo testing and that providing adequate information
and deep-down motivation of the healthcare worker and emotional support to activate an informed and re-
to create an intense relationship with the individual, sponsible decision is extremely important.
based on trust, collaboration, unconditional accept-
ance, authenticity, and empathy. Acknowledgments
training in basic counselling must include propae- Mark Kanieff for revising the manuscript and providing useful
deutics focussed on one’s own personal and relational suggestions.
dimensions, on the qualities that favour and hinder
communication, and on the acquisition of relational Submitted on invitation.
skills such as active listening, empathy, and self-aware- Accepted on 14 January 2010.
1. Global Programme on aIDS (WHo/GPa) Psychosocial HIV e nell’AIDS. Milano: McGraw Hill; 1997.
counselling for persons with HIV-infection, AIDS and related
7. Gallini r. Schola Medici. Basi e tecniche dell’apprendimento
disease. Geneva: WHo; 1989.
formativo. roma: Nis; 1991.
2. rogers cr. La terapia centrata sul cliente. Firenze: Martinelli;
8. Mucchielli r. Apprendere il counselling. trento: erickson; 1994.
9. De Mei B, Luzi aM, Gallo P. Proposta di un percorso
3. carkhuff r. L’arte di aiutare. trento: erickson; 1988.
formativo sul counselling integrato. Ann Ist Super Sanità
4. Giusti e, ticconi G. La comunicazione non verbale. roma: 1998;34(4):529-39.
Scione editore; 1998.
10. Pezzotta P, Gatti M, Bellotti GG. Il counselling. In: Bellotti
5. Bellani ML. Personal communication. roma, 2008. GG, Bellani ML, De Mei B, Greco D (ed.). Il counsel-
6. trotti e, Bellani ML. Il counselling nell’infezione da HIV. In: ling nell’infezione e nella malattia da HIV. roma: Istituto
Bellotti GG, Bellani ML (ed.). Il counselling nell’infezione da Superiore di Sanità; 1995. (rapporti Istisan, 95/28).
50 Anna Maria Luzi, Barbara De Mei, Anna Colucci, et al.
11. World Health organization. Guidelines for counselling about 20. european centre for Disease, Prevention and Control.
HIV infection and diseases AIDS Series n. 8 (WHo):1990. Stockholm, october 2008.
12. World Health organization. Global AIDS News n. 3. Geneva: 21. D’amato S, Pompa MG. Legal aspects. Ann Ist Super Sanità
WHo; 1993-1994. 2010;46(1):51-6.
13. Global Programme on aIDS (WHo/GPa). Source book for 22. Buttò S, Suligoi B, Fanales-Belasio e, raimondo M. Labo-
HIV/AIDS counselling training. Geneva: WHo; 1994. ratory diagnostics for HIV infection. Ann Ist Super Sanità
14. Global Programme on aIDS (WHo/GPa). Counselling for
HIV/AIDS – a key to caring. Geneva: WHo; 1995. 23. Suligoi B, raimondo M, Fanales-Belasio e, Buttò S. the epi-
demic of HIV infection and aIDS, promotion of testing, and
15. British association of counselling. Invitation to membership.
innovative strategies. Ann Ist Super Sanità 2010;46(1):15-23.
Bac: rugby; 1992.
24. Buttò S, raimondo M, Fanales-Belasio e, Suligoi B. Sug-
16. Spizzichino L. Counselling e psicoterapia nell’infezione da gested strategies for the laboratory diagnosis of HIV infec-
HIV. Dall’intervento preventivo al sostegno psicologico. tion in Italy. Ann Ist Super Sanità 2010;46(1):34-41.
Milano: Franco angeli; 2008.
25. UNaIDS/World Health organization. Guidance on pro-
17. Joint United Nations Programme on HIV/aIDS-UNaIDS. vider-initiated HIV testing and counselling in health facilities.
Guidance on provider-initiated HIV testing and counselling in Geneva, Switzerland: UNaIDS; 2007.
health facilities. Geneva: WHo; 2007.
26. De Mei B, Gallini r, Magnani F, Greco D. Metodi e tec-
18. Joint United Nations Programme on HIV/aIDS-UNaIDS, niche per la formazione degli operatori sanitari all’HIV/aIDS
World Health Organization. UNAIDS/WHO Policy Statement counselling. In: Bellotti GG, Bellani ML (ed.). Il counselling
on HIV Testing. Geneva: WHo; 2004. nell’infezione da HIV e nell’AIDS. Milano: McGraw Hill; 1997.
19. european centre for Disease, Prevention and control. Meet- 27. Knowles M, Halton III eF, Swanson ra. The adult learner:
ing Report – HIV testing in Europe: From policies to effective- the definitive classic in adult education and human resource de-
ness. Stockholm, 21-22 January 2008. velopment. Burlington USa: elsevier; 2005.