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SPECIFIC
COUNSELING ISSUES
People
infected and affected by HIV come from varying backgrounds and living
situations. In dealing with people who are alienated from society,
have special needs that "mainstream" health care addresses poorly
or lack influence owing to poverty, low self-esteem or other reasons,
physicians must be flexible and sensitive to each person's unique
circumstances.
Ethnic communities
Be
sensitive to cultural issues that may affect vulnerability to HIV
infection and understanding of the HIV epidemic, including:
- Different interpretations
of medicine, illness, sexuality, death, shame and reputation,
- Monogamy, homosexuality,
bisexuality, commercial sex, alcohol and drug use
- Cultural beliefs about
AIDS and HIV infection
- Disparity in male-female
roles.
Street-involved
people
Young
people and adults who spend time on the street are often confronted
with difficulties that place them at high risk for HIV infection.
They may use drugs; exchange sex for money, drugs, shelter or food;
and feel rejected. They may often be non-compliant with medical
care until trust is established with a physician. Being identified
as HIV-positive may place these people at risk of physical violence.
Adolescents
Assess
cognitive and emotional development of an adolescent; it may not
be in step with his or her physical development or chronological
age. Normal adolescent rebellion against parental and societal norms
may include both sexual and drug exploration; education and preventive
counselling on these issues are needed. Explore local support systems
for adolescents. Gay and bisexual adolescents may have difficulty
in disclosing their sexual orientation; physicians must provide
a safe, non-judgmental atmosphere in which these issues can be discussed.
Commercial sex
workers
The
personal life and sexual behaviour of those who trade sex for money
(men, women and children) are often quite distinct from their "working"
identity; physicians should inquire about both. Some patients are
more vulnerable to exploitation and HIV infection because of past
or ongoing history of physical or sexual abuse, drug use and social
isolation. Injecting drugs and drug dependence may undermine the
patient's ability to protect him- or herself and others against
HIV.
Provide
ongoing education about safer sex and safer drug use, including
how to deal with partners who refuse to implement risk-reduction
strategies.
Men who have
sex with men
Some
men who have sex with men do not identify themselves as either gay
or bisexual. Be sensitive to the fact that many gay or bisexual
men may be hostile or distrustful because of previous encounters
with homophobic health care professionals.
Prisoners
Risk-producing
activities, such as unprotected sex, sexual assault and sharing
of drug-injecting equipment, may occur in correctional facilities.
Discuss behaviours openly with recognition that the inmate, parolee
or previously incarcerated person may fear retribution for his or
her frankness. Appropriate print material can be obtained from the
National AIDS Clearinghouse to support counseling. Physicians working
with inmates should be particularly aware of a need for confidentiality
in a setting that tends to deny privacy. Knowing institutional requirements
for disclosure of a positive test for HIV before counseling inmates
on testing is essential.
Psychiatric
patients and the mentally challenged
Those
whose insight, impulse control or capacity to perceive risk is impaired
by psychiatric or neurological disorders are at increased risk of
acquiring and transmitting HIV. These people may also be poor or
marginalized, lack basic sex education, have multiple diagnoses
and have a history of past or ongoing sexual abuse.
In
counseling such people, use audiovisual material and identify any
underlying thought process or cognitive distortion that could interfere
with risk-reduction strategies.
Emerging issues:
Rapid, simple
testing for HIV
New
methods for testing for the presence of HIV provide a patient with
a definite negative or preliminary positive result in 10 minutes
or less. Rapid, simple testing for HIV may have advantages over
current protocols in specific settings, such as remote areas, developing
countries or outreach test sites.
The
advent of these tests, which do not require complex laboratory equipment
or advanced technical training to perform, raises significant scientific,
technical, epidemiological, cost and ethical issues.
The
use of these tests would affect the content of counseling information
provided. As a result, their introduction will have to be accompanied
by changes to counseling guidelines. However, it would not, in any
way, abbreviate counseling protocols.
The
introduction of rapid, simple testing does not decrease the need
for quality assurance in the testing methods and the training of
those carrying out counseling and testing.
Continuing unsafe
behaviour
An
ethical dilemma arises when a physician knows that an HIV-positive
person is exposing drug-using or sexual partners through risk-producing
behaviour. Fortunately, continuing unsafe behaviour among people
with HIV is not frequently encountered. The physician should intervene
to motivate the patient to disclose or stop unsafe behaviours. The
following steps should be taken in order:
- Counsel the patient by
exploring impediments to risk-reduction strategies. These may
include partner's refusal to use condoms, inaccurate information
about risks for HIV infection, poor social or economic living
situation, psychological or emotional state, or fear of disclosure
to partner(s).
- Inform the patient of the
physician's ethical requirement to safeguard others.
- Report the situation to
public health authorities.
Patients who
do not return for test results
Controversy
exists as to what steps should be taken if a patient does not return
for results of tests for HIV. Seek consultation from an expert colleague
in the field of HIV infection to determine the most effective intervention
for such people.
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