The Responses

Establishing the role of HIV counselling

One way counselling can be accorded its proper respect is by conducting studies on its delivery, quality and impact. Research findings on counselling can help convince decision-makers and service managers to endorse and provide resources in support of counselling services.

· In Uganda, TASO (The AIDS Service Organisation) conducted a study on 730 HIV-positive clients to whom it had given long-term counselling.

Counselling appeared to help these clients cope with their infection. Of the clients sampled, 90% had revealed the fact of their infection to another person, with 85.3% telling relations. The study also showed a high level of acceptance of HIV-positive people within families (79%) and in communities (76%), as reported by the TASO clients who had received regular counselling (see Key Materials, TASO Uganda - the inside story, 1995). After results were discussed at each hospital where TASO operated, the hospital managers provided more space for counsellors and encouraged doctors to refer clients to TASO counsellors.

· In 1992, a study in Rwanda examined the impact of preventive counselling. It was shown that for the women whose partners were also tested and counselled, the annual incidence of new HIV infections decreased from 4.1% to 1.8%. Among women who were HIV-positive, the prevalence of gonorrhoea decreased from 13% to 6%, with the greatest reduction in those using condoms. As a result of these findings, counselling was recognized as a mainstream intervention and the funders of the study established a project for counselling and discordant couples in Zambia (see Key Materials, Allen et al., 1992).

Proper selection of trainees for counselling

Candidates for a counselling training course should satisfy a number of conditions. They must be given a job description that specifies that they can provide counselling. They must have the necessary agreed professional background - this may be as a social worker, health worker, teacher, community worker, or a volunteer from a group of people living with HIV/AIDS. They should be good listeners, respected by others, motivated and resilient, and have warm and caring personalities.

In order to select people with good qualities for counselling, TASO uses the following approach. First, prospective trainees must have a job placement where they can see clients who require counselling. Second, TASO conducts a one-day AIDS counselling awareness workshop for a large group of people being considered for training. This awareness workshop must be conducted separately from training on the technical skills of counselling. During the awareness workshop, a number of issues concerning AIDS - including controversial matters such as compulsory partner notification - are brought up. The trainers observe the attitudes, reactions and interpersonal interaction skills of the prospective trainees, and based on this, select people for the actual skills training. In order to chose the right type of people to become counsellors, those selecting trainees should have a good understanding of the cultural context in which counselling is to be delivered.

Training workshop, followed by supervised practice

Most of the current effort in training takes the form of a single workshop, with no follow-up supervision. Instead, after the initial workshop the trained person should be placed in counselling work, with support and good supervision, and should participate in a second training workshop later.

Such an approach has been followed in several places. The Zambian national AIDS programme, for instance, has set up a countrywide programme for training in HIV counselling. This begins with a basic workshop, followed by placement in a work situation, which is later followed up by an advanced workshop.

Retention of trained counsellors

In Tanzania, a study showed that of those who had received counselling training, less than a quarter were reported to be practising counselling.

Counsellors often leave their jobs, most probably because of burnout and lack of proper support. If counsellors are given proper support, the stresses which can build up and cause burnout can be reduced. Such support can take three forms:

· administrative support, including the provision of better working facilities and timetables, and job descriptions that accommodate counselling;

· professional support, where a supervisor discusses cases with the counsellor or provides emotional support;

· peer support from colleagues.

Service development and support

Once the heads of service sites and AIDS programmes are convinced of the importance of counselling, then one can get down to establishing the basics for a good service (see Key Materials, Counselling for HIV/AIDS: a key to caring, WHO, 1995).

· Excessive workloads on counsellors that lead to burnout can be reduced by using trained part-time volunteers and a well-planned system of shifts - for example, a nurse may do counselling for four hours in the morning, and then work at the nurse station in the afternoon.

· The location and opening hours of the service should take into account the needs of the particular community. Counselling has been carried out in STD clinics, hospital outpatient departments and hospital wards. Some nongovernmental organizations (NGOs) have set up counselling centres inside hospital compounds. Others have established counselling services on their own premises, or in centres specially dedicated to HIV counselling (see Key Materials, Strategies for Hope No. 9, 1994). Counselling services for sex workers, as well as condom supplies, are sometimes offered in the vicinity of night clubs, and operate at night.

· HIV/AIDS educational campaigns should include details on how, where and when people can obtain counselling.

· Reception staff should be trained to adopt a supportive and sympathetic attitude, and sensitized to the need for confidentiality.

· If resources permit, counselling services for a symptomatic individuals, as well as preventive counselling, should be located separately from care services for AIDS patients. This enables those living with HIV but who have not yet developed AIDS to receive counselling without being depressed by seeing very ill AIDS patients.

· Counselling sessions need to be well planned so that, for instance, informed consent is always sought and counselling offered before a client takes an HIV test.

· Counselling should be integrated into other services, including STD, antenatal and family planning clinics.

· Community-based counselling services can be initiated and expanded quickly and at little expense.

Referral systems

The existence of good support for counsellors is directly related to the existence of a good referral system. A referral system should be developed in consultation with NGOs, community-based organizations, hospital directors and other service managers, as well as with networks of people living with HIV and AIDS. An efficient referral system will enable AIDS service organizations and other NGOs to refer clients requiring medical care to hospitals and clinics. At the same time medical services should refer clients to specialized NGOs for ongoing counselling, home care and social support, such as the provision of food and housing.

In Abidjan, Cd’Ivoire, NGOs such as Espoir work closely with Treichville University Hospital to provide medical, nursing and psychosocial care to inpatients and outpatients with HIV/AIDS. Espoir also operates a free, anonymous HIV counselling and testing centre.

At the Thai Red Cross Society, clients of the Anonymous Counselling Center are referred to the Wednesday Friends’ Club (a support group for people living with HIV and AIDS) and the Chulalongkorn Hospital Immune Clinic for follow-up on treatment and care.

Referrals should always be confidential, and clients should be advised to contact named individuals at the referral site, rather than being given a general referral note. A referral system can only function well if the referring caregiver discusses with the client the reasons why he or she is being referred and the services which are available at the referral site. It is suggested that regular meetings should be held among service providers to review and improve the referral system.