Acquired immunodeficiency syndrome (AIDS ) counseling, more properly called human immunodeficiency virus (HIV) counseling, refers to advice about health matters, HIV transmission, and high-risk behaviors given to clients before and after testing for HIV infection. It is sometimes referred to as voluntary counseling and testing, or VCT.
The first VCT programs were started around 1985, about four years after the first cases of AIDS in the United States were identified. At that time most individuals who sought HIV testing were gay men; about 20 percent of those who were tested proved to be infected. AIDS counseling in the mid-1980s was largely crisis-oriented; it focused on helping infected persons cope with the short-term emotional shock of a positive diagnosis and the longer-term concerns of employment, family relationships , finding medical treatment, and end-of-life care. Crisis counseling is often an important part of accepting and adjusting to a diagnosis of a terminal illness. Crisis counselors are trained to provide patients with coping strategies as well as the resources necessary to deal with various aspects of the disease and accompanying lifestyle changes.
The focus of HIV counseling shifted in 1991, after Magic Johnson, a heterosexual basketball star, was diagnosed with HIV. As a result of the publicity given to his diagnosis, large numbers of heterosexual men and women began to seek HIV testing. With the rapid rise of low-risk adults seeking testing for the virus, the number of those who tested positive at publicly funded test sites in the United States dropped to less than 2 percent. The counseling given to clients changed its focus from crisis intervention to an information-oriented public health approach. Clients were given basic health information about AIDS and advice about safer sex practices.
The focus of HIV counseling changed again in 1993, when the U.S. Centers for Disease Control and Prevention (CDC) evaluated VCT programs and found that they had poor outcomes. A client-centered approach was recommended instead of the existing counseling format. “Client-centered” is a term coined by therapist Carl Rogers (1902–1987). Rogers maintained that every person has an innate capacity for growth and change, and that it is the counselor's task to encourage this growth through empathic concern for and unconditional acceptance of the client. The problem with the CDC's 1993 recommendation is that VCT counselors were expected to obtain data about high-risk behaviors from clients seeking testing as well as offering a version of client-centered therapy. These two incompatible expectations meant that counselors usually conducted sessions with clients according to standardized questions about high-risk sexual behaviors. The result has been a depersonalized approach to counseling that resembles a research interview rather than genuinely client-centered counseling.
As of the early 2000s, HIV counseling still differs from standard mental health counseling in two major respects. First, most VCT counselors are not trained mental health professionals; they are nurses, outreach workers, or even volunteers with no more than a few days' training in VCT. Second, HIV counseling is not freely requested by people seeking testing; it is mandated by laws (at the state rather the federal level) regulating publicly funded HIV testing. The counseling is thus a precondition of receiving the test, and most clients regard conversation with the counselor about their behaviors an unpleasant preliminary to getting tested.
Most counseling for HIV infection in the early 2000s is aimed at young people and other groups considered to be high-risk—men who have sex with other men (MSM), intravenous drug users, and persons who have tested positive for another sexually transmitted disease (STD), such as syphilis, herpes, or gonorrhea. Most people do not think of seniors as sexually active and may not consider them in need of HIV counseling.
The demographics of HIV infection among the elderly, however, have changed since the early days of the AIDS epidemic. In the mid-1980s most cases of AIDS among seniors were the result of transfusions with contaminated blood. The introduction of effective screening tests for blood products has virtually eliminated this path of HIV transmission. As of 2008, almost all cases of AIDS in seniors are the result of sexual activity. In the United States, about 10% of all cases of AIDS occur in people over 50, and 3% in people over 60. About 35% of seniors who develop AIDS are homosexual or bisexual men; others are heterosexual men living in urban areas who engage in high-risk sex with prostitutes.
One reason that sexually active seniors are particularly at risk for HIV infection is that they are rarely concerned about contraception. Adults over 50 are five times more likely than younger people to have unprotected sex because they think of condoms as a method of birth control rather than a means of preventing disease transmission. According to the Merck Manual of Geriatrics, “Practically no prevention information on AIDS is targeted at elderly persons, although most elderly persons are sexually active.” According to statistics compiled by the Centers for Disease Control and Prevention, about 2,100 men between the ages of 55 and 59 are diagnosed with HIV infection each year, and 800 over the age of 65. Since the epidemic began in 1981, 15,000 seniors over age 65 have been diagnosed with HIV.
Who should seek counseling?
Some seniors are at higher risk than others of HIV infection. In order to determine whether HIV testing should be a personal priority, the senior should use the following checklist of high-risk behaviors (for 1978 and later).
- Shared needles for injecting drugs or steroids.
- If a male, had unprotected sex with other males.
- Had unprotected sex with someone known or suspected to be infected with HIV.
- Had a blood transfusion between 1978 and 1985.
- Had another sexually transmitted disease.
- Had unprotected sex with anyone with any of the five previous risk factors.
The present model for HIV counseling recommends before- and after-test counseling. Pre-test counseling allows the senior to talk over various concerns about testing. There are three major concerns: fear that the stress of testing positive would be greater than the stress of not knowing one's HIV status; fear that others would obtain the test results without the senior's permission; and fear that the results would lead to discrimination in housing or health insurance.
Most primary care doctors include the following points in pre-test counseling:
- Emphasizing that testing allows the patient and physician to work together to maintain the patient's health and prevent transmission of the virus to others.
- Education about the risks of transmitting HIV through oral, anal, and vaginal sex, and through needle sharing.
- Tailoring this information to the needs of specific groups. For example, heterosexual women should know that their male sex partners may engage in drug use or high-risk sexual relations with other men.
- Some seniors may need to know that HIV testing will not harm them and that they will still receive medical services if they test positive for HIV.
- Drug users should be encouraged to seek treatment for addiction in order to increase their chances of survival if they do test positive for HIV.
Some typical open-ended questions that the doctor may ask a senior may include:
- What, if anything, are you doing that may be putting you at risk for HIV infection?
- What are the riskiest things that you are doing?
- How often do you use drugs or alcohol?
- How often do you use condoms when you have sex?
- How risky are your sexual partners or needle-sharing partners? Have they been tested for HIV recently?
After-test counseling for persons who test negative consists of advice about avoiding high-risk behaviors, as well as information about the need for a retest if the person has engaged in high-risk behaviors during the six months previous to the test. The reason for a retest if the initial test is negative is that some people do not develop antibodies to HIV for several months after infection. If the test is positive, the senior is referred to other professionals for follow-up health care, support services, or further counseling. The counselor may offer advice about ways to inform the senior's sexual or needle-sharing partners.
Effectiveness of VCT
There are very few outcome studies of VCT as of 2008 that pay much attention to the actual counseling process. The evidence of the effectiveness of VCT is mixed for heterosexuals; some studies have found that persons who test positive for HIV are likely to reduce their risky behaviors while those who test negative are not. In fact, negative test results encourage some clients to increase their use of high-risk behaviors. There are relatively few outcome studies of men who have sex with other men, and none at all as of 2008 of the effectiveness of VCT among seniors.
2006 CDC recommendations
In 2006 the CDC changed its recommendations about screening tests for HIV, urging that these tests be offered routinely to patients between the ages of 13 and 64 in health care settings. These recommendations were made in part because the availability of six new rapid tests (some of which use oral fluid rather than blood serum) for detecting HIV infection. These new tests allow for quick (within 20 minutes) and simple testing at the point of care or in nonclinical settings. Seniors included in the age group in question do have the choice of refusing a screening test. This is called an opt-out choice.
As of 2008 there are two types of policies in use at HIV testing sites: confidential testing and anonymous testing. In confidential testing, the site records the senior's name along with the test result. The record is kept secret from everyone except medical personnel or the state health department. The senior should ask who has access to the test results and how the data are stored.
In anonymous testing, which is not available in all states, the senior is not asked for his or her name, and is the only person who is given the test results.
Insurance companies know that the senior was tested for HIV if he or she pays for the test through insurance. They will not know the results unless the senior has authorized release of the findings. Some insurance forms stipulate that the client's signature automatically authorizes the release of medical records. Seniors who are concerned about their insurance company should not sign any medical release forms unless they know their purpose. One alternative to paying for the test through one's insurance policy is to go to a publicly funded testing site, substance abuse treatment center, STD clinic, or family planning clinic. Many of these sites offer HIV testing for free or for a minimal charge. Testing in a doctor's office can cost as much as $200.
Seniors who test positive for HIV and depend on Medicaid may need special assistance to get treatment for the infection. They should consult a qualified counselor who is knowledgeable about the most recent changes in government policy.
Client-centered —An approach to counseling associated with Carl Rogers that emphasizes the client's ability to grow and change. The counselor is not supposed to assess or evaluate the client, but to feed this natural capacity for change through empathy and unconditional acceptance.
Point-of-care testing (POCT) —A term that refers to diagnostic testing (whether for HIV or other diseases) that is carried out at or close to a doctor's office, clinic, or other site of patient care.
Supportive —Referring to counseling or psychotherapy intended to provide emotional support and encouragement rather than intellectual exploration of the client's problems or behavioral change.
Special concerns for seniors
The new CDC guidelines for screening for HIV infection in health care settings states that screening should be performed routinely for all patients aged 13–64 years. The age cutoff of 64 years implies that older seniors will not be offered testing and counseling unless they are diagnosed with tuberculosis , develop one of the infections associated with AIDS, or seek treatment for another STD.
Seniors diagnosed with HIV infection are usually given supportive counseling after the test to help them cope with emotional stress. Supportive counseling is aimed at offering encouragement and advice rather than providing intellectual insight into the client's difficulties or changing his or her behavior. Seniors are likely to need considerable emotional support after diagnosis because HIV infection progresses much faster in older patients than in younger ones. Eighty percent of younger patients survive at least a year after diagnosis, whereas only 40% of elderly patients survive more than one year.
Beers, Mark H., MD, and Thomas V. Jones, MD. Merck Manual of Geriatrics, 3rd ed., Chapter 134, “Human Immunodeficiency Virus Infection.” Whitehouse Station, NJ: Merck, 2005.
Klausner, Jeffrey D., and Edward W. Hook, III, eds. Current Diagnosis and Treatment of Sexually Transmitted Disseases. New York: McGraw-Hill Medical, 2007.
Lee, Sharon Dian. HIV and Aging. New York: Informa Healthcare USA, 2008.
Branson, B. M., H. H. Handsfield, M. A. Lampe, et al. “Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health Care Settings.” MMWR Recommendations and Reports 55 (September 22, 2006): 1–17. Available online at http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5514a1.htm [cited February 14, 2008].
Gallant, Joel E. “HIV Counseling, Testing and Referral.” American Family Physician 70 (July 15, 2004): 295–308.
Available online at http://www.aafp.org/afp/20040715/295.pdf [cited February 16, 2008].
Deciding If and When to Be Tested. Centers for Disease Control and Prevention (CDC). January 22, 2007 [cited February 15, 2008]. http://www.cdc.gov/hiv/topics/testing/resources/qa/be_tested.htm.
Dubin, Jeff. “HIV Infection and AIDS.” eMedicine. February 5, 2007 [cited February 14, 2008]. WebMD. http://www.emedicine.com/emerg/topic253.htm.
HIV Partner Counseling and Referral Services: Guidance. Centers for Disease Control and Prevention (CDC). Washington, DC: U.S. Department of Health and Human Services, 1998.
Sheon, Nicolas. Theory and Practice of Client-Centered Counseling and Testing. HIV InSite. June 2004 [cited February 15, 2008]. http://hivinsite.ucsf.edu/InSite?page=kb-07-01-04#S1X.
Wilson, Thomas C. Counseling Roles and AIDS. Highlights: An ERIC/CAPS Digest. Ann Arbor, MI: ERIC Clearinghouse on Counseling and Personnel Services, 1987 [cited February 16, 2008]. http://www.ericdigests.org/pre-925/roles.htm.
Voluntary HIV Counseling and Testing: Facts, Issues and Answers. Centers for Disease Control and Prevention (CDC). Washington, DC: U.S. Department of Health and Human Services, 1998 [cited February 16, 2008]. http://cdcnpin.org/brochures/Testing.pdf.
Centers for Disease Control and Prevention (CDC), 1600 Clifton Road, Atlanta, GA, 30333, (404) 498-1515, (800) 311-3435, http://www.cdc.gov.
Centers for Disease Control and Prevention National Prevention Information Network (CDC NPIN), P.O. Box 6003, Rockville, MD, 20849, (404) 679-3860, (800) 458-5231, (888) 282-7681, [email protected], http://www.cdcnpin.org.
HIV InSite, University of California San Francisco, Center for HIV Information, 4150 Clement Street, Box 111V, San Francisco, CA, 94121, (415) 379 5547, [email protected] hivinsite.ucsf.edu, http://hivinsite.ucsf.edu/InSite.
Rebecca J. Frey Ph.D.