How this Course Works This online course offers the information that forms the foundation for the face-to-face HIV Counselor Training you will be attending soon. Both trainings build on over 25 years of experience talking with people about stopping the transmission of HIV. This online course is separated into pre-reading modules, followed by a 34-question quiz. There is no time limit to complete the pre-reading or quiz. Once you begin the quiz, you may go back to the readings. However, you may only submit your quiz answers once. Your quiz will be scored by a training administrator, and you will receive and email with your score. You need at least 80 percent of correct responses in order to be eligible to sign up for the training. If you do not pass on the first try, you will receive an email notification and you can re-take the quiz.
1 HIV/AIDS the basics… Goal: This module will present an overview of HIV/AIDS, the basics of how HIV passes from person to person, and a brief description of who is at risk for HIV in California. Learning Objectives: At the end of this module participants will be able to: • Differentiate basic HIV concepts, such as: exposure, infection, modes of transmission, replication, infectious/non-infectious body fluids • Explain the effects of HIV in the human body • Express basic AIDS concepts such as diagnosis and opportunistic infections • Evaluate basic local HIV epidemiology
H uman What are HIV and AIDS? I mmunodeficiency V irus A cquired I mmuno D eficiency S yndrome
What is HIV? • A retrovirus • Transmitted only between humans • Multiplies inside specific cells of the immune system • Destroys immune system cells • Causes inflammation of arteries and of the heart • Causes a condition called AIDS
HIV Invades CD4+ Cells • HIV is a virus that invades CD4+ cells, which are a critical part of our immune system. • Once inside a CD4+ cell, the virus uses the cell to create more virus. In the process HIV destroys the original cell. • As more and more immune system cells are destroyed, the body has a harder time fighting off both HIV and other illnesses.
HIV is an Inflammatory Disease We are learning that HIV seems to do more than just impair the immune system. It is also an inflammatory disease which over time can cause damage to arteries and to the heart. Because of this inflammatory effect, a person who has HIV and who does not smoke has the same risk for heart attack as a person who doesn’t have HIV but who does smoke.
What is AIDS? • A serious health condition caused by an advanced stage of HIV infection • The immune system becomes severely damaged by HIV and can no longer protect the body from infections. • Rare “opportunistic” infections and cancers become more common.
Opportunistic Infections (OIs) Illnesses that takes advantage of a person’s weakened immune system. OIs do not normally appear in persons with healthy immune systems. The Centers for Disease Control and Prevention (CDC) have generated a list of 40 OIs, which includes: Kaposi’s sarcoma, pneumocystisjirovecipneumonia, Toxoplasmosis, Cryptococcal Meningitis, Mycobacterium Avium Complex (MAC), Cytomegalovirus retinitis, among others.
What Gives an AIDS Diagnosis? • HIV positive, AND • CD4 (T-cell) count below 200 • OR presence of one or more opportunistic infections
Viral Load (VL) Viral load is the amount of HIV in a sample of blood. HIV medications fight HIV and work to keep the virus from making copies of itself. VL tests is used along with the CD4 cell count to monitor the status of HIV disease, guide recommendations for therapy, and predict the future course of HIV. It is important to keep VL at an undetectable level. Undetectable does not mean your HIV infection is gone. It means that the amount of HIV in your blood is too low to be measured with current tests. Also, an undetectable VL means that the risk of transmitting HIV has decreased but has not been eliminated. People do get infected with HIV even when their HIV+ partner is undetectable. Undetectable VLs in blood are not a guarantee that HIV is also undetectable in semen
Exposure vs. Infection Not every case of exposure will result in HIV infection.
Infectious Bodily Fluids • Blood • Semen • Precum • Vaginal Secretions • Breast Milk • (for infants) The body fluids containing HIV at levels high enough to infect someone else include:
Non-Infectious Bodily Fluids • Saliva • Tears • Sweat • Urine • Sputum • Nasal secretion • Feces Small traces of HIV have been found in some of the body fluids mentioned above. However, the amount of virus present is so small that these body fluids are not able to transmit HIV. These fluids only present a risk for HIV transmission if they are mixed with blood.
Requirements for Infection The following three factors need to happen in order for HIV to cause infection: 1. HIV must be present, 2. In sufficient quantities to cause infection, • Blood • Sexual fluids • Breast milk 3. And be able to get into the bloodstream • Directly through damaged skin or through injection • Absorption through mucous membranes If you remove one of these factors, infection cannot take place.
HIV is NOT transmitted by: • Hugging • Kissing • Massage • Shaking hands • Insect bites • Pets • Donating blood • Swimming pools or hot tubs • Casual contact with someone who has HIV (sharing dishes, food, showers or toilets, phone) • Casual contact with saliva, tears, sweat, or urine The U.S. National Institutes of Health and the U.S. Centers for Disease Control and Prevention have found that none of the above are ways that people contract the virus.
How does HIV look like in CA? • 74%of those who are HIV-positive are men who have sex with men (MSM) including MSM who inject drugs (MSM-IDU) (6%) • 29% are between 20 and 29 years old; • 36% are between 30 and 39 years old, • and 22% are between 40 and 49 years old • 18% are African American (7 percent of Californians are African American) • 30% are Latino (36 percent of Californians are Latino) • Women are the fastest growing demographic for HIV Source: California HIV/AIDS Surveillance Statistical Reports 2011
2 HIV Prevention Goal: This module will present the continuum of risk and some ways to reduce the chance of sexual transmission of HIV and the concept of harm reduction. Learning Objectives: At the end of this module participants will be able to: • Apply the continuum of risk in HIV counseling • Convey different options that might lessen the chance of infection during sex • Explain the concept of harm reduction
Continuum of Risk Different sexual activities pose different risks for HIV. It may be easier to think of sexual risk in terms of a continuum wheresome sex activities carry more HIV risk than other. As a counselor, you might rely on the continuum of risk to help clients think of small, incremental steps to reduce the chance of infection. For example, if a client is not going to use a condom, substituting oral sex for anal intercourse is a step that dramatically reduces the client’s chance of contracting or transmitting the virus.
How to Prevent HIV During Sex People can prevent HIV infection during sex by not taking blood, semen, pre-ejaculate, or vaginal secretions into the mouth, vagina, or anus. The following screens offer other options that might lessen the chance of infection during sex: HIV
Condoms When used properly, male and female condoms, and barriers such as dental dams are effective prevention methods. Condoms nearly eliminate the risk of HIV transmission during anal and vaginal intercourse.
Use Lube for Vaginal and Anal Sex Lubrication helps prevent tears in mucous membranes and lowers the risk of transmission
Testing, Linkage and Retention in Care and Treatment of HIV Early detection, proper care and treatment of HIV can prevent new HIV infections
Test for and Treat STDs Identifying and treating other sexually transmitted infections reduces the chance of infection with HIV
Replace Intercourse with Oral Sex The risk of HIV transmission from oral sex is extremely low. However, the presence of cuts, bleeding gums, or and STD elevates the risk. Options for lowering the risk of transmission during oral sex include using a barrier like a condom or dental dam. If a client does not want to use condoms, not allowing partners to ejaculate into the mouth offers some protection.
Serosorting Some people make a practice of only having sex with people of a specific HIV status. This could be the same or the opposite of their HIV status. This is called serosorting. The advantages and limitations of serosorting can be a rich topic of conversation during a counseling session.
Concept of Harm Reduction • Reducing and not necessarily eliminating harm resulting from drug use and/or sexual behaviors
Harm Reduction • Meet people “where they’re at” • Support clients in making any positive change • Although the concept of harm reduction was developed by substance users and their counselors, the principles are applicable to many other kinds of activities. For example, switching to more oral sex and less anal sex could be seen as an example of harm reduction
Harm Reduction Approaches Here are some suggestions, adapted from the Harm Reduction Coalition and Training Institute, for working with clients on harm reduction: Maintain a policy of respect for all clients: Recognize and set aside judgments about drug use and sexual behaviors Focus on a client’s strengths and abilities Support all positive changes Let people identify and set their own priorities When asked, provide accurate and honest information about the possible harm of drug use and sexual behaviors, both in general and specifically in terms of the client’s life
3 HIV Testing and Counseling Goal: This module will present the principles of HIV counseling. Objectives: At the end of this module participants will be able to: • Understand the goal and characteristics of HIV test counseling
What is HIV Testing • HIV testing is a health tool people use to find out if they are infected with the virus that causes a condition called AIDS • Conventional HIV tests are designed to detect HIV antibodies. Other more specific tests can detect antigens*, or even the virus itself *A pathogen that stimulates the production of an antibody when introduced into the body. Antigens include toxins, bacteria, viruses, and other foreign substances.
What Is Counseling • Counseling is a two-way communication process that helps individuals: • Examine personal issues • Make decisions • Make plans for taking action • In HIV counseling and testing the focus is to help clients make decision based on their HIV status
HIV Counseling Involves • Active listening • Being client focused • Maintaining confidentiality • Asking questions • Allowing clients to make their own decisions • Helping clients find other services they may need
HIV Counseling is Not • Advising clients what to do • Criticizing clients • Forcing ideas or values on clients • Fixing anything for the client • Internalizing clients’ resistance for ambivalence to change The purpose of counseling is to help clients work through their own decisions. As a counselor we can give some queues regarding the possible pros and cons to a decision, but we are not to give advice, pass judgment, or force our ideas as to what we believe the client should decide. People are their own experts in their lives!
Things You Need to Know About a Person Before You Counsel 4 Goal: This module will present the basic concepts of the stages of change, the window period, and clients’ context Learning Objectives: At the end of this module participants will be able to: • Name the 5 Stages of Change • Identify appropriate interventions for each stage of change. • Understand and explain the “Window Period” • Apply the concept of context when counseling clients
The Stages of Change If you have ever tried to stop smoking or lose weight, you know how hard it is. Going through this process, you probably went through several stages, starting with not wanting to change at all. Maybe later you considered the pros and cons of changing for a long time. Perhaps you had a few unsuccessful attempts before you succeeded in making a change, or maybe you’re still thinking about whether you want to try. That is totally normal. Two researchers, James Prochaska and Carlo DiClemente, discovered that there is a series of Stages of Change that almost everyone goes through when faced with changing an ingrained behavior. As HIV test counselors, understanding the Stages of Change can be important. The more we adapt our discussion with a client to the client’s stage, the more likely we are to be effective. Let’s look at those stages.
The Stages of Change According to Prochaska and DiClemente, there are five stages of change: Precontemplation Contemplation Preparation (Ready for Action) Action Maintenance
Stages of Change: Characteristics • It is not realistic to expect change after a single intervention • Once a clients initiate behavior change, they are susceptible to revert to a previous stage at any time • Clients may revert through stages repeatedly • Successful change involves not only restructuring patterns of behavior, but also restructuring thoughts about oneself and one‘s actions
Staging Interventions • When counseling clients around changing behaviors, it can be most helpful to match an intervention with their stage of change • Intervention: An action by the counselor that result in a change in the client’s thinking or understanding of themselves or their behaviors in relation to HIV On the following screens, we’ll look at each stage one at a time.
People in the Precontemplation Stage… • Have no intentions to change their behavior, they have difficulty in seeing that a problem exists in the first place • Are unaware of their HIV risk or deny the adverse outcome that could happen to them or others • Have made a decision not to change behavior, which can be due to personal safety or other survival issues
Precontemplation: Appropriate Interventions • Establish rapport and build trust • Follow the client’s lead to get a sense if they want to talk about their risks • Get a reaction, either cognitive or emotional • Help them think about their risk taking behavior patterns by: • Offering factual information about the risks of having unprotected sex and needle sharing • Exploring the meaning of events that brought the client to testing • Eliciting the client’s perceptions of the problem • Explore the pros and cons of risk taking behaviors • Examining discrepancies between the client’s and others perceptions of the problem behavior • Express concern and keep the door open
People in the Contemplation Stage… • Recognize that a problem exists and seriously think about changing a behavior, but has not yet committed to action. The contemplation stage can last for long periods of time. • Have indicated they are seriously considering changing their behavior within the next six months. • Know where they want to go but are not ready to do what is necessary to get there. • Spend considerable effort weighing the pros and cons of the problem and its solutions. However, they can’t maintain the change and sustain the new behaviors that change requires.
Contemplation: Appropriate Interventions • Normalize ambivalence • Help the client “tip the decisional balance scales” toward change by: • Eliciting and weighing pros and cons of engaging in risky behaviors and change • Changing form external to internal motivation • Examining client’s personal values in relation to change • Emphasizing client’s free choice, responsibility, and self-efficacy for change • Elicit self-motivational statements of intent and commitment from client • Elicit ideas regarding client’s perceived self-efficacy and expectations regarding change • Summarize self-motivational statements
People in the Preparation Stage… • Bring together the intention to change and the preliminary behavioral efforts to make the change. • Intend to take action within the next month or had unsuccessfully taken action in the past year. • Need work on strengthening commitment.
Preparation: Appropriate Interventions • Clarify the client’s own goals and strategies for change • Offer a menu of options for change • Negotiate a change and behavior contract • Consider and lower barriers to change • Help the client enlist social support • Elicit from the client what has worked in the past either for him or others who he knows
People in the Action Stage… • Make adaptations in order to change his or her attitudes, behaviors, or environment. • Try new behaviors, but these are not yet stable. • Have abstained from their risk taking behavior for a period ranging from one day to six months. • Have spent a considerable time and energy altering their behavior and their change is notable • Are particularly susceptible to relapse to an earlier stage
Action: Appropriate Interventions • Engage the client in new behaviors and reinforce the importance of maintaining them • Support a realistic view of change through small steps • Acknowledge difficulties for the client in early stages of change • Help the client identify high-risk situations and develop appropriate coping strategies to overcome these • Assist client in finding new reinforces of positive change • Help client assess support networks