In 1987, HIV counseling and testing was expanded due to the increased understanding of the scope and severity of the HIV epidemic and the predictive value of the HIV test. Those seeking care for sexually transmitted diseases, family planning, childbirth, or substance abuse were counseled in an attempt to reduce their risk for HIV transmission. Even more so now, the HIV tests have been proven in their reliability and predictive value and public awareness has greatly increased. Early detection of the virus allows the patient to benefit from early antiviral and prophylactic treatment.

Counseling is a direct, personalized, and client-centered intervention designed to help initiate behavior change to avoid infection, or, if already infected, to prevent transmission to others, and to obtain referral to additional medical care, preventive, psychosocial and other needed services in order to remain healthy.

1. To provide a convenient opportunity for persons to learn their current serostatus;
2. Allow such persons to receive prevention counseling to help initiate behavior change to prevent the transmission or acquisition of HIV;
3. Help persons obtain referrals to receive additional medical care, preventive, psychosocial, and other needed services;
4. Provide prevention services and referrals for sex and needle sharing partners of HIV-infected persons.

Following is an abbreviated list of the objectives identified to accomplish the above goals.

1. Identify persons who are unaware, uninformed, misinformed, or in denial of their risk for HIV infection and facilitate an accurate self-perception of risk.
2. Prepare clients for and provide them with knowledge of their HIV status.
3. Refer clients to resources that will provide psychosocial support and facilitate desired behavior change.
4. Provide referral to appropriate drug treatment services for clients whose substance abuse problems enhance their HIV risk.
5. Provide information on the increased risk of HIV transmission associated with other sexually transmitted diseases (STDs) and give referrals for STD examination and treatment. 

Necessary Elements

1. Maintenance of confidentiality

Strict protection of client confidentiality must be maintained for all persons offered and receiving HIV counseling services.

     2. Risk Assessment

Client-centered discussion that encourages the client to identify, understand, and acknowledge his or her personal risk for acquiring HIV.

3. Prevention Counseling

Provides an opportunity for the client to identify his or her risk of acquiring or transmitting HIV and reduce or eliminate behavioral risks.

4. Providing test results

Involves interpretation that is based upon the test result and the client’s specific risk. Skillful, client-centered counseling is required to reassess behavioral risks which may influence the interpretation of the test results. The client will most often focus on the actual result itself rather than behavioral and preventive messages.

5. Provision of Referrals

Clients may require referral for physical and psychological evaluations, appropriate therapies (i.e. drug therapies), and support services to enhance or sustain risk reduction behaviors.

Risk Assessment

The risk assessment should include reason for visit and other relevant concerns, personal circumstances, the client’s resources and support systems, behavioral and other sources of risk, demographic and epidemiologic factors that influence risk, client’s awareness of risk, readiness to change behavior, and receptiveness to available services and referrals. Risk assessment is not intended solely as a screening tool for client eligibility for HIV testing. A negotiated risk reduction plan should be the result and be a realistic, attainable strategy that is developed with the client to achieve behavior changes to reduce the risk for acquiring or transmitting HIV. Listen for and address information such as:

• Number of sex partners (casual and steady) and sexual activities including vaginal, anal and oral sex, both receptive and insertive activities;
• Sex with a person known to be HIV positive;
• Sharing needles or having sex with persons who share needles;
• History of STDs (both ulcerative and non-ulcerative);
• Assessment of current STD symptom status;
• Sex in exchange for drugs, money, or other inducements;
• Use of substances such as alcohol, cocaine, etc., in connection with sexual activity;
• Birth control/pregnancy prevention methods;
• A history of receipt of blood products, organs, tissues or artificial insemination (especially before 1985 which was pre-screening). This risk is primarily relevant for persons without other behavioral risks who are symptomatic or diagnosed HIV+.
• Sexual orientation. Although men who have sex with men are at an especially high risk, heterosexual transmission is a rapidly growing risk population; especially for those with: multiple partners, seropositive partners or partners with other behavioral risks or unknown sexual history.
• Persons with hemophilia or other clotting disorder that necessitates frequent administration of blood products.

Discuss related healthy behaviors, for example:

Limit the use of alcohol and other drugs;
Obtain family planning assistance;
Obtain early diagnosis and treatment for STDs, when appropriate;
Explain authorized disclosures and anti-discrimination protection;
Discuss bringing a supportive person of the client’s choice at the time of receiving the test results.
Assess the client’s concerns and anxieties during the waiting period. If necessary,
Arrange psychological referral to assist the client with coping during waiting time;
Provide a hotline telephone number(s) as a referral option;
Provide a subsequent counseling session or a follow-up telephone call.

Negative Results:(1) either the person is not affected, or (2) so recently infected that the test could not detect the infection.

Ensure that the client understands what the test result means including
Limitations of the test
Periodic retesting if the client continues to participate in high risk behaviors
Identify and encourage to continue any steps already taken by the client to reduce risk and provide positive reinforcement.
Assist the client in building skills to negotiate risk reduction activities with current or potential partners through discussion and role plays
Offer referral for further assistance in avoiding risk behaviors and maintaining low-risk behaviors
Discuss his/her need and ability to help partners realize they are also at risk for HIV infection and make positive persons aware of the availability of partner notification services at the Health Department.
Advise the client to refrain from donating blood, plasma, and organs and advise them that future sexual or needle-sharing partners must be notified before engaging in those behaviors. Failure to do so constitutes a felony crime in Florida.

Positive HIV Test Result: the person is infected with HIV and can transmit it to others.

Some HIV positive clients may be better prepared to receive positive test results than others. Counseling of patients with positive test results must be directed to the client’s specific circumstances and may require more than one session. Counselors should recognize that the emotional impact of learning about HIV positive results often prevents clients from absorbing other information during this encounter.

• Allow time for the client’s emotional response after learning his or her positive HIV result. A subsequent counseling session or follow-up telephone phone call may be required. Keep in mind the following;
• Ensure that the client understands what the test results means;
• Assess the client’s immediate needs for medical, preventive, and psychosocial support (e.g., financial, personal, and other);
• Provide the client with written referral information—the client might have complex or specific questions to be answered by experts in the area;
• Reassess the client’s risk for transmitting HIV and help facilitate behavior change to minimize and /or eliminate the risk of transmission;
• Discuss the responsibility to assure that sex and/or needle-sharing partners are counseled about their exposure to HIV and the need for them to seek medical evaluation;
• Discuss his or her specific plans for the next few days and ensure that the client has access to support systems during this time;
  Advise client against donating blood, plasma, and organs.

Interpretation of HIV-Antibody Test Results

A test for HIV is considered positive when a sequence of tests, starting with a repeatedly reactive enzyme immunoassay (EIA) and including an additional, more specific assay, such as a Western Blot, are consistently reactive.

The sensitivity (the probability that a test will be positive when the infection is present) of the currently licensed EIA tests is 99% or greater when performed under optimal laboratory conditions. This makes the chance of a false-negative result remote, except during the first few weeks of infection before antibody is detectable.

Sexual partners and those who share needles with HIV-infected persons are at risk for HIV infection and should be routinely counseled and tested for HIV antibody. Persons who are HIV-antibody positive should be instructed in how to notify their partners and to refer them for counseling and testing. If they are unwilling to notify their partners or if it cannot be assured that their partners will seek counseling, physicians or health department personnel can assist confidential procedures to assure that the partners are notified.
 Every reasonable effort should be made to improve confidentiality of test results. The confidentiality of related records can be improved by a careful review of actual record-keeping practices and by assessing the degree to which these records can be protected under applicable state laws. State laws should be examined and strengthened when found necessary. Because of wide scope of "need-to-know" situations, because of the possibility of inappropriate disclosures, and because of established authorization procedures for releasing records, it is recognized that there is no perfect solution to confidentiality in all situations.
Persons are more likely to participate in counseling and testing programs if they believe they will not experience negative consequences in areas such as employment, school admission, housing, and medical services should they test positive. There is no known medical reason to avoid an infected person in these and ordinary social situations since the cumulative evidence is definitive that HIV infection is not spread through casual contact. It is essential to the success of counseling and testing programs that people who are tested or HIV programs are not subjected to inappropriate discrimination. (CDC, HIV/AIDS Among U.S. Women, May 2002).