Philippine Handbook HIV Counseling Testing Handbook Section One

PHILIPPINE HANDBOOK
HIV
Counseling & Testing
Section One:
Introduction
Field Test Version 2017
ACKNOWLEDGEMENT TABLE OF CONTENTS
Chapter Page
The localization of HIV counseling handbook was commissioned by Department of Health Section One: Introduction
(DOH) National AIDS STI Prevention and Control Program (NASPCP) and World Health 1 What HIV Counselors Need to Know About HIV, STI, and TB: The Basics.................5
Organization under the technical directions of Dr. Jose Gerard Belimac, manager of NASPCP. 2 HIV Counseling: An Overview.........................................................................13
Funding to support this work was provided by the World Health Organization - Philippines
3 Key Elements of Ethical and effective HIV-counseling practice .............................21
and Save the Children International.
4 Behavior Change Strategies in HIV Counseling................................................35
The DOH-NASPCP would like to acknowledge the following for their valuable time, effort 5 Understanding Grief, Bereavement and mourning ..............................................47
and talent given for the development of this reference material: in the context of Philippine Culture
6 Counselor Self-Care ......................................................................................65
Annex A
Burnout Risk Survey.........................................................................................................73
HIV Master Counselors HIV Counseling Trainers

Section Two: HIV Test Counseling
7 Pre - HIV Test Counseling....................................................................................75
Dr. Rosario Jessica Tactacan-Abrenica Ms. Maria Cecilia Anonuevo
8 Post - HIV Test Counseling..................................................................................81
Dr. Mary Ann Joy Aguadera Mr. Efren Chanlionco
9 Supporting HIV Disclosure.............................................................................91
Dr. Julia Alcala Ms. Clarissa Jose
Dr. Gerardo Alcantara Ms. Yasmin Pimentel 10 HIV Care Counseling............................................................................................99
Bro. Lolito Cruz Mr. Ryan Pinili Annex A
Dr. Ethel Dano Ms. Pricilla Madula-Senoc Burnout Risk Survey.........................................................................................................73
Mr. Aureo de Castro
Ms. Jhaye Encabo Section Three: Population Specific HIV Counseling
Dr. Jonathan Fontilla Other Contributors 11 Working with Suicidal Clients .............................................................................121
Dr. Honielyn Fernando
12 Drug and Alcohol Users...................................................................................127
Mr. Jogie Maglaqui Dr. Dennis Gregg Almonte
13 Males who are having Sex with Males, ..............................................................139
Dr. Evelyn Magsayo Mr. Gideon Bendicion
Dr. Gerna May-as Manatad Dr. Weby Claracay Transgender and Intersex Clients
Ms. Mary Joy Morin, RN Dr. Ma. Nerissa Dominguez 14 Male, Female, and Transgender sex workers .....................................................155
Mr. Celestino Ramirez Dr. Antoinette Evangelista 15 Overseas Filipino Workers...............................................................................163
Dr. Pretchell Tolentino 16 Counseling Children and Adolescents.............................................................171
Dr. Ali Tumama 17 Tuberculosis – HIV Co-infection......................................................................189
18 Pregnant Women, New Mothers, and their Partners.......................................197
The Love Yourself
19 Counseling Health Workers After Occupational Exposure.............................209
Annexes
Annex A List of Psychiatric Facilities..............................................................................216
Annex B List of Countries with Travel Restrictions for HIV Positives............................217
Annex C HIV Testing Services Administrative Order......................................................218
Annex D Feeding Options for HIV-Exposed Newborn,.................................................228
Infant and Young Child
1
For queries, comments and suggestions for the improvement of this reference material,
kindly inform Dr. Jose Gerard B. Belimac, Program Manager of the National HIV, AIDS, and
STI Prevention and Control Program, at [email protected].
The Basics
HIV | STI | TB
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Chapter 1 The Immune System
What HIV counselors need to know about HIV, STI, and TB: The Basics
The immune system is a collection of cells and substances that defend the body against for-
Your work as an HIV counselor will require you to understand and communicate to clients eign substances, also known as antigens. An antigen is a substance (such as HIV) that, when
a number of facts about HIV: how it is transmitted, how it is diagnosed, how the disease introduced into the body, stimulates the production of an antibody (the word antigen is short
progresses, and how HIV treatments work. It is also important that HIV counselors understand for ”antibody generating”; antibodies fight antigens). Antibodies form in a person’s blood
how sexually transmitted infections (STIs) are transmitted, treated, and relate to HIV. As HIV when HIV or other antigens enter the body. Usually antibodies defend against disease agents.
fuels the tuberculosis (TB) epidemic, it is important that counselors understand the relation- The replication of HIV in the body over time, and especially without pharmacological inter-
ship between HIV and TB, and the role counseling plays in addressing TB-HIV co-infection. vention, breaks down the immune system to the point where it can no longer fight disease.
This guide assumes that counselors have the opportunity to consult with or make referrals to The immune system can be compared to an army guarding the borders of a state and pro-
a doctor or medical officer for clinical problems. tecting it from foreign invasion. As long as the army is strong, the state has little to fear. But if
the army is weakened or encounters a stronger enemy, the state becomes vulnerable and can
no longer defend itself against attacks, even from smaller neighbors.
The immune system functions in a similar way. It is composed of cells (called T-lymphocytes
and B-lymphocytes) that perform the role of defending army. Among the T-lymphocytes are
What is HIV? How is it different from AIDS? cells that carry what are known as CD4 receptors. These cells are called T4 lymphocytes (or
T-cells or CD4 cells).
HIV stands for Human Immunodeficiency Virus, a type of retrovirus that attacks the immune
system of a person. Researchers have identified two types of HIV: HIV-1 and HIV-2. HIV-1 and HIV infects a person’s CD4 and T-cells and uses them to make copies of itself–a process
HIV-2 are transmitted in the same way and are associated with similar opportunistic infections, known as replication. In a person infected with HIV, CD4 cells are progressively destroyed. As
though they differ in the efficiency of transmission and rates of disease progression. HIV-1 these cells are destroyed, an infected person’s immune system is weakened and the person is
accounts for the majority of infections in the world; there are more than 10 genetic subtypes. more likely to develop opportunistic infections (OIs) and certain cancers. Any other infection
HIV-2, found primarily in West Africa, appears to be less easily transmitted and progresses that stimulates the immune system is likely to accelerate this destruction, making the person
more slowly to AIDS than HIV-1. A person can be infected with both types of HIV simultane- more vulnerable.
ously. It causes AIDS in humans.
AIDS is an acronym for ”Acquired Immune Deficiency Syndrome”. Acquired means “trans-
mitted from person to person”; immune is the body’s system of defense; deficiency means
a ”lack of” or not working to the appropriate degree; and a syndrome is a group of signs Principles of HIV Transmission
and symptoms. AIDS is a condition of advanced stage of HIV infection, wherein the immune
system is severely compromised. This makes the individual prone to various opportunistic There are four body fluids that carry high concentration of HIV: blood, semen, vaginal fluids,
infections manifesting with different signs and symptoms. Not all persons living with HIV will and breast milk. It can be transmitted in any of four ways:
have AIDS.
• through sexual contact with an infected person;
• from infected mother to baby before or during birth or through breast-feeding after
birth;
• through infected blood and blood products (transferred via blood transfusions and
organ transplants); or
• through the sharing of needles, syringes, and other injecting equipment (including
tattooing equipment).
Field Test version only Field Test version only

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For HIV to be successfully transmitted, it should meet the four principles: Transmission through infected blood
• Exit - the virus must exit the body of an infected person HIV infections resulting from the transfer of infected blood account for about 5% of all HIV
• Survive –the virus must be in conditions in which it can survive infections in the Philippines. Transmission can occur through transfusion with contaminated
o (TAMA) – temperature, atmosphere, moisture, acidity blood or blood products, the exchange or sharing of needles or contaminated syringes, and
• Sufficient – sufficient quantities of the virus must be present to cause infection needle stick injuries.
• Enter – the virus must enter the blood stream of another person
Table 1.1 HIV Exposure Risk
The chance that a person will become infected with HIV varies greatly depending on the type
of exposure he or she has had. For example, the risk of becoming infected with HIV through Risk of
a blood transfusion with infected blood is very high compared with the risk of becoming in- Type of Exposure
Transmission
fected from an accidental needle prick in the health-care setting. Similarly, there is less risk of
acquiring HIV from unprotected oral sex than from unprotected anal or vaginal sex. Blood Products 90 %
Mother to Child Transmission 13 - 48 %
Needle Sharing; IV drug use 0.67 %
Unprotected anal intercourse 0.56 %
Needle Stick 0.3 %
Unprotected vaginal intercourse

0.1 %
M --> F
Unprotected vaginal intercourse

0.05 %
F --> M
It is important that your clients understand that HIV may be present in and transmitted by MMWR Jan 21, 2005/ 54(RR02); 1-20 adapted
semen, vaginal fluids, breast milk, and blood. In order for your clients to reduce risk they will
need to understand that different behaviours carry different levels of risk. HIV counselors
must assess each client’s understanding and impart relevant information depending on his or Transmission during pregnancy, delivery and breastfeeding
her needs and level of knowledge. Clients and patients must be encouraged by counselors
to make informed decisions about testing and behaviour change. Such informed decisions A mother can transmit HIV to her child during pregnancy or delivery, or through breast-
require a clear understanding of the modes of transmission, the risk involved, and the im- feeding. The risk of transmission is affected by factors related to the virus, the mother, the
plications of an HIV test result, as well as the correction of clients’ misconceptions. About delivery process, the baby, and infant-feeding practices. During pregnancy and delivery, the
70%-80% of global HIV transmission occurs through unprotected sexual intercourse between mother’s health, disruption of the placental barrier, preterm delivery, and hemorrhage are
infected persons and their partners. The sexual contact may be heterosexual or homosexual. significant predictors of the child’s infection. Viral, bacterial, or parasitic placental infections
are other factors that increase the opportunity for transmission during this period. Most infants
In the Philippines, from 1984 – 2009 the predominant mode of transmission was male -fe- who acquire HIV during delivery have been exposed to maternal blood or cervical secretions
male sex. Beginning 2010, the trend shifted to male-male sex as the predominant mode of that contain the virus. Prolonged membrane rupture and invasive delivery techniques have
transmission and has continually increased since then.1 While the probability of transmitting also been associated with higher risks of mother-to-child transmission (MTCT) during labor
HIV in a single sexual act is quite low, even a lower-risk activity can get people infected if it and delivery. The risk of MTCT increases if a woman has a higher viral load, which occurs
is done often enough. Furthermore, the risk of infection can increase dramatically because of if she becomes infected or reinfected with HIV during pregnancy or if she becomes ill with
several factors, including the presence of a prior STI (sometimes manifested in genital sores AIDS. HIV counselors should emphasize early initiation of anti-retroviral therapy (ART) upon
or discharge) and unprotected intercourse with sexual partners. diagnosis or at least 4 weeks before delivery. Condom use must also be emphasized during
pregnancy to prevent reinfection of HIV and other STI.
After delivery, breastfeeding is the most significant risk factor without ART. WHO recommends
that HIV positive mothers (and whose infants are HIV uninfected or unknown HIV status) should
1
Epidemiology Bureau. Feb 2017
exclusively breastfeed their infants for the first six months of life, introducing appropriate

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complementary foods thereafter and continue breastfeeding for at least 12 months for up to HIV Disease Progression
24 months or longer. Breastfeeding should then only stop once a nutritionally adequate and
safe diet without breast milk can be provided. Mothers should be fully supported for ARV HIV infection is the successful entry of HIV in the body. HIV induces the body’s immune system
adherence. to produce antibodies. At the time of infection, 30%-50% of people have a recognizable acute
illness characterized by fever, lymphadenopathy (enlarged lymph nodes), night sweats, skin
rash, headache, and cough or commonly described as flu-like symptoms.
HIV-positive individuals may remain asymptomatic for up to 10 or more years. In this phase
they are potentially a critical factor for HIV transmission, as they are infectious but can be
identified only through HIV test. At this point, it is crucial for the person to know his/her HIV
status.
After a period that varies from person to person, an individual’s viral load (number of virus
present in the body) increases as HIV continues to multiply, and along with it, the immune
system is weakened by the destruction of CD4 cells, resulting in a condition called AIDS
Table 1.2: Timing of transmission of HIV from mother to child or Acquired Immunodeficiency Syndrome. Progression depends on a number of factors:
w/ ART + the type of HIV infection, the person’s age, other infections, possibly genetic (hereditary)
mother factors, lifestyle, and other risky behaviors. Infections, diseases, and malignancies occur
MTCT Risk without ARV infant
on ART
prophylaxis among HIV-infected individuals and are related to the degree of immune suppression.
During pregnancy 35% 2%* ---
Overall without breastfeeding 20 - 25% 0%* 0%*
Overall with breastfeeding up to 6mos 25 - 30% 1.08%** 1.08%**
Overall with breastfeeding up to 12mos 30 - 35% 11%* 2%*
Overall with breastfeeding up to

30 - 35% 22%* ---
18 - 24 mos
Source: de Cock K. et al. Prevention of mother-to-child HIV transmission in resource-poor countries: Translating research
into policy and practice. JAMA 2000, 283: 1175-1182.
* UNAIDS. Ending new HIV Infections among children. 2012
** Chikhungu Lana, Stephanie Bispo and Marie-Louise Newell. Postnatal HIV Transmission rates at age six and 12 months
in infants of HIV-infected women on ART initiating breastfeeding: a systematic review of the literature. WHO. 2016
The window period

WHO clinical staging
For an HIV-infected individual, the window period is a common term used for the time between
the initial HIV infection and the detection of HIV antigens and antibodies. If a person is non - For people who present with clinical symptoms, diagnosis is usually based on the WHO
reactive to HIV antibody tests, the HIV counselor should explain that the person may either clinical stage (see table 1.3 below). Though counselors are not expected to make diagnoses, they
be non-infected or may have been infected from the most recent exposure but the body must be aware of clinical staging to facilitate referral to medical providers for clinical management.
has not produced sufficient level of antibodies that can be detected by the HIV test kit.
However, HIV is replicating in the body and the person can already transmit the virus to
another person.
HIV Counselors should encourage retesting for HIV after six (6) weeks from the last HIV test
result for individuals who received non-reactive result but with significant risk for HIV.

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Adults and Adolescents Children

a
Table 1.3 WHO Clinical Staging
Clinical Stage 4c
HIV wasting syndrome Unexplained severe wasting, stunting or
Adults and Adolescents a Children severe malnutritiond not responding to
Pneumocystis (jirovecii) pneumonia standard therapy
Clinical Stage 1
Recurrent severe bacterial pneumonia Pneumocystis (jirovecii) pneumonia
Asymptomatic Asymptomatic
Chronic herpes simplex infection Recurrent severe bacterial infections
Persistent generalized lymphadenopathy Persistent generalized lymphadenopathy (orolabial, genital or anorectal of more than (such as empyema, pyomyositis, bone or
one month in duration or visceral at any joint infection, meningitis, but excluding
Clinical Stage 2 site) pneumonia)
Moderate unexplained weight loss Unexplained persistent hepatosplenomegaly Esophageal candidiasis Chronic herpes simplex infection
(<10% of presumed or measured body (or candidiasis of trachea, bronchi or lungs) (orolabial or cutaneous of more than 1
weight) Recurrent or chronic upper respiratory tract month’s duration or visceral at any site)
infections (otitis media, otorrhoea, sinusitis, Extrapulmonary tuberculosis
Recurrent respiratory tract infections tonsillitis) Esophageal candidiasis
(sinusitis, tonsillitis, otitis media, pharyngitis) Kaposi sarcoma (or candidiasis of trachea, bronchi or lungs)
Herpes zoster
Herpes zoster Cytomegalovirus infection Extrapulmonary tuberculosis
Lineal gingival erythema (retinitis or infection of other organs)
Angular cheilitis Kaposi sarcoma
Recurrent oral ulceration Central nervous system toxoplasmosis
Recurrent oral ulceration Cytomegalovirus infection
Papular pruritic eruption HIV encephalopathy (retinitis or infection of other organs with
Papular pruritic eruption
Fungal nail infections onset at age older than one month)
Fungal nail infections Extrapulmonary cryptococcosis,
Extensive wart virus infection including meningitis Central nervous system toxoplasmosis
Seborrhoeic dermatitis (after the neonatal period)
Extensive molluscum contagiosum Disseminated nontuberculous mycobacterial
infection HIV encephalopathy
Unexplained persistent parotid enlargement
Progressive multifocal leukoencephalopathy Extrapulmonary cryptococcosis,
Clinical Stage 3 including meningitis
Chronic cryptosporidiosis
Unexplained severe weight loss Unexplained moderate malnutritionb not Disseminated nontuberculous mycobacterial
(>10% of presumed or measured body adequately responding to standard therapy Chronic isosporiasis infection
weight)
Unexplained persistent diarrhoea Disseminated mycosis (extrapulmonary histo Progressive multifocal leukoencephalopathy
Unexplained chronic diarrhoea for longer than (14 days or more) plasmosis, coccidioidomycosis)
1 month Chronic cryptosporidiosis (with diarrhoea)
Unexplained persistent fever Lymphoma (cerebral or B-cell non-Hodgkin)
Unexplained persistent fever (intermittent or (above 37.5°C, intermittent or constant, for Chronic isosporiasis
constant for longer than 1 month) longer than one 1 month) Symptomatic HIV-associated nephropathy or
cardiomyopathy Disseminated endemic mycosis
Persistent oral candidiasis Persistent oral candidiasis (extrapulmonary histoplasmosis,
(after first six weeks of life) Recurrent septicaemia coccidioidomycosis, penicilliosis)
Oral hairy leukoplakia (including nontyphoidal Salmonella)
Oral hairy leukoplakia Cerebral or B-cell non-Hodgkin lymphoma
Pulmonary tuberculosis Invasive cervical carcinoma
Lymph node tuberculosis; HIV-associated nephropathy or
Severe bacterial infections (such as pneumonia, pulmonary tuberculosis Atypical disseminated leishmaniasis cardiomyopathy
empyema, pyomyositis, bone or joint infec-
tion, meningitis, bacteraemia) Severe recurrent bacterial pneumonia
a In the development of this table, adolescents were defined as 15 years or older. For those younger than 15
Acute necrotizing ulcerative stomatitis, gingivi- Acute necrotizing ulcerative gingivitis or years, the clinical staging for children should be used.
tis or periodontitis periodontitis b For children younger than 5 years, moderate malnutrition is defined as weight-for-height < –2 z-score or
Unexplained anaemia (<8 g/dl), Unexplained anaemia (<8 g/dL), mid-upper arm circumference ≥115 mm to <125 mm.
Neutropaenia (<0.5 × 109/L) or c Some additional specific conditions can be included in regional classifications, such as penicilliosis in Asia,
Neutropaenia (<0.5 × 109/L) and/or Chronic thrombocytopaenia (<50 × 109/L) HIV-associated rectovaginal fistula in southern Africa and reactivation of trypanosomiasis in Latin America.
Chronic thrombocytopaenia (<50 × 109/L) d For children younger than five years of age, severe wasting is defined as weight-for-height < –3 z-score;
Symptomatic lymphoid interstitial pneumonitis
stunting is defined as length-for-age/height-for-age < –2 z-score; and severe acute malnutrition is either
Chronic HIV-associated lung disease, including weight for height < –3 z-score or mid-upper arm circumference <115 mm or the presence of oedema.
bronchiectasis
Source: Adapted from: WHO case definitions of HIV for surveillance and revised clinical staging and immuno-
logical classification of HIV-related disease in adults and children. Geneva, World Health Organization, 2007
(www.who.int/hiv/pub/guidelines/HIVstaging150307.pdf).

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Table 1.4 Type of sexually transmitted infections according to etiology

What does clinical management involve?
Individuals who are reactive to HIV test or confirmed HIV positive should be immediately
linked to care at the DOH-designated treatment hub or primary HIV care facilities of choice
by the individual for clinical assessment and management, including ART initiation, immune
system monitoring, adherence counseling, follow up care, and appropriate referrals.
Antiretrovial therapy
Antiretroviral Therapy (ART) refers to the use of a combination of three or more ARV drugs
to achieve viral suppression. This generally refers to lifelong treatment aimed at prolonging
and improving the quality of life of a person living with HIV (PLHIV).
Opportunistic infections
Other Opportunistic In counseling clients with STI, the following must be considered:
An individual with a low CD4 count is susceptible to Infections in the Philippines
opportunistic infections (OI). The prevention and treatment • It is difficult to change sexual behaviour. Knowledge does not automatically lead
Oral Candidiasis
of OI decreases the mortality risk of HIV infection. Individuals to behaviour change. STI control is difficult because sexual practices are rooted in
Syphilis
with low CD4 counts are prescribed preventive medications everyday life and culture. Counselors should let their clients know that they can help
called OI prophylaxis. If CD4 count is below 200, Co-tri- Retinitis
them make these changes.
moxazole, Azithromycin and Isoniazid are given to prevent Warts
pneumonia, and TB infections. Pneumocytis Pneumonia
• People find it embarrassing to discuss sex. Sometimes people are shy about asking
Other types of Pneumonia for the information they need, slow in seeking treatment, or reluctant to discuss
The clinical management of OIs may also involve nutrition Cryptococcal Meningitis the issue with their partners. People can feel uncomfortable talking about sex, and
counseling and treatment of HIV wasting and severe weight Cytomegalovirus retinitis the subject is sometimes taboo. Counselors should carefully explain to the client or
loss, chronic or intermittent fever, and chronic or intermittent patient why discussing these sensitive issues is so critical.
Herpes zoster
diarrhea
• Many people with STI exhibit no symptoms. People with STIs can spread infection
Hepatitis B and C co-infection even without knowing they are infected. Counselors should refer all clients presenting
Hepatitis B (HBV) and hepatitis C (HCV) co-infection are common among people who inject with transmission risks for STI screening.
drugs (PWID). HBV transmission is similar to HIV transmission. HCV, on the other hand, is
transmitted by infected blood products through sharing of injecting equipment. Both HBV • Treatment is not always available, easy, or effective. Counselors can support clients
and HCV cause liver inflammation, which may complicate the patient’s ARV treatment. Coun- in initiating and maintaining treatment adherence.
selors should therefore urge their clients to be tested for the presence of these infections.
Patients with HBV or HCV should be counselled to avoid or limit their alcohol intake to prevent
liver damage.
Other Sexually Transmitted Infections
Sexually transmitted infections (STI) are infections transmitted through unprotected sexual
intercourse through oral, vaginal or anal. STI are caused by bacteria, viruses, fungi, protozoa,
and parasites (see Table 1.4).
If left untreated, STIs can lead to serious consequences. A person with STI has an increased
risk for HIV. Thus, to reduce the risk of HIV infection, one must avoid contracting other STIs.
If other STIs do occur, they must be treated promptly and effectively to minimize the risk of
acquiring or transmitting HIV.

2
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STI Core Messages
- Every sexual activity is an opportunity to acquire STI including HIV. Condom do not
cover everything
HIV Counseling:
An Overview
- Co-infection and multiple infections are common
- Some STI may have signs and symptoms, others may not. If you do not have sign and
symptoms you can still transmit the infections and they can continue to damage your
health
- If you are sexually active and having STI expose your partner/s, and if your partner/s is/
are not treated you will get STI back again
- Do not self-treat or medicate, you need the right drug for your infection, don’t risk with
fake drugs, don’t use your friend’s drugs.
- Complete the treatment even if you feel better and the symptoms disappear, untreated
or incomplete treatment of STI can lead to complications
- Having an STI can become serious when you have HIV- it can complicate your treatment
- STI can be passed from mother to child and can cause serious illness or birth defects to
the child
- Get checked if you have Hep-B. Get vaccinated so you are protected. You will need to
complete the whole course of injections and go for a post vaccination check-up to
ensure, you are protected.
STI and its link to HIV

- Same Modes of Transmission
- Same Preventive Measures
- STI services is the entry point for HIV services
- Persons with STI have higher risk of acquiring and transmitting HIV
- Persons with STI should be treated and offered HIV testing

14 15
Chapter 2
Counseling is Counseling is NOT
HIV Counseling: An Overview
• Supportive relationship to HELP a person Advising
HIV counseling is a confidential interactive communication process between a person and a cope with some aspect of his or her life
health care provider or volunteer trained in HIV counseling that enables a client to make an Directing
informed choice about being tested for HIV and assist a client understand and cope with HIV • Process to empower people to acknowledge
Prescribing
test result and be able to identify options for future plan including physical, mental, social, and understand their problem
reproductive and other personal concerns. HIV counseling follows five guiding principles.
• Interpersonal communication to ASSIST a
person to evaluate his/her current situation,
Five C’s of HIV Counseling
explore his/her feelings, and arrive at
1. Counseling
possible solutions to the problem
2. Consent
3. Confidentiality • Counseling offers continuous support
4. Correct Results especially to those needing it such as PLHIV
5. Connection (Link to Care)
Counseling
Types of HIV Counseling
Counseling is goal-oriented
HIV counseling is done with a purpose of helping the client explore and understand a Pre-HIV test counseling
specific problem related to HIV. Both the counselor and the client must work towards achieving a
particular goal. The goal varies depending on the type of counseling, for example, the goal Pre-HIV test counseling is confidential counseling that
during pre-test counseling if for the client to consent to HIV testing. will enable an individual to make an informed choice
HIV counseling is aimed at: about being tested for HIV. This decision must be left
entirely to the individual and must be free of coercion.
• preventing HIV transmission by providing information about transmission risks (such as To make an informed choice about testing, an individ-
unsafe sex or needle sharing); ual needs to consider the potential benefits and risks
• assisting people in developing the personal skills needed to negotiate safer practices; associated with testing. His or her personal risk history must also be considered.
• providing psychological support to people who are infected with and affected by HIV;
The counselor supports the client in managing the potential risks and difficulties by con-
• improving their emotional, psychological, social, and spiritual well-being; and
sidering the possible psychosocial, legal, and health implications of knowing the client’s
• supporting clients in treatment adherence. serostatus.
In some situations where there are many clients or where the HIV test is offered as part of
Counseling is issue-centered provider-initiated counseling and testing and opportunities for one-on-one counseling are
limited (because of time or human resource constraints), group pre-HIV test information may
HIV counseling involves facilitating client’s prioritizing of problems, identification of resources
be offered. Information can be given in a group, but the informed consent component must
for support, and coming up with solutions. Effective counseling helps another person to be
always take place in a one-on-one setting to ensure that the patient’s choice is autonomous
autonomous (able to choose, decide, and be responsible for his or her own actions).
and not coerced. Pre-HIV Test counseling is discussed in detail in Chapter 14.
Counseling is client-focused
HIV counseling is centered on the client’s situation, thoughts and feelings. The presence of
the HIV counselor is to provide a safe environment to allow the client express his/her concerns
related to HIV without being judged, belittled while expressing genuine care and compassion.

16 17
Post-HIV test counseling Treatment adherence counseling
Patients are confronted with many difficulties when required to take medication. Those
Post-test counseling is done primarily to ensure that taking medication for HIV, TB, STI, or hepatitis in particular must deal with many psycho-
individuals understand the meaning and implications logical, physical, and practical barriers to treatment adherence. Non-adherence can lead
of their test results. If the client tests positive for HIV to inadequate suppression of bacteria and, in the case of HIV, viral replication. Counseling
antibodies, post-test counseling must make it easier for treatment is provided to improve the patient’s knowledge of both the disease and the
for him or her to adapt to life with HIV. Ideally, post- medications and their side-effects. Counseling helps the patient set goals, develop positive
HIV test counseling should be provided by the coun- beliefs and perceptions, and increase self-efficacy in maintaining treatment. (Note: Treat-
selor who conducted the pretest counseling. Howev- ment Adherence is discussed further on separate training and reference material.)
er, a counselor may have to provide counseling to an
individual who was tested without his or her knowl-
edge and consent. Counselors providing post-test counseling under the latter circumstances Paediatric counseling
may report having to manage client anger, which is often projected onto the counselor. HIV infection has a profound impact on the lives of children and their families. Not only do
children have to cope with the physical aspects of ongoing illness due to HIV immune -
related deficiency and its associated treatments, but they also suffer from the emotional
HIV prevention counseling: HIV transmission risk reduction and social effects of chronic illness and impending death. Counselors must often provide
support to children, assisting them in coping with separation and loss issues related to the
The counselor assists infected and uninfected clients in identifying and exploring the difficul-
parents’ or the child’s own illnesses. Other common presentations seen in children with HIV
ties involved in reducing transmission risk behaviour. Counselors may use a variety of strate-
infections are behavioral disturbances, cognitive and motor impairment, and poor treat-
gies ranging from the simple provision of information to the more therapeutic evidence-based
ment adherence. Counselors caring for HIV-positive and HIV-affected children often have to
strategies that can include motivational interviewing, structured problem solving, and
support them in responding to stigma and discrimination. Furthermore, in many endemic
infant-feeding counseling. Prevention counseling is employed in pre-HIV test and post-HIV
areas counselors must assist children who have taken on a parental role to care for younger
test counseling and in counseling across the disease continuum. It is recognized that it is diffi-
orphaned siblings. HIV counselors provide various forms of support to a child to ease his or
cult for clients to sustain changes in behaviour over extended periods of time. When providing
her entry into substitute-care settings. The tasks may include working with substitute care
counseling across the disease continuum, counselors must continually assess the challenges
givers to understand how to give emotional support to children who have experienced
that will face their clients as they strive to maintain behaviour changes, and provide practical
not only the death of parents but also societal rejection or discrimination. Additionally, the
strategies that can help address these challenges.
counselors are often required to facilitate HIV testing and counseling of children to be ad-
opted. Those found to be infected with HIV often fail to be adopted or fostered once they
are diagnosed with the disease.
Ongoing counseling
The chronic and progressive natural history of HIV infection means that the psychosocial issues Children who present with HIV may have other psychological conditions associated with
confronting both infected and affected individuals change throughout the course of the illness. child sexual assault, child trafficking (including the selling of children into child labor), or ex-
In addition to issues directly related to HIV, patients may present with a range of psychosocial perience in the military or with prostitution. In some situations physical abuse in association
problems that are pre-morbid or only indirectly related to HIV. For many, becoming infected with the disclosure of the child’s HIV status within communities and schools is also an issue.
with HIV reactivates previously unresolved issues such as acceptance of sexual orientation,
specific traumatic events such as sexual assault, or unresolved relationship problems. Infected Consent
and affected individuals may also need practical assistance such as referral to welfare services,
All people taking an HIV test must give written informed consent prior to being
liaison with caregivers, the preparation of wills, and the organization of substitute care for chil-
tested. The key defining characteristics of informed consent are:
dren. Counselors must work with multiple clients who present a range of problems that vary
across the disease continuum. • The client should be told sufficient details about what is being agreed to and any
risks or implications involved
• The client should be capable of understanding what he or she is told (capability is

often defined in terms of age, intellectual capacity or psychiatric state)

18 19
• The client should not be coerced in any way into giving consent. That is, they should • During the ‘window period’ an HIV test will not indicate if a person has the virus,
not be forcefully persuaded or pressured by the counselor even though the counselor therefore, this test cannot be relied on to decide on medical procedures and
believes it is in their best interests to have an HIV test. Often references are made to precautions during surgery;
the unequal relationship between a health care worker and a client, which may cause
the client to feel unable to make their own choices. Therefore there is a duty to provide • It can lead to a ‘false sense of security.’ Universal precautions should be applied to
honest and objective information upon which the client can make an informed decision. ALL clients.
Mandatory testing is prohibited in the Philippines based on the RA 8504. For people
seeking employment outside the country, they may be required to undergo HIV test, as
part of pre-employment screening process. In these instances, HIV testing should still
be accompanied with pre- and post-test counseling. This will be further discussed on
Chapter 9: Overseas Filipino Workers.
Fig. 2.1 Informed consent (included in HTS Counseling Form) Exceptions to the mandate of confidentiality (RA 8504)
Confidentiality • when complying with reportorial requirements in conjunction with the AIDSWATCH
• when informing other health workers directly involved or about to be involved in the
Ensuring confidentiality of a client’s information is one of the cornerstones of the HIV
treatment or care of a person with HIV/AIDS, provided that such treatment or care
counseling process. It should be performed to the highest ethical and professional
carry the risk of HIV transmission
standard. The HIV counselor must take all reasonable steps to communicate clearly the
extent of confidentiality they are offering to clients. Normally, this should be made clear in • when responding to a subpoena duces tecum and subpoena ad testificandum issued
the pre-HIV test counseling. by a court with jurisdiction over legal proceeding where the main issue is the HIV
status of the individual
The client should be informed by the counselor that his or her HIV status can be shared
with other health workers who are directly or about to be directly involved in the client’s
Correct Results
treatment and care. This is called shared medical confidentiality. The integrity of shared
medical confidentiality is expected to be maintained by the healthcare workers. The correct and official HIV non reactive test result must be signed by the HIV proficient
Medical Technologist who performed the test and countersigned by the pathologist. For
If client confidentiality is breached, there can be psychosocial effects for the client and Social hygiene clinics and TB DOTS facilities without a pathologist, the supervising physician
according to RA 8504, it can have legal ramifications for the counselor and caregiver. Stigma shall countersign.
and discrimination are the major concerns, and can result in denial of access to medical
care, breakdown of family and personal relationships, and even loss of employment. Anti- The confirmed HIV test result is the final result derived from a combination of test formats
discrimination legislation exists in the Philippines which prohibits discrimination against a and Western Blot or Nucleic Amplification Tests (NAT) performed by NRL-SLH/SACCL or
person with HIV in particular areas (e.g. medical care, employment, insurance, immigration), other DOH accredited testing centers or using rapid diagnostic algorithm (rHIVda), or other
but this does not always prevent discrimination in practice. test format combinations as recommended by NRL-SLH/SACCL.
PLHIV can seek assistance for legal cases involving

The HIV counselor has an ethical obligation to check the consistency of the test result,
discrimination and breach of confidentiality.
the label on the envelope and with that of the identified client, before releasing to
the result.
It is sometimes argued that in a medical emergency, the consent requirement can be
ignored and that health workers may have to know the client’s HIV status in order to Connection (Linkage to Care)
protect themselves. Non-consensual HIV testing cannot be justified in these circumstances
because: All clients who are reactive to HIV screening test must be referred to the DOH-designat-
ed treatment hub of choice by the client for linkage to care and for proper management.
• The risk of occupational transmission of HIV, though extremely small, can be eliminated It is primarily the role of the counselor to facilitate referral to other facilities for early as-
through universal precautions; sessment, access of treatment, care and support services for all clients with reactive result.
HTS Referral Form should be used for this purpose. The HIV counselor must inform the
• In an emergency, there is never time to get the results of the test before surgery; receiving facility of said referral, and ensure that all barriers for the client to access the ser-
vices will be addressed accordingly. The receiving facility should inform the HIV counselor
once the client has been accommodated.
20 21
3
Key Elements of
Ethical and Effective
HIV Counseling
Practice

22 23
Chapter 3 decision-making of their clients by offering clear and accurate information, and assisting cli-
ents in weighing the perceived benefits and risks of each intervention offered. Specifically for
Key elements of ethical and effective HIV testing, a client must provide a written informed consent.
HIV-counseling practice
This chapter gives the reader an overview of what is involved in ethical and effective HIV Consistency and accuracy
counseling, and reviews some basic counseling micro-skills and counseling service documen-
Information provided through counseling (e.g., about HIV infection, infant-feeding options,
tation.
infection risk, risk reduction, and treatments) should be consistent with recognized scientific
research and national HIV guidelines. HIV counselors should not impose their own opinion to
Developing skills in effective HIV counseling clients during counseling sessions.
In order to effectively counsel, it must be emphasized to HIV counselors that counseling
skills cannot be learned simply by reading a text. These skills must be rehearsed in a spe- Confidentiality
cialized training program under the supervision of an experienced counselor.
Trust is the most important factor in the counselor-client relationship. It enhances the relation-
ship and improves the odds that an individual will act decisively on the information provided.
Given the discrimination, ostracism, and personal recrimination that an individual diagnosed
Elements of ethical and effective counseling with HIV may have to face, it is all the more important to guarantee confidentiality. Where
Effective counseling has several key elements, as discussed below. the counselor is required by law or public health policy to provide information to a third party
against a client’s wishes, he or she should discuss with the client the reasons for doing so,
along with the relevant process and procedures. HTS must be confidential and client’s privacy
Ample time shall be ensured at all times. The counseling session between the HTS provider and the cli-
ent will not be disclosed to anyone else without the expressed consent of the person being
Providing the client with adequate time is important from the very beginning. The counsel-
tested except as stipulated in the RA 8504 (see Chapter 2).
ing process cannot be rushed. It takes time to build a supportive relationship.
Sociocultural considerations
Acceptance
Effective and ethical counseling must recognize the impact of culture on a client’s percep-
Counselors should not be judgmental of clients. Rather they should try to accept clients,
tion of the world. Counselors should take a holistic view of clients and their sociocultural
regardless of socioeconomic, ethnic, or religious background, occupation, sexual orientation,
background, including beliefs about HIV, sexual mores, traditional healing practices, gender
gender identification, and drug or alcohol use.
inequalities, marriage practices (e.g., monogamy, polygamy), customs, and social practices.
Counselors should keep in mind that culture and tradition shape attitudes and beliefs, par-
Accessibility ticularly regarding illness and death. Thus, they should be sensitive to and respect cultural
Clients need to feel they can ask for help at any time. Counselors differences. A counselor should refer clients to another counselor if differences of gender,
need to be available to clients at appropriate times and should have race, ethnicity, religion, sexual orientation, disability, or socioeconomic status interfere
systems in place to respond to clients’ needs as appropriate (e.g., pro- in any way with counseling. One of the goals of counseling is to explore, discover, and clarify
vide services after hours or work during lunchtime on a rotating sys- ways of living more resourcefully. To achieve this goal, counselors need certain interpersonal
tem). It is important that counselors maintain appropriate boundaries and communication skills.
in their after-hours contact with clients. They must also maintain appro-
priate professional distance (e.g., counselors should not provide their
personal contact information). Instead, HTS facility should maintain an official con- Interpersonal skills
tact number, and should not enter into non-professional relationships with their Interpersonal skills are the skills that we employ to establish effective counselor-client
clients, especially sexual relationships. relationship.
Consent Establishing rapport
Clients must be given an opportunity to consent to or decline HIV testing, treatments, or Establishing rapport with clients is crucial in all counseling situations and is key to developing
procedures in an informed and voluntary manner. Counselors facilitate the informed a trusting relationship.

24 25
To establish rapport, one useful technique is to ask questions such as, ”What’s the worst these differences. They must respect clients’ views, beliefs and practices at all times. HIV
thing that could happen?” or ”If we could deal with only one thing today, what would be counselors should be aware that their own attitudes and actions can convey respect or the
most important to you?” Such questions help define and prioritize a client’s agenda and lack of it.
may be particularly appropriate at the start of a session. Furthermore, through this process
the counselor is able to encourage the client to be explicit in describing sensitive issues, An HIV counselor demonstrates respect for clients by:
including sexual behaviour patterns.
• helping clients make informed decisions about their lives and supporting them
An HIV counselor demonstrates good rapport with clients by: through the process (without demanding or telling them what to do)
• being a guide/facilitator and not a preacher
• showing interest in and respect for a client’s issues and concerns
• showing concern for clients’ welfare
• being respectful and non-judgemental
• seeing each client as a unique individual
• facilitating decision-making to achieve a common or complementary goals
• seeing clients as capable of determining their own fate
• allowing open verbal and non-verbal communication; and
• assuming that they can count on the good will of their clients unless and until
• building mutual trust
the clients demonstrate otherwise
• keeping appointments and apologizing for being late or failing to keep an
Ensuring privacy and confidentiality
appointment
Generally, all clients accessing HTS services need to be assured of privacy and con-
fidentiality. During counseling, privacy and confidentiality must be ensured by:
Acknowledging difficult feelings
• providing adequate and appropriate space for counseling to take place;
The presence of difficult feelings of clients and/or counselors is a substantial and unavoid-
• understanding that no information about a client can be divulged without the client’s able component of counseling. To help address difficult feelings, counselors should:
consent;
• maintaining adequate records of any work with a client and taking all reasonable mea- • be aware of their own feelings;
sures to preserve the confidentiality of the information; • acknowledge clients’ feelings and realities;
• ensuring that colleagues, staff members, and trainees understand and respect the need • understand that it is not the counselor’s job to “remove” or “fix” feelings;
for confidentiality in HTS services; and • articulate and respond to non-verbal messages; and
• being aware that notions of shared confidentiality and partner notification often raise an • normalize and validate clients’ feelings
ethical dilemma in the context of HIV counseling. The term shared confidentiality refers
to confidentiality that is shared with a limited number of people such as health service While counselors may want to resolve problems and “fix” feelings, most often this is neither
providers who are involved in the clinical management of the PLHIV wherein disclosure possible nor desirable. Rather, such negative feelings need to be acknowledged. Examples
of the HIV status is important in making clinical decisions. Remember to ask the client of statements that acknowledge a client’s feelings are: “This must have been hard to deal
to sign consent for release of information (HTS Form 3) especially when referrals are with” and “So you believe that he cares for you, but it hurts to think about him having sex
involved. with someone else.”
Showing respect Showing empathy
HIV counselors need to understand that each person perceives and copes with predica- The ability to empathize is one of the most essential counseling skills. Empathy involves
ments in uniquely personal ways determined by numerous factors including culture, social identifying with the client, understanding his or her thoughts and feelings, and communi-
class, personality, and past experiences. Recognizing the fundamental rights, dignity, and cating that understanding to the client. For a counselor to communicate understanding of a
worth of all people is critical in HIV counseling. This can be achieved when counselors are client’s world, he or she must enter that world (understand the client so well that the coun-
aware of cultural and role differences in gender and gender identity, race, ethnicity, reli- selor feels like the client). Simply stated, this means that “counselors should put themselves
gion, sexual orientation, disability, and socioeconomic status, and strive to eliminate their in their clients’ shoes”. Empathy requires sensitivity and a moment-to-moment awareness
own personal prejudices and biases about such differences, especially during counseling of a client’s fear, rage, tenderness, confusion, or whatever else the client may be experienc-
sessions. Counselors must not participate in or condone discriminatory practices based on ing. To understand what the client is feeling, the counselor must be attentive to his or her
verbal and non-verbal cues.

26 27
Offering acceptance • Acknowledge the client’s feeling, e.g. “I can see you feel very sad”
• Do not interrupt the client unnecessarily while the client is speaking. Ask questions if
For clients to be honest in describing their problems and concerns during counseling, it is you do not understand. Do not take over and tell your own ‘story’
critical that they feel accepted. The counselor can facilitate this by being non-judgemental • Repeat back the main points of the discussion in similar but fewer words to
and accepting. Counselors should appreciate the stress caused by the fear of being infect- check you have understood the client correctly (this is known as paraphrasing, reflec-
ed or the need to change behaviour, and accept the consequent emotions and reactions. tion of feelings, clarification, summarizing)
Even if hostility is directed towards the counselor, he or she should recognize that s/he is
not the real target and refrain from reacting (except to avoid physical harm). To validate • “You seem to be saying …………………..”
acceptance, the counselor recognizes feelings such as anger, sadness, and fear in a direct,
• “In other words, ……….”
unemotional way, indicating in words and behaviour: “Your feelings are very strong. I accept
• “You feel ………. because ……….”
them, and I accept you.”
• “You seem ……….. What’s happening for you?
• What are you thinking about?”
Counseling communication skills and techniques • “I wonder if you are feeling because ?”
• “Correct me if I am wrong, but ……….”
A major component of a counselor’s job is communicating with clients. This exchange is a
• “Let me check if I have understood you correctly. You ………., is that
two-way dialogue using both verbal and non-verbal communication methods. To identify a
client’s needs and provide appropriate information, counselors must have solid communi- correct?”
cation skills. They must hear and understand the client’s message and be clear in their own • “What I hear you saying is ……….”
communication with the client.
As a foundation, HIV counselors need to develop or enhance the following counseling An important component of good listening skills is the ability of the counselor to convey
microskills which are essential for effective communication and the development of a sup- empathy. Empathy involves trying to understand how individuals view themselves or their
portive client-counselor relationship: world. Demonstrating empathy helps establish rapport with clients, and facilitates the client
feeling “safe” to disclose the truth about their feelings and circumstances.
+ Listening + Questioning
Empathy is conveyed by using all of the listening skills indicated earlier. In particular, the
+ Silence + Non-verbal behaviour following techniques can be utilised:1
Paraphrasing, which involves restating, in your own words, the essence of what the client
has said but without changing the meaning or essence of the client’s statement. Paraphras-
1) Listening1 ing assures the client that you are really listening and it assists the client in focusing on his/
her situation more clearly
The term listening refers to the ability of the counselor to actively listen to the client when
he or she is talking. Client: “I feel so helpless. I can’t get my housework done, get the children to
school on time or even cook a meal. I can’t do the things my wife used to do.”
• Good listening involves all of the following: Eye contact (culturally appropriate) Demon-
strate attention, e.g. nodding Encouragement, e.g. “Mm-hmm”, “Yes” Counselor: “You feel inadequate about doing things you have not done in
life especially when your wife was alive”
Active listening involves attending or the counselor’s ability to pay close attention to the
client by minimizing distractions (e.g. TV, telephone, noise) and giving full attention to the Reflecting emotions: This is similar to paraphrasing except that the focus is on the emo-
client. Responding to the client by nodding affirmatively and using key words such as “yes” tions being expressed by the client. Reflecting emotions assists the client in becoming
and “I see” when appropriate demonstration of attentiveness is shown by responding to aware of how they are feeling, and to explore their reactions to events they are describing.
the client. Listening signals concern for the client’s problems and allows the counselor to
detect common themes and revealing omission in the client’s remarks.

28 29
Client: “I don’t know what to do. Before he died, I promised my husband that Open questions generally begin with ”what”, “where”, “how” or “when”. They invite the
I would take care of his mother for the rest of her life. But I no longer have the client to continue talking and to decide what direction they want the conversation to take.
energy. I cannot seem to get myself sorted out to do anything. He knew that his
mother and I did not get along and that the situation would be miserable. Why c. Leading questions
did he die and leave me in this mess?” Leading questions are questions where the counselor guides the client to answer in
a particular way.
Counselor “You seem to be feeling very low and helpless right now; but at
the same time you seem to be feeling guilty and angry about your promise to e.g. “You do practice safer sex, don’t you?”
your husband.” e.g. “Do you agree that you should always use a condom?”
2) Questioning2
Questioning is an important part of counseling. It helps us understand the client’s situa- d. Information-Risk Reduction-Question Method
tion and it helps us assess clinical conditions. In HIV counseling, clients are being assessed through a detailed personal risk assessment
A detailed assessment is designed to inform the client about how each potential exposure
When asking questions: risk can result in HIV transmission and how to reduce the risk for each behaviour, and to
DO ask one question at a time ascertain whether, when, and what type of specific exposure risk has occurred.
DO look at the person
DO be brief and clear The I-RR-Q method (Fig. 3.1) enables the client to provide detailed account of their be-
DO ask questions that serve a purpose havior when they get information and can see the reasons such detailed and personal
DO use questions to help the client talk about their feelings and behaviours questions are being asked.
DO use questions to explore and understand issues and to heighten awareness
DO NOT ask questions simply to satisfy curiosity — irrelevant questions may cause
people to feel pushed or reluctant to answer. Too much time may be spent think-
ing
of questions rather than actively listening. Too many questions will be experienced
as
intrusive and similar to an interrogation
Information Risk Reduction Question
There are essentially three styles of questions:
a. Closed questions
A closed question limits the response of the client to a one-word answer, usually a yes
or a no. “Vaginal sex: HIV can “You can reduce the “Have you had sex
be transmitted during risk of aginal sex by without a condom?”
e.g. “Do you practice safer sex?” vaginal sex. HIV can using a condom. If the answer is yes,
e.g. “Do you know how to use a condom?” be found in the fluids It is important that the then ask” Can you tell
of the woman’s vagina, condom be put on the me the last time this
in the fluids that lubri- penis before it enters happened?”
Closed questions may not require clients to think about what they are saying. Answers
cate the man’s penis the woman’s body.”
can be brief and often result in the need to ask more questions. during sex.”
b. Open questions
An open question requires more than a one-word answer response. It is aims to encour-
age the client to provide elicit knowledge and feelings.
e.g. “What difficulties do you experience in practicing safer sex?”

e.g. “How might you react if you received a HIV-positive test result

30 31
• The counselor’s body language–the gestures, facial expressions, intonation,

The Four Reasons
distance, etc., that indicate the counselor is listening and understands what
the client is saying; and
“I need to discuss some things with you today that we would not nor-
mally talk about with others.” We need to discuss these things to: • The client’s perceptions–the client’s point of view when talking about his or
her experience, behaviours, and feelings.
• give you realistic feedback about your risk of being infected–you may
be worrying unnecessarily;
Counseling code of ethics
• make sure you know how to keep yourself and your partners safe –
different practices have different risks; The purpose of the counseling code of ethics is to:
• see if you have other potential health problems that this test will not • establish and maintain standards for counselors; and
identify–I may need to do other types of tests as well; • inform and protect members of the public who seek and use their services.
• if you have been infected, to know when you most likely became The code of ethics outlines the fundamental values of counseling, namely, integrity, impartial-
infected – it may make a difference in the type of treatment we offer. ity, and respect. A number of general principles arise from these. They address such issues
We can only know this if we know what you have been doing and as client safety, clear contracting, and competence. Counseling is a non-exploitative activity
when. and counselors should have the same ethical values in both voluntary and paid counseling
positions.
“As you can see there are some good reasons for us to talk openly
about these things, even though it may be uncomfortable.”
Your responsibilities to the client:
Client safety
3) Silence
• Gives a client time to think and reflect about his/her situation or issue. Gives Counselors should take all reasonable steps to ensure that the client suffers neither physical
a client space to experience their feelings Allows a client to proceed at their nor psychological harm during counseling.
own pace
• Provides a client with time to deal with ambivalence about sharing Client autonomy
• Gives a client freedom to choose whether or not to continue • Counselors must not exploit their clients financially, sexually, emotionally, or in any other
way. Engaging in sexual activity with the client is unethical.
4) Non-verbal behavior • Counselors are responsible for working in ways that promote the client’s control over his
It’s not what you say but HOW you say it! or her own life, and respects the client’s ability to make decisions and change in the light
of his or her own beliefs and values.
The majority of communication is non-verbal. Counselors need to be aware of what they • Counselors do not normally act on behalf of their clients, unless at their express request or
may be communicating to their clients through their non-verbal gestures and expressions. in certain exceptional circumstances.
They also need to give attention to what is being communicated through the non-verbal • Counselors are responsible for setting and monitoring boundaries between the counsel-
behaviour of their clients. ing relationship and any other kind of relationship, and making these boundaries explicit
to the client.
REMINDER: • Clients should be offered privacy during counseling. The client should not be observed by
The counselor should pay attention to the following: anyone other than their counselor or counselors unless they give informed consent. This
also applies to photos/audiotaping/videotaping of counseling sessions.
• The client’s experience–what the client sees as happening or not happening
to him or herself;
Contracting
• The client’s behaviour–what the client does or does not do;
• The client’s feelings–the emotions that arise from experience and behaviour; • Counselors are responsible for communicating the terms on which counseling is being
• The client’s problems and worries–client explanations rather than counselor offered, including availability, the degree of confidentiality offered, and their expectations
assumptions; of clients.

32 33
• It is the client’s choice whether or not to participate in counseling. Reasonable steps Research
should be taken in the course of the counseling relationship to ensure that the client is
given an opportunity to review the terms on which counseling is being offered and the • The use of personally identifiable material gained from clients or by the observation of
methods of counseling being used. counseling should be used only after the client has given consent, usually in writing, and
• If records of counseling sessions are kept, clients should be made aware of this. At the cli- care has been taken to ensure that consent was given freely.
ent’s request, information should be given about access to these records, their availability
to other people, and the degree of security with which they are kept.
• Counselors should gain the client’s permission before conferring with other professional Confidentiality issues
workers. Confidentiality with respect to clients, colleagues, and others
Counselor competence • Confidentiality is a means of providing the client with safety and privacy.
• Counselors treat with confidence personal information about clients, whether obtained
• Counselors should monitor actively the limitations of their own competence through
directly or indirectly or by inference.
counseling supervision or consultative support, and by seeking the views of their clients
• Counselors should work within the current agreement with their client about confidential-
and other counselors.
ity.
• Counselors should not counsel when their functioning is impaired by personal or emo-
• Exceptional circumstances may arise which give the counselor good grounds to believe
tional difficulties, illness, disability, alcohol, or drugs, or for any other reason.
that the client will cause physical harm to him or her. In such circumstances the client’s
• It is an indication of the competence of counselors when they recognize their inability to
consent to a change in the agreement about confidentiality should be sought whenever
counsel a client and make appropriate referrals.
possible unless there are also good grounds for believing the client is no longer able to
take responsibility for his or her own actions. Whenever possible, the decision to break
Responsibility to self as a counselor confidentiality agreed on by a counselor and client should be made only after consultation
with a counseling supervisor or experienced counselor.
• Counselors have a responsibility to themselves and their clients to maintain their own
• Any breach of confidentiality should be minimized both by restricting the information con-
effectiveness, resilience, and ability to help clients. They are expected to monitor their
veyed to that which is pertinent to the immediate situation and to those persons who can
own functioning and to seek help or withdraw from counseling, whether temporarily or
provide the help required by the client. The ethical considerations involve balancing be-
permanently, when their personal resources are sufficiently depleted to require this.
tween acting in the best interests of the client and in ways that enable clients to resume
• Counselors should receive basic counseling training before starting counseling, and
taking responsibility for their actions, and the counselor’s responsibilities to the wider com-
should maintain ongoing professional development.
munity.
• Counselors should take all reasonable steps to ensure their own physical safety.
• Counselors should take all reasonable steps to communicate clearly the extent of the con-
fidentiality they are offering to clients. This should normally be made clear in the pre-coun-
Responsibility to other counselors seling or initial contracting.
• If counselors include consultations with colleagues and others within the confidential rela-
• A counselor who suspects misconduct by another counselor that cannot be resolved or tionship, this should be stated to the client at the start of counseling.
remedied after discussion with the counselor concerned should implement a complaints • Care should be taken to ensure that personally identifiable information is not transmitted
procedure (if there is any) without unnecessary breaches of confidentiality. through overlapping networks of confidential relationships.
• It is therefore good practice to avoid identifying specific clients during counseling super-
Responsibility to colleagues, members of the caring professions, and the community vision/ consultative support and other consultations, unless there are sound reasons for
doing so.
• Counselors should be accountable for their services to colleagues, employers, and fund- • Any agreement between the counselor and the client about confidentiality may be re-
ing bodies as appropriate. This should be achieved with respect for the client’s needs. viewed and changed by joint negotiations.
• No colleague or member of the caring professions should be led to believe that a service • Agreements about confidentiality continue after the client’s death unless there are overrid-
is being offered by the counselor when it is not, as this may deprive the client of the offer ing legal or ethical considerations.
of such a service from elsewhere.
Any discussion between the counselor and others should be purposeful and not trivial.
Counselors should work within the law and should take all reasonable steps to be aware of
all current laws affecting their work.

4
34 35
Counseling Set-Up
HIV testing and counseling rooms should be private and adequately sound proof
(i.e., discussions within the room should not be discernibly overheard from the outside or the Behavior Change
Strategies in
adjoining rooms) to ensure the client’s confidentiality is maintained.
Counseling rooms should have a minimum of two chairs, at arms’ length in distance to create
an informal, relaxed environment.
The important documents for the Pre-HIV Test Counseling should be at hand at the start
of the session. They are the following: DOH EB Form-A, HTS Counseling Form, and IEC
HIV Counseling
Material (optional).
References:
1 Nelson-Jones R. (1988). Practical counseling and helping skills: Helping clients to help
themselves. Holt, Rinehart and Winston: Sydney, pp. 13 - 35
2 Ministry of Health and Family Welfare, National AIDS Control Organisation, Government
of India, HIV/AIDS Counseling training manual for trainers
3 Adapted from: Ministry of Health and Family Welfare, National AIDS Control
Organisation, Government of India, HIV/AIDS Counseling training manual for trainers,
pp. 82-83 and Family Health International (2001), Zimbabwe HIV Counseling training
manual, pp.49-51.

36 37
Chapter 4 HIV-related behavior-change counseling

Behavior change strategies in HIV counseling
In STI and HIV counseling, sexual behavior, drug or alcohol use, and poor treatment ad-
What does it take to change behavior? herence are probably the most important behaviors to consider in relation to HIV trans-
mission risk. Reducing HIV transmission in the community and helping HIV-positive clients
Individuals’ lifestyles and behaviors have a major impact on physical and emotional health. stay healthy are essential components of the counseling process. The counselor’s job is to
Behaviors that affect health include eating, personal hygiene, sexual activity, physical ac- support clients in recognizing which behaviors are a transmission risk (see chapter 1: How
tivity, smoking, and drug or alcohol abuse. Because these behaviors are often deeply in- is HIV transmitted?) and to assist clients in choosing and sustaining safe and healthy behav-
grained, they are not easy to change. Yet unless harmful behaviors are changed, they can ioral patterns. The counselor must explain the advantages and disadvantages of behaviors
result in preventable illness, poor quality of life, and possibly a premature death. Unhealthy such as the use of alcohol, tobacco, and other drugs; sexual activity; and eating habits. The
behaviors must be unlearned. This is most always a complex process; if the intent is to counselor facilitates change by:
change behavior, simply providing clients with information is rarely sufficient. Let us look at • helping the client to anticipate challenges to behavior change;
an example that illustrates this point below: • working collaboratively with clients to develop effective strategies to meet the antici-
pated challenges; and
• reinforcing the achievements.
Information alone rarely leads to behavior change
Stages of Change
The client is a doctor who has worked in a large public hospital and has
seen the effects of smoking on his patients’ health. He is aware of the
scientific evidence about the harmful effects of smoking on his health,
yet he continues to smoke. He has a chemical dependency on nicotine,
he is overworked, and he smokes when he experiences stress. He also
indicates that he is in the habit of holding a cigarette when he drinks
alcohol at social functions, when he talks on the phone, and when he is
writing up his patient records.
The client clearly knows that his behavior is harmful. However, a number of other factors
contribute to his smoking habit. He has a physiological dependency on a substance in
cigarettes. He has situational behavioral triggers, which have become entrenched
behaviors (e.g., phone in one hand and cigarette in the other). He is also stressed and
perceives smoking to be stress-reducing. He will not give up smoking until he sees that the
benefits of not smoking outweigh the benefits of smoking, unlearns automatic behaviors
such as smoking to keep an empty hand occupied while talking on the phone, manages his
symptoms of nicotine withdrawal, and finds substitute strategies for coping with stress.
To change behavior, the individual needs to:
• identify the behavior as harmful;

• understand available alternatives;
• be able to act on that knowledge; and Supporting behavior change is a complex interaction between the counselor and client that
• receive the support needed to maintain the behavior change. requires a great deal of insight into human nature and motivation. It requires the counselor
to help clients recognize behaviors that are harmful to their health and to acknowledge the
difficulties that changing behaviors will present.

38 39
No single strategy for behavior change can address all harmful behaviors. The three
strategies presented here–risk elimination, risk reduction, and harm reduction–can be thought
Stage of Change Behavior change counseling strategies
of as tools for assessing clients and their concerns. In this chapter we will primarily address
behavioral strategies for reducing STI and HIV transmission.
Pre-contemplation • Provide personalized information about the client’s HIV
status and the risk taking associated with drug use (lack of
How do I get a client to want to change his or her behavior? safer sex practices, unsafe injecting, etc.).
The client does not
For example: ”You have had several HIV tests because you
perceive that he or she
Decisions to change certain behaviors, for example, by abstaining from drug or alcohol use have not been able to inject safely or use a condom. Each
has a problem or that it is
or starting to use condoms, are difficult to make. Clients don’t often state openly that they time you have been anxious about the result. Do you want
an immediate problem.
would like to change these behaviors. Often they are in a state of ambivalence and fluc- to continue going through this?” Or, if the client is already
tuating motivation before deciding to make a change. If a client is either not ready or am-
HIV-positive: ”Now that your doctor has recommended that
bivalent about change, advice in the form of demands or attempts to use heavy persuasion
you start treatment.” In both cases you should provide the
may put him or her on the defensive and increase the resistance to change. The concept of
stages of change developed by Prochaska and Di-Clemente1 (see figure above) shows that, client with information.
for most persons, a change in behavior occurs gradually, with the patient moving from being Contemplation • Acknowledge the client’s ambivalence.
uninterested, unaware, or unwilling to make a change (pre-contemplation) to considering
• Ask the client what he or she (not the counselor) sees as
a change (contemplation) and deciding and preparing to make a change. Genuine, deter- The client is seriously the benefits and problems of continued drug use, and the
mined action is then taken and, over time, attempts to maintain the new behavior occur.
considering giving up benefits of and barriers to stopping.
Relapses are perceived as almost inevitable and become part of the process of working to-
drugs in the next six • Help the client to see potential solutions to the vari-
wards sustained change.
months. ous barriers raised (loneliness, common practice among
Motivational interviewing is a non-confrontational approach to counseling. Studies have friends, withdrawal symptoms, etc.).
found it to be highly effective with clients in the pre-contemplation or contemplation stages • Help identify potential resources (e.g., detoxification
of behavior change related to drug, alcohol, or tobacco use, as well as safer sex practices. facility services, recovery groups, treatment buddies).
The goal is to explore the clients’ ambivalence towards change and to encourage them to
express their concerns and individual reasons for change. The key concept in motivational Preparation • Establish an action start date.
interviewing is resolving ambivalence about the need for change. First let us take a look at • Help client develop awareness of practice of keeping a
the summary table of interventions appropriate to each stage of change in relation to drug
The client intends to quit habit diary (if illiterate, interview and do the recording,
use. Then we will look at motivational interviewing strategies in more detail.
within the next month; or use low-literacy self-recording), noting issues such as
has tried to quit in the when he or she uses drugs, who with, how much, etc. If
Stage of Change change counseling strategies
Behavior past year or has made the client is illiterate, interview and do the recording.
behavioral changes (e.g., • Establish degree of dependency. Use ICD 10 or other
Pre-contemplation • Find out whether the client is experiencing life problems
tries to use clean inject- standard diagnostic criteria.
such as lack of money or a relationship breakdown.
ing equipment or reduce • Interview the client about past attempts to stop using
The client does not • Find out the health impact of the behavior from the client’s
use). drugs. Determine the process with the client, including
perceive that he or she perspective.
detox, gradual withdrawal,
has a problem or that it is • Ask the client how much drug use is affecting or contribut-
• oral substitution therapy.
an immediate problem. ing to his or her problems.
• Interview the client to establish why the client uses drugs
• Provide personalized information about general health
(social use, depression, strategy for coping with sex work,
problems resulting from continued drug use.
etc.).

40 41
Example: Your client uses injecting drugs and shares injecting equipment
Stage of Change Behavior change counseling strategies and does not use condoms for sex

Action Phase • Help the client develop a plan of action.
• The skills you will primarily use here are reflective listening and open questioning. Your job
• Facilitate referrals or preliminary visits to drug treatment is simply to develop an understanding of the client’s feelings without criticism, judgement,
services. or blame. Use an opening strategy such as talking about the client’s life and the current
• Support skills rehearsal, e.g., informing partner of wish stresses he or she is facing: “How is your life at the moment?”; “What’s happening in your
to enter a methadone program. life right now?” You do this even if the client has come in about a specific health problem
like an STI or for an HIV test.
Maintenance phase • Anticipate and normalize relapse.
• At this point the client may discuss the positive aspects of using drugs and say that he or
• Review triggers for relapse and coping strategies.
The client is free of she is in control of the use of drugs.
• Support progress and monitor health and highlight
drugs or in recovery
positive consequences of changes • The counselor could then say, “How do you see your drug use affecting your health?”,
program for six months
(e.g., increased condom use during sex; less STIs; or talk about whatever issues the client raises (e.g., relationships, financial situation). The
improved appearance; improved relationships with main point is to build rapport with the client and assess his or her readiness for change.
partners, families; new friends; better financial situation).
• Avoid using terms such as “problems” or “concerns” and do not assume that a given issue
Termination • Congratulate the client and again remind him or her that or circumstance is a “problem” for the client. Do not confront resistance or denial at this
stage and simply say something like, “I can see how this does not feel like a problem for
you are available for follow-up
you right now.”
The client is 100%
confident in all trigger • The counselor then begins to focus on the events of the day and how the client feels about
situations. them. Questioning shifts to inquiries such as, “Tell me about a typical day in your life…
How about last Friday?”; “After you got up in the morning, how long was it before you had
your first hit that day?”; “How did you feel after it?” Explore a typical day in the life of the
Getting started with motivational interviewing client. The counselor mainly asks simple, open-ended questions. The aim here is to raise
the client’s awareness of the relationship between drug use and what is happening in his
Counselors should select the strategy for a given session depending on the patient’s read- or her life. This strategy is particularly useful for pre-contemplators.
iness for change. More than one strategy can be used in a session. The counselor works
through the list of strategies in box below as the client becomes more ready to change. • The next step, either in the same session or in a later session, is to ask the client about the
good things and the things that are not so good about drug use and then to respond with
a reflective statement that links the two responses. For example: “So your use of heroin
Strategies used in motivational interviewing helps you relax when you are having sex with clients.” Or: “On the other hand, you say that
sometimes clients hurt you, don’t pay you, or have sex with you without using condoms
• Opening strategy: lifestyle, stresses, transmission risk behavior, and because you are relaxed.”
substance use
• A “typical day” / Session review • Providing information about drugs is routine in health services, especially with people at
• The good things and the less good things about change risk of or living with HIV. The important issue here is the way the information is exchanged.
The information should be impersonal and neutral. For example, you may want to say
• Information provision
something like: “Using drugs can cause liver problems and make it difficult for people to
• The future and the present
protect themselves from sexually transmitted infections. It can even make it difficult for
• Concerns about change people with HIV to use and benefit from the new HIV treatments.” Or: “Sharing injecting
• Help with decision making equipment and engaging in unprotected sex as well as missing some doses of medication
can make people resistant to treatment.” This should be followed up with a simple open
question such as: “How do you feel, or what do you think about that information?

42 43
• The strategy called Future then Present, about the future and the present, can be used
Risk elimination: “Abstaining from sex and refraining from injecting drugs is best”
with clients who are becoming concerned about their behavior. The counselor can focus
on the present behavior and how the client would like to behave in the future, thus in-
Risk elimination relies on abstinence to eliminate the risk of HIV infection. According to this
dicating a discrepancy. This can provide the motivation to change behavior. Ask: “How
strategy, the client should abstain from sex and refrain from injecting drugs. The risk of infec-
would you like things to be in the future?” Once future goals have been elicited, a coun-
tion is eliminated because the behaviors that lead to it are eliminated. Examples of preven-
selor can return to talking about the present, asking for example: “What’s stopping you
tion education messages based on risk elimination are the sexual abstinence and just say no
right now from having or doing those things?” Listen, and then ask: “How is your drug
to drugs campaigns. Both campaigns have failed to reduce HIV or change the behavior that
use affecting you right now?” This will lead to a direct exploration of the concerns and
leads to HIV infection.
problems that drug use is causing the client, and to a discussion of behavior change.
While adherence to risk elimination guarantees 100% safety from infection attributable to
those behaviors, it is often the least-useful behavior-change strategy because most people
Motivational interview strategies can be used effectively when integrated with the stages-
find it extremely difficult to do away with risky activities such as drug injection or sex. This
of-change model. Knowing which stage of change the patient is in gives you a place to start
strategy does not acknowledge that certain behaviors are pleasurable and it does not allow
when deciding which strategy to employ
for alternatives.
Strategies for the action and maintenance phases

Risk reduction: “Use a condom and do not share injecting equipment”
Using a simple structured problem-solving approach Realizing that many people cannot stick to the risk elimination strategy, some counselors and
Once the client decides to make a change, the counselor’s role is to facilitate behavior by educators opt for risk reduction, a strategy that realistically acknowledges that some indi-
collaboratively engaging the client in structured problem solving. This approach can be sum- viduals will continue to engage in risky behaviors. Assuming that abstinence is not a realistic
marized as: alternative, the risk reduction strategy advises individuals to engage in ”safer” behaviors –
using condoms during sex or when engaging in low-risk sexual activities, and not sharing
• describing the problem that results in HIV transmission; needles when injecting drugs.
• brainstorming about the options for behavior change–selecting the risk elimination, risk
reduction, or harm reduction approach The risk reduction strategy, however, cannot offer a 100% guarantee that a person will remain
• critically evaluating the options–asking the client to consider the benefits and potential uninfected. For example, if a condom breaks during intercourse, the client will be at risk.
problems associated with each strategy; and
• developing an action plan with opportunities for a “provisional try”.
Harm reduction: “Follow a step-by-step process of change”
As a counselor you must then offer support in developing the skills needed to fulfil the action
The harm reduction strategy recognizes that risky behaviors not only occur but also have
plan. This may include, for example, role-plays that involve condom negotiation, practice in
meaning. This strategy assumes that risk is a part of life and ranks an individual’s risk of HIV
using condoms, or training in cleaning injecting equipment.
infection among other life issues, such as illness, unemployment, and drug use. The harm
reduction strategy rejects the all-or-nothing approach to behavior change. Instead it
conceives of change as incremental and taking place over time. Any positive change brings
Reviewing options
the individual one step closer to healthy behavior. The counselor works with the client to iden-
The client reviews the advantages and disadvantages of different ways of altering behavior. tify risky behaviors, understand the reasons why he or she may continue to engage in them,
The counselor asks the client to brainstorm about the advantages and disadvantages of and identify what the client can do to move towards healthier behaviors. Needle - ex-
different options. In our example of risk elimination for a drug user, this may include change programmes, for example, acknowledge that some clients engage in risky behavior
abstinence, brainstorming about the gradual reduction in drug use, or considering oral sub- (injecting drugs). Eliminating the behavior that puts them at risk might not be an immediate
stitution therapy. In the case of sexual transmission risk reduction, options might include goal of this strategy, but for some it can be a long-term objective.
abstaining from sex, using condoms for sexual partners other than a tested regular partner,
and choosing sexual activities with a lower transmission risk. Three broad strategies that re- These three strategies, and many others, are available to HIV counselors and educators. Ele-
late specifically to choices for transmission risk reduction are presented later in this chapter. ments of different strategies may be appropriate at different times for the same client. Most
importantly, HIV educators and counselors must be familiar with these strategies and know

44 45
how best to use them – not as absolutes but as tools for interacting with clients. Educators
and counselors should also keep in mind that they can adapt each strategy to their own style The principles and strategies outlined in this chapter can be applied to a range of target be-
and culture. haviors. Behavior-change counseling may not always be about changing adverse behaviors; it
can also be about developing new behaviors–improving diet or developing an exercise habit.
Developing an action plan with a timeline

The action plan should be a clear list of tasks associated with the behavior change; each task
should include a date (e.g., visit potential detoxification centres, or buy condoms). The strat-
egy should be built up in steps so that small changes can be rewarded or acknowledged. For
example, this may involve setting a goal of asking one person to use a condom in week 2
or to enter a detoxification programme and join an anonymous anti-narcotic support group.
Making a provisional try (an initial attempt at behavior change)
The provisional try takes place when a client leaves the counseling session and attempts a
step towards changing behavior. Though provisional tries may not always be successful, the
minimal attempt at behavior change can be considered a success and must be supported by
counselors. Counseling strategies during the provisional-try stage include:
• reinterpreting the concept of ”failure” (”This was an experiment and we just wanted to
see what happened so we could plan for problems”);
• asking ”why” in a positive way (”Let’s look at what happened so we can carefully plan”);
• providing closure (”Different strategies work differently for different people; we can try
something else”).
Preventing a relapse
Relapse prevention strategies are an important part of behavior-change interventions.
Clients should not feel they have failed. Planning for a relapse makes them aware that a
relapse is likely to occur as it is a natural part of the behavior-change process, and that it does
not mean failure or even a setback.
Most relapse prevention plans call attention Preveting Relapse Strategies

to possible triggers that can bring forth the • Identify high-risk situations (triggers)
old behavior (e.g., send a drug or alcohol • Develop trigger management skills
abuser back to his or her drug of choice, or • Rehearse trigger management skills
let somebody share injecting equipment or • Engage in structured problem solving
not use a condom during sex). The client is • Get back on track after a relapse
encouraged to come up with a list of poten-
tial triggers that need to be avoided or addressed once they occur. The counselor can ask
the client to monitor his or her drug use, for instance, or contexts where it may be harder
to use condoms. If the client cannot keep a record, then the counselor can ask questions
that will elicit this information.

46 47
Grief, Bereavement
and Loss
Field Test version only

5 Field Test version only
48 49
Chapter 5 Grief, Bereavement, and Loss Table 5.1 Characteristics of a normal grief resolution
Understanding Grief, bereavement and mourning in the Feelings Physical Behaviors Cognition
Sensations (Perception)
context of Philippine Culture
Sadness Hollowness in the Absent-mindedness Disbelief
In the Philippines, grieving for the departed loved ones take on different expressions. It is stomach
culturally acceptable that some of the relatives may experience encounters with the “soul”
of the departed ones (paramdam). The family would hold bereavement rituals (3 days, Anger Digestive Problem Preoccupation Sighing
pa-siyam, 40 days, baban-luksa) in respect for the departed.
Guilt / Tightness in the Crying Hallucinations
Self - blame chest
It is crucial for counselors to be aware and always consider the different cultural practices
related to death and bereavement of Filipinos across the country. Anxiety Tightness in the Sleep and appetite Confusion
throat disturbances
Lonliness Oversensitivity to Generalized tension Sense of presence
Working with grief, bereavement, and mourning in adults noise (e.g., perception that the
Fatigue Shortnes of breath Restlessness deceased is around or is
Grief is an emotional response to a personal loss of a loved one, over one’s (ill) health, or a talking to you, or a sense
financial loss that results in an intense feeling of sorrow or sadness. When we think of grief, of being healthy again)
Helplessness Weakness Agitation
we often think of death, but other losses can elicit similar reactions. A PLHIV may grieve
over the loss of good health, or a couple undergoing divorce may grieve over the loss of
Shock Lack of Energy Visiting places or Depersonalization
the relationship. A normal grief reaction can involve a variety of feelings, physical sensa-
tions, cognitions (perceptions), and behaviours. Table 18.1 presents some of the feelings carrying objects that (e.g. “Nothing seems real
Yearning Dry mouth bring the deceased to me including myself)
and reactions that are normal when someone experiences grief.
Emancipation Muscleache and pain back to mind
Because there is no cure for HIV, people often experience grief upon learning that they,
their partner, or a friend is HIV positive. People also feel grief when a loved one dies of
Dreaming of the
AIDS. It may often set in long before a person experiences death. Thus, counselors must Relief Heart palpitations
understand grief and learn how to help clients through the grieving process. deceased / the one lost
Avoiding reminders of
Numbness Headaches
Grief is multidimensional – it is experienced emotionally, mentally, the deceased

spiritually, and physically. People experiencing grief need nurturing,
compassion, and patience. Increased allergic Treasuring objects that
reactions belonged to the
deceased
Bereavement is the response to the death of a significant other (whereas grief can result
Weight loss or gain Searching and calling
from loss not involving death, such as loss of a job, limb, or status).
out (not always aloud)
Mourning denotes the actions and manners of expressing grief and consists of conscious,
unconscious, and cultural reactions to loss. As used here, grief refers to the personal ex-
periences associated with any loss, while mourning refers to the process that occurs after
the loss. Bereavement and mourning are sometimes used interchangeably when in fact a
distinct difference exists between them. Bereavement identifies the specific reactions ex-
perienced after the death of a significant other, whereas mourning speaks to the way the
individual displays his or her grief.

50 51
The stages of grief Working with grief

While there is no single way to grieve, adults generally experience common stages of griev-
ing when they are bereaved. It is helpful to be aware of these stages and remember that Each person has a unique combination of diverse past experiences, with different person-
intense emotions and swift changes in mood are normal. The stages are fluid–an individual alities, attitudes, styles, and ways of coping. All these characteristics influence how people
may move in and out of them in his or her own manner and time. accept the circumstances around them. For some people, grief is an intense experience
while for others it is milder. For some, grief begins the moment they hear of the loss; for
Denial (numbness) others, grief is delayed. In some cases, grieving is relatively brief, whereas in others it seems
to go on forever. The following factors affect how a person responds to a loss:
Denial is usually the first reaction (e.g., ”It can’t be true!”). This stage may last between a few
hours and many days. While it may helpful for a client to go through some denial at first, it
can be a problem if it lasts too long. Past experiences
It is important to know about prior medical history, previous or similar losses a person has
Anger (yearning and searching)
faced, and how the person grieved. Questions include: “What other losses were faced in
Denial is usually replaced by deep yearning and searching for the person who died (or for childhood, adolescence, or adulthood?”, “How frightening were these experiences?”, “Did
the lost ”object” or health). This can lead to anger, which can manifest itself in different ways, the person have good support?”, “Were feelings allowed to be expressed in a secure envi-
including blaming others for the loss, getting easily agitated, finding it hard to concentrate, ronment?”, “Has there been a chance to recover and heal from the earlier losses?”
relax, or sleep, and unleashing emotional outbursts. In addition, people often feel deep
guilt about arguments they had with the deceased or about failing to express emotions and
Relationships with the deceased/lost object/lost health
wishes.
Grieving is affected by the relationship with the deceased or ill person and the nature of
Bargaining the attachment. For lost health, grieving depends on how good the person’s health was
previously. Questions include: “How close was the relationship (the strength and security
A bargaining stage is most
of the attachment/importance the person attached to his or her health)?”, “What was the
likely when people themselves are
degree of ambivalence (love-hate balance) in the relationship, conflicts with the deceased,
dying. After the dying person or
lost object, or lost health?”
family member has vented his or her
anger at friends, family, or a
higher power, he or she enters the
Roles the person/object/health played in life
bargaining phase. This stage is
seen as an attempt to enter some The more predominant the role of a loved one or health in a client’s life, the more difficult
agreement or finish an important the grieving process will be. Questions to ask include: ” How major was that role?”, ”Was
task to prolong life. During the bargaining stage, the affected person often makes promises the deceased/ill person the sole breadwinner, the driver, the handler of financial matters?”,
to a higher power, agrees to change his or her life if allowed to live, and asks for an oppor- ”Was the person the main emotional support, an only friend?”, ” How dependent were
tunity to do something special before he or she dies or faces a disability. you on the role that person filled?”, ”What role did good health have in ensuring he or she
could perform duties?”
Depression
Bargaining is followed by bouts of depression and sadness, set off by reminders and mem-
Circumstances surrounding the death/lost object/lost health
ories of the deceased person or of the dying person’s good health (”It’s all over”). People
who are grieving often feel extremely tired because the process usually requires physical and The cause of death, illness, or loss is also important, as is where and how the death or loss
emotional energy. occurred. Questions to ask include: “Was it natural, accidental, suicidal, homicide, etc.?”,
“Near or far, sudden or expected?”, “What warning was there that there would be a loss?”,
Acceptance “Was there time to prepare, time to gradually come to terms with the inevitable?” Or, in
case of illness: “How and when did the person acquire the illness?”, “Do you feel that the
The final stage of grieving is acceptance–letting go and moving on with life. This may mean
death/loss could have been prevented?”, “How much was left unsaid or undone between
resignation, not necessarily contentment. This stage helps lingering depression to clear and
the deceased and yourself?”, “Does the extent of unfinished business foster a feeling of
sleep and energy patterns to return to normal.
guilt?”

52 53
Influences in the present Avoiding clichés. Sometimes words meant to comfort clients can be unintentionally hurtful.
Among the greatest potential offenders are clichés, or comments that seem to diminish the
The current state of a person’s life, including stress level, management of feelings, social vari-
person’s loss by offering simple solutions to difficult realities. Some examples of clichés are:
ables, ethnic and social subcultures, and religious faith, greatly affects how he or she grieves.
”You’re holding up so well”; ”Time heals all wounds”; ”Think of all you have to be thankful
The degree of perceived emotional and social support (inside and outside the family) is also
for”; ”Be happy he is out of pain”; ”He’s in a better place”; ”She’s at peace now”; or, ”God
important.
never gives us more pain than we can handle”. Such clichés fail to acknowledge the depth
Questions to ask include: “What are the secondary losses from this death or loss? Loss of
of the feelings of the bereaved. Moreover, these comments often are more about the per-
income? Home? Family break-up?”, “What other stresses or crises are present?”, “What do
son who died than the person who is grieving.
friends, relatives, or others impose?”, “What is in social, cultural, and ethnic backgrounds
that offer strength and comfort?”, “Do religious/philosophical beliefs bring comfort or add
Understanding the uniqueness of grief. Counselors should keep in mind that each client’s
sorrow and guilt?” “What other life stresses have been present during the recent loss?”,
grief, and method of handling grief, is unique. Though there are fundamental similarities in
“Has there been a move to a new area?”, “Were there financial difficulties, problems, or
the grieving process, people do not respond to the death of a loved one or loss of health
illness with another family member or with one’s self?”
in exactly the same way.
Several tools, processes, and procedures can be employed to help a grieving person deal
Counselors should be aware of the above factors when loss occurs to someone under their
appropriately with his or her grief.
care. Awareness of these factors, which affect the manner, intensity, and duration of grief,
enable the counselor to guide the grieving person to relevant support.
There is no ”right” way to grieve, nor is the timetable
for healing the same for everyone.
Grief counseling
Grief counseling processes and tools
Grief counseling helps grieving individuals go through the phases/stages of grief and can be
done individually or in a group. The goals of grief counseling include:
Forceful language. Counselors should inform their clients that it is ”okay” to grieve, cry,
• helping the person accept loss by talking about it heal, and laugh. In addition, counselors should use appropriate words such as ”AIDS”,
• helping the person identify and express spoken and unspoken feelings (e.g., ”died”, and ”death”, and talk of the deceased in the past tense, e.g., ”Your son died”,
anger, guilt, anxiety, helplessness, and sadness) instead of, ”You lost your son” or ”He passed away”; these substitutes can confuse the
• helping the person overcome difficulties in readjusting to life after the loss grieving person and can perpetuate denial and stigma.
• encouraging the person to say goodbye (sometimes before the loss)
• allowing time for grieving, and giving permission to grieve Symbols. Symbols (e.g., music, photographs, and places) can be used to trigger reminders
• describing normal grieving and the difference in grieving among different indi- and help release grief. A client can be encouraged to look at photographs, listen to music,
viduals, and helping the person understand his or her coping methods or visit a place as a way to tell a story about the deceased, express grief, or celebrate happy
• providing continuous support, identifying coping problems (if applicable), and memories.
making necessary referrals for professional or ongoing grief therapy
Writing and drawing. Sometimes a client can release grief by writing a letter to the
deceased. This can be particularly useful if the client needs to deal with ”unfinished busi-
Counselors can do a number of things to facilitate a client’s grief process, as follows.
ness”, if the client is having difficulty with closure (”letting go”), if the death was sudden
and unexpected, or as a way of venting emotions.
Listening actively. A counselor’s mere presence and desire to listen without judging are crit-
ical helping tools. In difficult times, many people need to talk about their experience, review
Rituals. Philippine culture has various traditional ways of mourning that can help process
the details, and tell the story. People feel comforted when counselors show empathy and try
grief, although in some cases these may actually hinder the process. Help your client iden-
to understand.
tify rituals common in his/her area or create meaningful ”rituals” that may assist in the
mourning process (e.g., lighting a candle at church, singing a song, or making a shrine in
Showing compassion. Clients need permission to express their feelings without fear of
memory of the deceased). See box 18.2 for information on the AIDS Memorial Quilt project.
criticism, and to experience hurt, sorrow, resentment, anger, fear, anxiety, or pain without
concern for what is ”acceptable”.

54 55
The AIDS Candlelight Memorial every third Sunday of May is observed to commemorate Working with grief, bereavement, and mourning in children
people with HIV who already died. and adolescents
Children express loss and grief differently from adults. They tend to move in and out of
Fig. 5.1 AIDS Candle light intense feelings, rather than sustaining high levels of one emotion for long periods of time.
Memorial day
When adults see a grieving child playing or laughing, they may mistakenly believe that the
(Photo: PhilStar, 28 May 2011)
child is ”over it”. This perception may influence how much grief support a child receives.
Experience of Loss Among Young Key Affected Populations

Young Key Affected Populations (YKAP) such as children living on the streets may have
already experienced considerable losses, including the loss of families where parents have
made them leave home for work or because of behaviour problems. Children who lose a
parent must cope not only with grief over their loss but possibly with significant disruptions
to their home and family life such as placement in foster care facilities or the home of anoth-
er relative. This loss may be further complicated by a child’s unexpressed past resentment
Role-playing and imagery. Help persons in mourning imagine what they would tell the de-
over a deceased or surviving parent’s lifestyle (e.g., a sex-worker or drug-using parent).
ceased if the person were still alive (especially if the mourner did not have the opportunity
to say these things). Imagery can also be used to create a peaceful picture that offers healing
Children living with drug- or alcohol-using parents or close friends may experience different
and strength (e.g., a bright warm sun, the beauty of a flower). Clients themselves should
types of losses. The loss may be either direct, through accidental or deliberate overdose,
choose the imagery; it should be something with special meaning for them.
or ambiguous. Ambiguous loss occurs when a family member is either physically or psy-
chologically absent, as in the case of a parent with a chemical dependency. Children who
Cognitive restructuring. Help clients find alternative ways of thinking about the loss. En-
are abducted or incarcerated also experience significant grief and loss issues. YKAP may
courage them to consider the message the deceased might have for them, if that person
have lost friends to HIV or drug overdose or other illnesses common to those living on the
were with them now. This may offer inspiration or insight.
streets. The impact of loss of street peers should not be underestimated. For many children
living on the streets they regard their peer network as alternate families. Frequently street
Processing grief and loss through the AIDS Memorial Quilt Project
children have experienced multiple losses and exhibit signs and symptoms of disordered
The AIDS .Memorial Quilt is a living memory to those who have died from mourning.
AIDS. It is made up of a set of eight panels, each 90 cm x 180 cm, that are
sewn together to form a 4 m x 4 m patchwork square. There are many thou- Social support and increased age have been associated with improved grief outcomes, but
sands of these larger squares. The quilt is an international activity coordinated paediatric HIV and AIDS patients may be lacking on both counts.
by an organization, called the NAMES Project Foundation. Each quilt panel
commemorates the life of someone who has died of AIDS. Panels are made Often counselors have to work with the family members of YKAP. Families dealing with
by friends, lovers, and family. HIV and AIDS are faced with concerns of separation and grief. Grief and mourning may be
complicated by feelings of guilt, or anger over the lifestyle of the child or adolescent. In the
Each panel includes a wide variety of materials from photographs to real life event of a parent’s death, a grandmother or other extended family members may be called
objects such as T shirts, caps, belts, and buttons. Through the panels the quilt upon to raise the children. Grandmothers experience grief regarding the loss of their own
makers spread their sincere prayers for not repeating the pain and loneliness children, as well as the stress of assuming parenting responsibilities at a late age. Addition-
they have experienced in losing a loved one to AIDS. ally, some families are now experiencing multiple losses. HIV and AIDS are unique in their
ability to strike multiple members of the immediate family as well as the larger community,
Many other countries in the Asia and Pacific regions and throughout the world thus severely compromising traditional social support systems. Paediatric HIV and AIDS
have their own AIDS memorial quilts and other complementary memorial patients who die may leave behind not only grieving parents, but also grieving siblings.
activities that facilitate grieving. The topic of children’s reactions to sibling death is one that does not receive widespread
attention, but there is evidence that the sibling relationship is one of the most important so-
Information available: http://www.aidsquilt.org cial relationships people have. Better family adjustment after the death of a child has been

56 57
shown in the oncology literature to be related to open communication and social support. “Have you ever had someone close to you or a pet die? What happened?” (May malapit
Siblings and parents of deceased paediatric HIV and AIDS patients may be at risk because of na kakilala or alagang hayop ka na ba na namatay? Ano ang nangyari?)
the social isolation associated with HIV.
“Does everybody and do animals die?” (Namamatay ba lahat?)
“Why do things die?” (Bakit sila namamatay?)
Talking about death and dying with children and adolescents
Children and adolescents go through stages of awareness of death as they develop. The in- Summary of developmental stages and death conceptualization
terventions we use should be guided by these stages. The stage of death conceptualisation
Infant death conceptualization. Up to age two, there is no formal concept of death. Key
should always be assessed. Adults are often reluctant to talk about death and dying with chil-
points:
dren. However, children are aware of death through fairy tales, games, television, overheard
adult conversations, religious instruction, and attendance at funerals. If we permit children to Infants’ awareness of the world is narrow. This includes their awareness of mother,
talk about death we can prepare them for crisis, and help them when upset, and address any physical being, and separation.
fears. Infants need warmth, physical contact, and consistency.
Some points to remember regarding children and death:
Infants will grieve over the loss of a loved one they were used to being with. Before children
- What children sense or overhear may be worse than the truth. can talk, they communicate with sounds of crying and cooing, body language, and physical
- We can make it easier for them if we are honest and open symptoms such as colic and fretfulness. Grieving babies can be difficult to console. If a sur-
viving parent or family members are grieving too, chances are that the baby will sense their
distress. It may also be difficult for the grieving family member to remember all the needs
of an infant. Counselors can help in these circumstances by looking for support for families.
At each developmental stage, a child’s perceptions and concepts of death change because Ask friends, neighbors, groups, religious organizations, or NGO community groups to help
he or she reaches a different level of cognitive development, possesses a greater storehouse with a toddler’s or baby’s care while the family is in crisis.
of experience, and has new ideas about the world.
Death conceptualization: Preschool age (2-4 years).
Assessing death conceptualization in children and adolescents Among this age group, common issues include:
Before either grief or loss counseling starts, or a child is told about impending death, the • fear of abandonment
counselor must assess the child’s conceptualization of death. • preoccupation with physical function
• ”How does he play now that he is dead?”
Key questions to ask: • ”He will get hungry if Mommy can’t feed him”;
• death as impermanent and reversible
”What does ‘dead’ mean?” (Ano ang ibig sabihin ng namatay?) • death confused with sleeping (or fear development)
• Natutulog lang ba sya?
”Can dead people come back to life?” (Maari bang mabuhay ang mga namatay na tao?) • Kailan sya magigising?
”Tell me what you know about dying or dead people.” (Ano ang alam mo sa mga namatay o • Bakit sya namatay?
mamatay na tao?)
As children learn to use our symbolic language of words, they can begin to share feelings
”Can dead people get hungry?” (Nagugutum ba ang mga patay na?)
with words. They learn what ”sad”, ”mad”, and ”scared” mean. They communicate about
”Can dead people feel things like pain?” (Nakakaramdam ba ng sakit ang mga patay? ) the concrete world-what they can see, touch, hear, taste, and smell. The future and the idea
of ”never” are outside their understanding. They fully expect their loved one to return.
Additional questions to ask children: They will believe, for example, that if they are ”good” the dead mother or father will return
(“Magpapakabait ako para bumalik si Nanay/Tatay.”). Children will seek out the dead peo-
“Have you heard adults talking about death? What did they say about it?” ple; they will continually ask where that person has gone and may even look for them (“Saan
(Narinig mo na bang pinag uusapan ng mga matatanda ang kamatayan? Ano ang sabi nila sya pumunta? Pwede ako sumama?”).
tungkol dito?)

58 59
Death conceptualization: 5-9 years. At this age: Death conceptualization: Adolescents
• 15% of children at this age think about death at night and believe people die at night.
For adolescents, death is understood as an abstract concept:
• Death comes from an external source-a monster, ghost, or angel that takes people death as a distant prospect
away. fear of death
• Death is something that can be ”outwitted” or escaped, feeling of invincibility (“Hindi ako mamatay!”)
• Often the child’s exposure to death has been through TV or the sight of a dead ani- tests of mortality (driving fast, extreme sports).
mal.
• Death is associated with “mutilation” and horrible images. Adolescents are more likely to engage in high-risk behaviour, especially after a death. One
young person said that her friend was always careful and followed all the safety rules, but
• Children will often shock adults with detailed questions about decayed bodies and
died anyway. She asked, ” Bakit pa ako mag-iingat?” Teenagers are usually growing in
mutilation of bodies.
independence. Teenagers living on the streets for many years will often have a veneer of
• Death is seen as punishment. adult toughness. They may feel a need to hide their feelings of grief to show their control of
• Children will try to make bargains with death: “Magpapakabait na po ako, huwag themselves and their environment. Teens often prefer to talk with peers rather than adults
lang po mamatay si Nanay/Tatay” when they are grieving.
Key fears around death: Vulnerable as they are, most particularly during moments of grief, their encounter with an
• fear of losing another parent or family member adult might put them at risk for violence, abuse including sexual abuse.
• fear of dying at same age as the deceased
• fear of going to sleep Telling a child about a death: Basic principles
• fear of separation
• Keep it simple. Use died (namatay), not ”He is sleeping (Natutulog lang sya).” For
• fear of loss of protection
example: ”Miguel, may aksidente sa kalye kanina. Tumawid ang kaibigan mo at
Around the age of six, children begin to understand that the loved one is not returning. This can nahagip ng kotse. Nabagok ang ulo nya kaya namatay..”
bring about a multitude of feelings at a time of other significant changes in a child’s life, includ- • Allow the child/adolescent to express raw feelings freely or ask questions.
ing entering first grade. Children who do not remember their parent may feel an acute sense • Answer questions honestly and simply. Do not go into details unless asked. Offer
of loss as they see peers with their parents and hear their family stories. Children at this age are only as much detailed information as is requested.
increasingly interested in biological processes about what happened to their loved one. Ques-
• If the death was due to a violent crime, explain how the child/adolescent can re-
tions about disease processes and what happens to the body are of keen interest. (“Bakit sya
main safe.
namatay?”) When asked questions, it is important to clarify what it is the child wants to know.
• If the body is suitable for viewing, allow the child/adolescent to see the deceased
Children’s worlds are sometimes disorganized and may have a high level of energy. Sometimes, loved one, if he or she asks to. Prepare the child/adolescent for what he or she
grief is also confusing. It does not always take a form that makes adults comfortable. Parents will see.
and caregivers should be informed that allowing your child to express feelings through cre- • Tell the child/adolescent what will be happening in the few days after a death.
ative play can be helpful (finger painting, clay molding, drawing, and other expressive arts). • Give the child/adolescent choices in what to do. Some children want to go to
The counselor or parents may want to join in the creative play. school or continue to work or engage in their normal social activities the day of
the death. Familiar routines are comforting.
Death conceptualization: 9-12 years
• Reassure the child that he or she will be cared for and explain the plan.
Among this age group:
• Majority of children realize death is the end of life and is permanent.
Counseling tasks and interventions
• Death is increasingly seen as a biological process.
• More conscious of the consequences of death, for example, they may wonder:
There are four key tasks that children work through as they mourn a loss: understanding,
”Malungkot kaya sya doon?”, ”Paano na ako pag wala na sina Mama at Papa?”
grieving, commemorating, and moving on. One of the first questions asked when a person
• Children 10 years of age show an interest in rituals such as huling lamay, libing and
has experienced a loss is ”Why?” During the task of understanding, a child or adolescent
other ceremonies associated with death.

60 61
seeks to determine what caused the loss and why it happened. The task of grieving means • ”I know just how you feel. (Alam ko kung ano ang nararamdaman mo, naranasan
allowing children and adolescents to experience the painful feelings associated with a loss. ko na yan.)”
In commemorating a loss, children and adolescents are encouraged to develop a personally • ”I know just how you feel… My dog died last year. (Alam ko kung ano ang nar-
meaningful way to affirm and remember the lost person or object. During the last task which aramdaman mo, namatay ang aso ko nung isang taon.)”
is moving on, children and adolescents discover new ways to ”maintain an inner connection
• ”Lick your wounds and move on. (Huwag mo na pahirapan ang sarili mo. Move
with and representation of the deceased as they develop other friendships, attend school,
na.)”
play, and perform all the things that shape their daily lives”.
• ”You’ll get over it. (Lilipas din yan.)”
Several interventions have been found to be useful in helping children and adolescents • ”It will be okay. (Okay lang yan.)”
tackle the tasks of mourning that they are faced with. Some interventions we have found to be • ”Don’t think about it. (Huwag mo na isipin yan.)”
effective with this population are the use of loss genograms; play therapy; narrative therapy, • ”You are better off without him. (Mas maganda nga na wala sya sa buhay mo.)”
such as a ”Letter to Loss”; art therapy, such as drawing a picture to show ”what happens when • ”Don’t cry. (Huwag kang umiyak.)”
someone dies”; or commemoration of the loved one or object through a CD, tape, journal, • ”It’s your fault. (Kasalanan mo kasi.)”
or scrapbook/photobook.
• ”You drove your father to drink. (Ikaw ang dahilan kaya uminom ang _______ mo.)”
• ”If only you had ___________________ . (Kung sana __________.)”
Appropriate communications • ”Tears won’t bring her back. (Hindi na maibabalik ng luha ang buhay nya.)”
• ”Be strong. (Magpakatatag ka.)”
Offering support to a grieving child or adolescent can begin with a simple statement or • ”Forget about it. (Kalimutan mo na yan.)”
open-ended question. Here are some conversation starters: • ”You are the man/woman of the house now. (Ikaw na ngayon ang haligi / ilaw ng
• ”Nakikiramay ako sa pagkawala ng iyong __________________.” tahanan ngayon.)”
• ”Ano ang naaalala mo sa kanya?” • ”You should feel… (proud, relieved, happy, sad, etc.). (Dapat nga __________ ka.)”
• ”Okay lang ba sa yo na kwentuhan mo ako tungkol sa kanya?”
Memory books/boxes: A tool for disclosure and grief counseling with children
• ”Ano ang paborito nyang pagkain?”
• ”Ano ang pinaka mami-miss mo sa kanya?”
Memory is a key component of identity, but as HIV and AIDS leave many children without
• ”Kung makakausap mo sya, ano ang gusto mong sabihin sa kanya?” parents, they lose this fundamental link to their roots. For children affected by HIV and AIDS,
• ”Hindi ko alam ang pinagdaraanan mo ngayon pero naalala ko ang pakiramdam metaphorical and literal memory boxes can create strong links in a chain of familial history
nung namatay ang ______ ko.” while easing the grief of losing a loved one. A memory book is a similar tool to preserve
• ”Pinahahalagahan ko ang nararamdaman mo. Nandito lang ako para sa yo. ” memories.
• ”Gusto mo bang pag-usapan natin ito?”
• ”Kung gusto mo ng kausap, nandito ako tuwing ____________.” When I am sad, I take out the things left to me by my mom and it makes me feel better…
I know she loved me, and I do not feel so alone.
• ”Tuwing gusto mong pag-usapan ito, nandito ako para sa iyo.”
• “Naaalala kita palagi, lalo na ngayong (state occasion) ni ________ .”
– Response of a 10-year-old orphan when asked about the memory box her mother left her
• ”Handang akong makinig kung gusto mong mag-usap, o kung gusto mo lang may on her death.
kasama, nandtio lang ako.
History of the memory book and memory box
The memory book/box was inspired by a group of HIV-positive women in some countries
Avoiding words that can hurt to help them disclose their HIV serostatus to their children, plan their funeral, sort out the
will, begin the process of grieving, and plan for the future with their children. This concept
The following are a few of the potentially harmful comments that are often offered to children has been adopted and revised in various settings to include memory books, memory boxes,
and adolescents grieving the loss of someone who is important to them. narrative therapy (telling the story), and art therapy.

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What is a memory book/box? Section 3: Understanding your own grief, bereavement, and mourning
A memory book is a written account of a family’s history. The pages are then inserted into The loss of a loved one is among the most intensely painful experiences a human being can
the memory book. Examples of headings are: suffer. Such a loss is painful not only for the mourner but for the counselor as well, especially
• ”Our family came from…”; if he or she feels unable to make a difference. Moreover, being with the bereaved may make
counselors aware of losses in their own lives. If counselors have not dealt adequately with
• ”Your grandparents’ names were…”;
their own losses, they may find it hard to help and relate to a client in mourning.
• ”These are some of the jobs our family did…”; and
• ”You walked when you were…” In addition to being reminded of their own past losses, many who work with the dying and
the bereaved may be haunted by the fear of losses yet to come–for example, of their own
Since a memory book is written, and some people have trouble writing, a memory box is children, parents, or spouses. Counselors are often unaware of their own fears of losing
sometimes easier to create. Memory boxes can be as simple or as ornate as one chooses loved ones. However, if the loss experienced by the bereaved client is similar to the one the
and may contain mementos, letters, diaries, photographs, documents, certificates, tapes, counselor fears most, then that fear can affect his or her ability to help the grieving client.
transcribed family history, and personal treasures, objects of sentimental value, and favour-
ite faith or spiritual passages. The counselor’s ability to help clients is affected not only by past loss and fear of future loss,
but by his or her own personal death awareness. By hearing of others’ losses every day,
counselors may be made aware of the inevitability of their own death. The situation can be
Why make a memory project? especially difficult when the bereaved person is of similar age, sex, or professional status.
Thus, people who work with the bereaved should explore the history of their own losses first.
Memory projects create space to discuss sickness and death and to cope with the loss of a Counselors should try to identify their own ways of coping and, if they have been successful,
loved one or news of HIV infection. These reminders can provide children with a sense of use those experiences to help clients. Similarly, it is beneficial for counselors to recall how
comfort and belonging for the rest of their lives. Developing a memory project can gently other people were helpful, and what kinds of things failed to help, or even hurt.
encourage parent(s) to write a will and discuss issues relating to disclosure of HIV status.
It can be helpful for counselors to examine the personal losses that have affected them
Memory projects help HIV-positive parents develop their communication skills. The proj- most, including the deaths of clients with whom they had a special bond. Counselors may
ects become a joint activity between parent and child where they sit together to tell the also have to go through a grieving process after a client’s death. By looking at their own
story of the child(ren) from birth to the present. Similarly, parents tell their own life stories. It experiences of loss and grief, counselors can become more aware of their own inherent
becomes easier for parents to disclose their HIV status to children as they gradually recount limitations. From this they may learn to ask colleagues for assistance. It is important that
special family memories and cultural history. This process also provides an opportunity for counselors share their own more recent losses with their counseling team, know where to
children to ask questions of parents and get clarifications. Sharing personal memories, get emotional support, know how to reach out when they need it, and understand their own
recording those memories, and storing them in a memory box helps family members break limitations.
the silence surrounding HIV and AIDS. In addition to helping family members communicate
with and understand each other, memory projects allow helpers (e.g., caretakers).
We cannot be an effective counselor if we do not deal with our own loss.

Young Key Affected Population (YKAP) children and adolescents and
special cautions
Counselors need to work carefully to address the grief and bereavement counseling needs
of YKAP. Too often adults take street toughness as a sign of a child’s or adolescent’s adjust-
ment to a death. Disordered mourning results from a lack of psychological processing of
normal grief reactions. Disordered mourning has been associated with suicide, increased
HIV transmission risk behaviour, increased drug or alcohol use, and accidental overdose.
Disordered mourning has also led to increased vulnerability to physical, emotional, and
sexual abuse among children or adolescents.

64 65
Counselor Self-Care
Field Test version only

6 Field Test version only
66 67
Chapter 6 Counselor self-care

The physical and emotional exhaustion associated with burnout causes individuals to cut
corners in their work (when they used to pride themselves on doing a thorough job). This
The potential impact of your work may result in guilt or shame. Other common warning signs are: physical inability to shake
off a lingering cold or fever, frequent headaches, or sleeplessness. Another telltale sign of
In the Philippines HIV counselors are faced with the challenge of working with highly mar- burnout is when the thought of going to work in the morning loses its appeal.
ginalized clients, often with limited resources. Many counselors have received only limited
training and work in contexts where counseling is a new concept. Frequently within health As burnout progresses, many experience changes in their outlook. This might involve de-
services counselors fail to encounter professional recognition and reward. Many newly veloping an attitude that pushes others away or being bitter towards one’s job. Emotional
trained counselors, often idealistic and enthusiastic, promise themselves that they will never and behavioural signs such as angry outbursts, obvious impatience or irritability, or treating
become like some of the more experienced counselors they have known – tired, cynical, others with apparent contempt are common. These often lead people to experience severely
frustrated individuals who no longer seem to care about what they do and who have lost negative feelings towards themselves, others, or, in extreme cases, all of humanity. Intense
their compassion. It is difficult for these new counselors to imagine that the burned-out loneliness and alienation are characteristics of the end stages of burnout, as one’s coping
counselors were once idealistic as well. structure and psychological defences wear down. A slight emotional bump can set off an
overly sensitive and personal reaction. Frequent mood swings with short highs and long
lows might also occur.
Counselors never start out in this profession planning for the days when work no longer
seems vibrant and exciting. It is therefore important to discuss burnout during training. An-
ticipating the predictable stresses and strains of HTC and the toll it can take on one’s physi- Thinking about burnout as the culmination of a series of stages may make it easier to rec-
cal and emotional health allows counselors to take steps to minimize these negative effects. ognize. Symptoms associated with the three stages of burnout – stress arousal, energy
conservation, and exhaustion – are listed below.
Stage 1: Stress arousal (includes any two of the following symptoms)

Stress and Burnout
• persistent irritability; • forgetfulness;
Stress can be defined as anything that stimulates • persistent anxiety; • heart palpitations;
an individual and increases his or her level of alert- • periods of high blood pressure; • unusual heart rhythms (skipped beats);
ness. Life without stress would be incredibly dull and • teeth grinding at night; • inability to concentrate; and
boring; on the other hand, life with too much stress • insomnia; • headaches.
becomes unpleasant and tiring, and may ultimately
damage health and well-being. Too much stress interferes with work performance. Stress If any two of these symptoms are present, you may be experiencing stage 1 of the burnout
often originates from an external event or circumstance that places a demand on an indi- cycle.
vidual’s inner or external resources. How stressful an event is experienced depends partly
upon the individual’s resources. If the demands on the person (e.g., disclosing an HIV-pos- Stage 2: Energy conservation (includes any two of the following symptoms)
itive test result) exceed his or her ability to cope with them, the person experiences stress.
• lateness for work; • social withdrawal (from friends or family);
Burnout generally refers to a state of mental/physical exhaustion caused by excessive and
• procrastination; • cynical attitudes;
prolonged stress. It is a gradual process by which a person, in response to prolonged
stress and physical, mental, and emotional strain, detaches from work and other meaning- • needed three-day weekends; • resentfulness;
ful relationships. The result is lowered productivity, cynicism, confusion, and a feeling of • decreased sexual desire; • increased coffee/tea/cola consumption;
being drained, or having nothing more to give. Burnout has been described as a ”physical, • persistent tiredness in the morning • increased alcohol consumption; and
emotional, psychological, and spiritual phenomenon; an experience of personal fatigue, • habit of turning in work late; • apathy.
alienation, and failure”. It has also been described, with respect to those in the helping and
care professions, as a ”progressive loss of idealism, energy, and purpose”. The term burn-
out evokes an image of a fire going out or the ashes left over. Any two of the above symptoms may signal stage 2 of the burnout cycle.
Stages of burnout

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Recognizing that you are not immune Recognizing burnout

Almost anyone can experience burnout. Burnout cuts across demographic characteristics,
Counselors can recognize burnout by its physical, behavioural, and/or cognitive symp-
affecting people regardless of age, length of time on the job, marital status, number of
toms, including those listed in the table below.
dependents, or the number of hours worked each week. However, some people may be
more likely to experience burnout than others. For example:
The visible effects of burnout in HIV counseling are high turnover, absenteeism, declining
• highly committed individuals who hold high expectations of themselves; quality of service, decreasing communication, disorganization, declining enthusiasm, and
• frontline workers (more than those ”behind the scenes”) – for example, nurses are increasing client complaints.
more likely to suffer from burnout that physicians; and
• Ensure that there is an opportunity for individual, peer, or group supervision or
• counselors dealing with difficult issues such as HIV.
counseling for counselors (if available).
• refusal to communicate;
People suffering from burnout may progressively feel a lack of personal accomplishment in • purposeless movements, pacing, restlessness/psychomotor agitation;
their work. There is also evidence that clients can identify a counselor suffering from burn- • intimidating behaviour/threats or gestures;
out. It has been documented that clients become dissatisfied and tend to be more critical of
• attacks on property; and
the ”burned out” counselor’s actions and interventions.
• direct threats/reports of violent/homicidal ideation or
Are you at risk of burnout? Take some time to complete the questionnaire in Annex A of
this handbook. Managing verbal de-escalation and distraction
Causes, or the stresses and strains, of counselor burnout • Clients will often settle down if time is spent calmly discussing their concerns and
if offered suitable support.
Counselor burnout can be caused by a number of factors. These stresses and strains are • If the client is standing and yelling at you, calmly ask the client to sit and do not
enumerated below, not to alarm, but to create awareness of the realistic stresses and strains
respond until the client sits with you. Offer the client time to state his or her con-
that a counselor might face. These include:
cerns.
• a strong sense of commitment; • If the client remains standing up then stand slightly to his or her side, calmly ask-
• job stress; ing the client to sit with you. Keep repeating this request and do not respond to
• lack of adequate support; any aggressive verbalization.
• isolation and alienation; • Focus on the here and now, and do not delve into long-term grievances or issues,
• fear of HIV infection; or to irrelevant complaints. React in a non-judgemental way, in a lowered voice,
• ostracism and stigma; and with relaxed body posture, explaining your desire to help sort out the client’s
• excessive work; current difficulties.
• increasing responsibilities; • Attempt to ascertain the cause of the violent behaviour. Try to calm the client
• diminishing resources; by responding calmly and evenly. Do not become aggressive or threatening in
• political pressures; response.
• client-related issues (e.g., how to inform clients or their partners of test results, • Courtesies, such as offering a cup of tea (lukewarm!), a sandwich, or access to a
especially if they are HIV-positive or a discordant couple or a couple refusing to be phone, attending to physical needs, providing an opportunity to rest, can be very
separated; conflict between counseling and giving advice; conflict between en- helpful, as is regular orientation to place/person/situation.
couraging a client and giving false hope; the counselor’s own emotions surrounding • Getting relatives or trusted staff to talk with the client may help.
HIV); and • Encourage the client to choose help such as agreeing to talk to a mental health
• boredom—day after day and year after year clients enter a counselor’s office and professional or, where necessary, accepting medication voluntarily if you have
tell their stories, ask similar questions, and expect the counselor to do essentially a prescribing medical practitioner available (e.g., ”It seems to me things are a
the same thing;

70 71
bit out of control. Will you let us help you? This medication will help calm things Managing time
down”).
• If aggression escalates and violence seems imminent, withdraw from the patient Counselors can better manage their time by working more efficiently, rather than hard-
er. A range of skills might help in time management: assessing value and use of time;
and mobilize help. If trapped, a submissive posture with eyes averted, hands down
setting goals and routines; creating more time; managing and avoiding distractions;
and palms towards patient may help. If all else fails, lift arms to protect head and
increasing productivity and personal effectiveness; and choosing priorities. For effective
neck, shout ”NO” very loudly, and try to escape. time management, it is important to learn to say no, plan projects or duties so they are
done properly with adequate resources, do one thing at a time, and break down large
If further intervention (such as medication) is required, having a number of staff backing up the tasks into manageable components.
nominated clinician speaking to the patient (sometimes known as a show of force) may facili-
tate the client’s cooperation. One person should lead the staff and negotiate with the client.
Changing the way one thinks
Stress management and preventing burnout
Sources of stress can sometimes be recast or neu-
Stress management refers to efforts to control or reduce the tension felt when a situation is tralized by transforming negatives into positives.
perceived to be especially difficult or beyond one’s resources. Heavy demand and high per- For example, if counselors experience significant
formance is expected of HTS. There are several strategies for coping with stress and burnout. stress from other people, or realize they are not
The techniques selected by counselors will depend on the cause of the stress and burnout in control of their life, they can eliminate nega-
and the situation in which stress occurs. Thus, counselors should ask themselves where the tive feelings by having a more positive outlook, keeping things in perspective, setting
stress is coming from. For example, if important events and relationship difficulties are causing personal goals, welcoming changes, or recognizing and changing irrational beliefs. It is
stress, a positive-thinking or imagery-based technique (changing the way we think) may be important to avoid generalizing, focusing on unimportant details, jumping to conclusions,
useful. Where stress and fatigue are long-term, lifestyle and organizational changes (adopting ”making mountains out of molehills”, and taking things too personally. In addition to
a healthy lifestyle and time management) positive thinking, counselors can employ an imagery method. With imagery, a person
may be appropriate. If feelings of stress come from within (caused by anxiety, worries about substitutes actual experience with scenes from his or her imagination. The body will react
client results, issues beyond their control, or anxiety based on their own behaviour), relaxation to the imagined scenes almost as if they were real. Imagining pleasant scenes can reduce
techniques might be more appropriate. stress.
Employing relaxation techniques

Adopting a healthy lifestyle
Relaxation techniques are often effective in managing stress when stress appears to be
Counselors can care for themselves by talking to others coming from within. Meditation helps one feel peaceful, relaxing the body and clearing
(friends, family members, colleagues, supervisors) about their the mind of stressful thoughts. Concentrating on one thing for an extended period (pos-
stress and asking for help when needed. They can try physi- sibly 20-30 minutes) helps achieve the desired effect. The focus of one’s concentration
cal exercise or recreation, avoid smoking, drink alcohol only might be breathing, an object, a sound, or an imagined scene. Progressive muscular re-
in moderate quantities, adopt an adequate sleep routine, and laxation and deep breathing are purely physical techniques for relaxing tense muscles and
eat balanced and regular meals. They can either withdraw or confront the stressful situa- calming stress. They can be used in conjunction with mental techniques such as imagery
tion, directly targeting a mood change and shifting the focus from counseling exclusively (by or meditation.
broadening their focus, interests, and activities). Counselors should try to get plenty of rest.
A common stress reaction is for people to bury themselves in work or activity. This can be
self-defeating physically and mentally. If sleep is interrupted, the counselor should get up and Setting boundaries between personal and professional lives
replenish himself or herself by having a glass of orange juice or milk, eating, reading, talking,
or writing about pressing feelings. After a while the counselor should return to bed. It is critical that counselors maintain boundaries between their professional and home
lives. Counselors should regulate the balance between their work life and personal life
so that work does not consume all of their time. Some counselors may find it easier to
maintain the boundaries by avoiding work-oriented social networks. It is also helpful to

72 73
develop a decompression routine, a ritual that signals one part of life is ending and another
part is beginning (the work day is ending and the personal life is beginning). These routines Annex A Burnout Risk Survey
help counselors diffuse emotional energy from work and enter their personal lives in a re-
laxed manner. The questions in the survey do not predict burnout, but might help identify individuals
at risk of burnout. For example, answering ”yes” to three of the questions indicates risk;
answering ”yes” to more than four questions suggests high risk. The same items can be
used to identify corrective actions and hence prevent burnout.
Finally…
HIV counseling will expose you to many situations that are hard to deal with. It is important Questions Yes No
that you know yourself, and are able to respond to some of the situations or events that Do you derive your self-esteem from achievements?
you will face as a counselor. This may mean identifying issues that you have trouble dealing
with yourself. No counselor is perfect and each has his or her own personal experiences and Is your personal identity tied to your work role or
professional identity?
beliefs, which result in specific reactions to certain situations and issues. Some of these may
involve past experiences with sexual assault, domestic violence, or even beliefs about sex- Do you tend to withdraw from offers of support?
uality. Even with extensive training and the use of the techniques outlined in this handbook Do you hesitate to ask for or accept help?
and other publications, it is not uncommon to find that some issues still make us react in an Do you always make excuses, like ”it is faster to do it myself
uncontrollable manner. This can evoke feelings of vulnerability, anger, or fear. than to show or tell someone”?
“It’s not stress that kills us, it is our reaction to it.” Do you always prefer to work alone?
- Hans Selye Do you lack a close confidant with whom you feel safe
discussing problems?
When you find yourself with a client who needs to discuss such issues, it is important for you Do you ”externalize” blame (obsessively seek to place
to be honest and ask yourself, Can I provide this client with the advice and services that he blame away from yourself)?
or she needs? If the situation allows it (if another counselor is available), then you should not
Are your work relationships asymmetrical?
feel guilty telling the client that you would like him or her to speak with another counselor. Are you always giving?
Do not do this in a manner that will make the client feel uneasy or embarrassed; rather, you
may want to be honest and say that you have personal reasons for not being able to discuss Do you have more difficulty making a commitment to yourself
to exercise or relax than making a commitment to others?
these issues with him or her. You are not confident that you would be able to focus on them,
and their needs. If the situation does not allow for another counselor to come in, then you Do you overload yourself or have difficulty saying no?
may want to ask the client to wait for you, and you can step outside and try to organize your
Do you have few opportunities for positive and timely
thoughts before going back in. It is not a sign of a bad counselor to acknowledge limita- feedback outside your work role?
tions. Rather, it will help you minimize undue stress to do a better job

For queries, comments and suggestions for the improvement of this reference material,
kindly inform Dr. Jose Gerard B. Belimac, Program Manager of the National HIV, AIDS, and
STI Prevention and Control Program, at [email protected].

Philippine Handbook HIV Counseling Testing Handbook Section One

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PHILIPPINE HANDBOOK

HIV Master Counselors HIV Counseling Trainers

Chapter 1 The Immune System

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Needle Stick 0.3 %

Unprotected vaginal intercourse

Unprotected vaginal intercourse

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Overall without breastfeeding 20 - 25% 0%* 0%*

Overall with breastfeeding up to 6mos 25 - 30% 1.08%** 1.08%**

Overall with breastfeeding up to 12mos 30 - 35% 11%* 2%*

Overall with breastfeeding up to

The window period

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Adults and Adolescents Children

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Table 1.4 Type of sexually transmitted infections according to etiology

Other Sexually Transmitted Infections

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STI Core Messages

STI and its link to HIV

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Post-HIV test counseling Treatment adherence counseling

• The client should be capable of understanding what he or she is told (capability is

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PLHIV can seek assistance for legal cases involving

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Consent Establishing rapport

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Showing respect Showing empathy

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e.g. “What difficulties do you experience in practicing safer sex?”

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• The counselor’s body language–the gestures, facial expressions, intonation,

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Chapter 4 HIV-related behavior-change counseling

To change behavior, the individual needs to:

• identify the behavior as harmful;

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Strategies for the action and maintenance phases

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Developing an action plan with a timeline

Making a provisional try (an initial attempt at behavior change)

Most relapse prevention plans call attention Preveting Relapse Strategies

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The stages of grief Working with grief

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Experience of Loss Among Young Key Affected Populations

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Death conceptualization: 5-9 years. At this age: Death conceptualization: Adolescents

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History of the memory book and memory box

Overall with breastfeeding up to 6mos 25 - 30% 1.08% 1.08%