Risk assessment and symptoms assessment

Untitled Document

• Expectations

• Sexual History

• Risk Assessment

• Partner Notification

• Safe Sex

• Ongoing Counseling

• HIV Counseling

• Psychological

• Nutritional

• Bereavement

• Women & Child

• Specific Issues

RISK ASSESSMENT

Assessment of STI/HIV risk ( View Image)

Partner change/multiple partners
Types of sexual activity
Condom usage
Context of risk taking (drugs, alcohol, holidays in high STI prevalence countries, anonymous sex etc)
Previous STI ("have you ever had a sexually transmitted disease of any kind?")
Partner risk behaviours ("have you ever felt that a sex partner put you at risk for any reason" OR "do you think your partner is at risk for STI or HIV infection?")
History of STI in partner
Abuse or rape
Symptom review
Dysuria
Sores, lesions
Discharge (vagina, penis, rectum)
Pruritis/burning
Abdominal/pelvic pain
Abnormal bleeding
Skin rash
Testicular pain/swelling
Rectal pain
Rectal discharge
Swollen lymph glands

Sexual history

May include questions on:
Sexual development
Sexual preference
Sexual habits
History of abuse or rape

Suggestions for specific questions

Some practitioners find it useful to develop a couple of initial questions: such as:
When did you last have sex?; then
Who was it with - someone you know well, or someone pretty casual?

Try to keep it low key. Adapt to the cues you get from the patient in response to your initial questions. Try not to appear to be working through a list of questions, but slip some sexual history questions in throughout the course of the consultation (or indeed during the examination) in between other more standard medical type questions. If you don't get much of a response, you can always back off for a bit and resume the standard medical history then come back for a later try! Always ask men (even the most apparently obvious heterosexual man) about sex with men. Casually slip in a question such as 'By the way, have you ever had sex with another guy?'

Questions may include:

Have you begun having any kind of sex yet?
Have you ever had any sexually transmitted disease?
How old were you the first time you voluntarily had sex?
Had you had sex with men, women, both?
How many sex partners have you had in the past 3 months? 12 months?
How many days since you last had sex with your regular partner?
How many days since you last had sex with a casual partner?
Did you use a condom the last time you had sex with your regular partner?
Did you use a condom the last time you had sex with someone who is not a regular partner?
Do you always use a condom (regular partner, casual partner/s)?
Have you ever exchanged sex for money or drugs?
Have you ever injected yourself with drugs?
Have you ever had sex with someone who had ever injected drugs?
Have you ever had sex with a gay or bisexual man?
Have you had a blood transfusion?
Sex practices: what parts of your body may have been exposed to an STI?
Penis/anus/mouth/vagina/rectum?
Tell me a bit about your partner.
How long have you been together?
How's your partner's health?
Does he/she have and of the sort of symptoms you've been having?
Do you know if he/she has ever had an STI?
What does your partner do? Does he/she travel much?
Do you think your partner is at risk of STI?
Do you think your sex partner has other partners besides you?
Do you think your sex partner has exchanged sex for money or drugs?

Other relevant history

Medical history
Gynecological or prostate surgery
Obstetric history
Psychiatric history (especially anxiety and depression)
Prescribed drugs
Alcohol consumption, use of other drugs

Conducting an Individualized Risk Assessment

Provide the following information:

Client-centered HIV counseling is distinguished by the development of a personalized risk reduction plan for each client. In order to create this plan, the client's individual risk situation must be assessed. This risk assessment includes gathering information about the participant's sexual and other risk behavior as well as their emotional, interpersonal, social and resource situation. The counselor may initiate the assessment by asking the client what he or she knows about the ways in which HIV can be transmitted. Readiness to change risk behavior and perceived self-efficacy (ability) to change risk behavior are also assessed.

Risk Assessment Questions

Ask the counselors to generate a list of all the questions they might ask a client in the process of conducting an individualized risk assessment. List the questions on the chalkboard or on poster paper. Be sure that the list of questions includes questions about behavior as well as questions about the client's emotional state, resources and readiness to change. Note that open-ended questions ('Tell me more about the sexual relationships you are having now') are generally more productive then closed-ended questions ('How many sexual partners do you have?') for eliciting detailed information and for showing interest without judgment. It may be useful to categorize questions as they are listed by the group as questions about emotions, behavior, social support/peer norms, previous behavior change efforts and questions about the client's environment (finances, living situation, job situation, etc.).

Risk Assessment Role-Play

After the counselors have exhausted the list of potential questions, ask for a volunteer to be the client and a volunteer to be the counselor. Ask the 'client' to assume the role of a client they have worked with in the past, and to be interviewed by the counselor for the purpose of assessing risk. Allow the counselors to take turns interviewing this 'client', encouraging each to build on what the was asked by the previous counselor. Keep each counselor's interaction with the 'client' short (a few minutes). When counselors have had a chance to interview the client, start the discussion by asking the client to report on their experience of being interviewed. Next, engage the entire group in a discussion of the client's risk assessment, challenging the group to summarize this client's risk for HIV.

Discussion Questions:

What are this client's HIV-related risk behaviors? Which are most likely to put him or her at risk for HIV infection or for infecting others with HIV?

Does the client have any resource limitations that might hinder his or her efforts at behavior change?

Does the client have any resources (human, psychological, environmental) that might help him or her to change risk behavior?

As the counselor, what was your experience of asking the client questions about their risk behavior? Were some types of questions easier or more difficult than other types of questions?

[Note: Exercise should be repeated as time and interest allow, giving different counselors the opportunity to role-play a particular client and in that role to give other counselors feedback about their interview questions and style. From this exercise the counselor trainer/supervisor should choose several client stories to be used in the next exercise].

Developing an Individualized Risk Reduction Plan

Provide the following information for discussion:

After the risk assessment is completed, the counselor asks the participant to propose some ideas about how to reduce their own risk for exposure to HIV. At this point the counselor may initiate the discussion of risk reduction by listing several alternative risk reduction strategies for the participant to consider. For each risk reduction behavior, the counselor assesses internal and external barriers to change, perceived efficacy to enact the new behavior, readiness to change and the availability of resources to change. In supporting the participant's enactment of the personalized risk reduction plan, the counselor will acknowledge and support the client's strengths (e.g. social support, self-efficacy, previous success in changing behavior) and offer problem solving in areas of concern or expected difficulty in enacting the plan. If condom use is part of the risk reduction plan, the counselor asks the client to tell what they know about condoms and invites the client to practice putting a condom on the penis model before the counselor conducts a condom demonstration. If the client does not mention condoms, the counselor may introduce this topic as information that is useful to have whether or not the client is planning to use condoms now.

Finally, the counselor elicits a commitment from the client to make specific behavior changes before the next counseling session. The risk reduction plan should be challenging, but not so difficult that the client will fail to complete it or become frustrated. It can be useful to provide several goals, some that are easy to attain and some that are more difficult to attain. It can be useful to break the new behavior into steps and encourage the client to change his or her behavior one step at time. If the client can read and is not concerned about the privacy of this information, the risk reduction plan may be written and given to the participant to take home.

Risk Reduction Plan

Using client descriptions from Exercice, resume practice with the purpose of developing an individualized risk reduction plan for each client. The counselor's task is to ask the client how he or she would like to reduce their risk, listen without judgment to the client's plan, provide feedback on the client's plan in the form of additional information, and suggest additional or alternative risk reduction plans (if appropriate). Allow the counselors to take turns interviewing each client, encouraging each to build on progress by the previous counselor. Keep each counselor's interaction with the client short (a few minutes). When each counselor has had a chance to interview the client, start the discussion by asking the client to report on their experience of developing a risk reduction plan.

Next, engage the entire group in a discussion of the client's risk reduction plan, challenging the group to critique the plan and to assess the likelihood that the client will succeed in changing his behavior and that this behavior change will indeed reduce the client's risk to become infected or to infect a partner with HIV.

[Note: Exercise may be repeated as time and interest allow. The trainer may also take this opportunity to provide feedback to the counselors regarding their basic counseling skills, non-verbal communication and HIV/AIDS knowledge as appropriate].