Review of issues surrounding HIV/AIDS counselling in Nigeria

Conceptual framework on HIV counselling

According to Iyanwura and Oloyede (2011), HIV counselling is referred to an interactive section on HIV/AIDS anchored by qualified professional usually before a HIV test is carried out. They identified counselling in HIV/AIDS as a core element in a holistic model of health care, in which psychological issues are recognised as integral to patient management.

Aniebue and Aniebue (2011) stated that HIV/AIDS counselling is geared towards the prevention of HIV transmission and support of those affected directly and indirectly by HIV. In their opinion, it is vital that HIV counselling should have these dual aims because the spread of HIV can be prevented by changes in behaviour resulting from an effective counselling section.

Daniyam and Agada (2010) are of the opinion that one to one prevention counselling enables frank discussion of sensitive aspects of a patient’s life which may be hampered in other settings by the patient’s concern for confidentiality or anxiety about a judgmental response. Also, when patients know that they have HIV infection or disease, they may suffer great psychosocial and psychological stresses through a fear of rejection, social stigma, disease progression, and the uncertainties associated with future management of HIV. Good clinical management requires that such issues be managed with consistency and professionalism, and counselling can both minimise morbidity and reduce its occurrence. Based on this, Abebe (2014) suggested that all counsellors should have formal counselling training and receive regular clinical supervision as part of adherence to good standards of clinical practice.

Type of HIV/AIDS counselling

HIV/AIDS counselling comes in different forms depending on the situation and the person being counselled. Some of the types of HIV/AIDS counselling include:

  • HIV prevention counselling
  • Pretest counselling
  • Post-HIV test counselling
  • Ongoing counselling for people affected by HIV
  • Treatment adherence counselling

HIV prevention counselling

In HIV prevention counselling, the counsellor assists infected and uninfected clients in identifying and exploring the difficulties involved in reducing transmission risk behaviour. Counsellors may use a variety of strategies ranging from the simple provision of information to the more therapeutic evidence-based strategies that can include motivational interviewing, structured problem solving, interpersonal and brief psychotherapy for risk reduction, cognitive behavioural therapies, relationship counselling, and infant-feeding counselling (Oshi, Ezugwu, Dimkpa, Korie & Okperi, 2013).

According to Daniyam and Agada (2010), prevention counselling is employed in pre-HIV test and post-HIV test counselling and in counselling across the disease continuum. It is recognized that it is difficult for clients to sustain changes in behaviour over extended periods of time. When providing counselling across the disease continuum, counsellors must continually assess the challenges that will face their clients as they strive to maintain behaviour changes, and provide practical strategies that can help address these challenges. To change behaviour in the context of drug or alcohol dependency, for example, counsellors must assess whether the client is dependent (addicted) and whether he or she can implement harm reduction and substance dependency management strategies

Pretest counselling

Pretest counselling is confidential counselling that will enable an individual to make an informed choice about being tested for HIV. According to World Health Organisation (WHO) (2012), this decision must be left entirely to the individual and must be free of coercion. To make an informed choice about testing, an individual needs to consider the potential benefits and risks associated with testing. His or her personal risk history must also be considered. The counsellor supports the client in managing the potential risks and difficulties by considering the possible psychosocial, legal, and health implications of knowing the client’s serostatus. The counsellor also assesses the client’s capacity to cope with the possibility of a positive HIV antibody test, provides information on HIV, and engages in prevention counselling, mainly to reduce transmission risk behaviour and thereby reduce the risk of HIV transmission

Aniebue and Aniebue (2011) stated that while individual one-to-one counselling offers the best standard of support to clients, alternative models of providing pre-HIV test information are also available. Pre-HIV test counselling may be offered to couples. In some situations where there are many clients or where the HIV test is offered as part of provider-initiated testing and counselling(PITC) and opportunities for one-on-one counselling are limited (because of time or human resource constraints), group pretest information may be offered. Information can be given in a group, but the informed consent component must always take place in a one-on-one setting to ensure that the patient’s choice is autonomous and not coerced.

Post-HIV test counselling

Post-test counselling is done primarily to ensure that individuals understand the meaning and implications of their test results. If the client tests positive for HIV antibodies, post-test counselling must make it easier for him or her to adapt to life with HIV and STI infection. Suicide presents a significant challenge to counsellors. There are two periods when people with HIV are more likely to attempt suicide. When the person is first diagnosed, suicide may occur as an impulsive response to the emotional turmoil that follows (Ikechebelu, Udigwe & Imoh, 2014).

The second period of high risk occurs late in the course of the disease when complications of the nervous system resulting from AIDS develop, capacity to earn income declines, and people feel they are a burdento family members and carers. Consequently, after the diagnosis counsellors are required to conduct suicide risk assessments and to manage suicidal thoughts throughout the course of illness. Post-HIV test counselling is typically provided by the counsellor who conducted the pretest counselling. However, a counsellor may have to provide counselling to an individual who was tested without his or her knowledge and consent (Ikechebelu et al., 2014).

Ongoing counselling for people affected by HIV

The chronic and progressive natural history of HIV infection means that the psychosocial issues confronting both infected and affected individuals change throughout the course of the illness. In addition to issues directly related to HIV, patients may present with a range of psychosocial problems that are pre-morbid or only indirectly related to HIV.

For many, becoming infected with HIV reactivates previously unresolved issues such as acceptance of sexual orientation, specific traumatic events such as sexual assault, or unresolved relationship problems. Infected and affected individuals may also need practical assistance such as referral to welfare services, liaison with caregivers, the preparation of wills, and the organization of substitute care for children (Onyeonoro, 2011).

Treatment adherence counselling

WUsu and Okoukoni (2011) identified the fact that HIV patients are confronted with many difficulties when required to take medication. Those taking medication for HIV, TB, STI, or hepatitis in particular must deal with many psychological, physical, and practical barriers to treatment adherence. Non-adherence can lead to inadequate suppression of bacteria and, in the case of HIV, viral replication. Counselling for treatment is provided to improve the patient’s knowledge of both the disease and the medications and their side-effects. Counselling helps the patient set goals, develop positive beliefs and perceptions, and increase self-efficacy in maintaining treatment.

Elements of ethical and effective HIV/AIDS counselling

According to the Federal Ministry of Health (FMOH) (2012), effective counselling has several agreed elements such as:

  • Ample time: Providing the client with adequate time is important from the very beginning. The counselling process cannot be rushed. It takes time to build a supportive relationship.
  • Acceptance: Counsellors should not be judgemental of clients. Rather they should try to accept clients, regardless of socioeconomic, ethnic, or religious background; occupation; sexual orientation; gender identification; and drug or alcohol use.
  • Accessibility: Clients need to feel they can ask for help at any time. Counsellors need to be available to clients at appropriate times and should have systems in place to respond to clients’ needs as appropriate (e.g., provide services after hours or work during lunchtime on a rotating system). It is important that counsellors maintain appropriate boundaries in their after-hours contact with clients. They must also maintain appropriate professional distance (e.g., counsellors should not provide their home contact information to clients), and should not enter into non-professional relationships with their clients, especially sexual relationships.
  • Consent: Clients must be given an opportunity to consent to or decline HIV testing, treatments, or procedures in an informed and voluntary manner. Counsellors facilitate the informed decision-making of their clients by offering clear and accurate information, and assisting clients in weighing the perceived benefits and risks of each intervention offered.
  • Consistency and accuracy: Information provided through counselling (e.g., about HIV infection, infant-feeding options, infection risk, risk reduction, and treatments) should be consistent with recognized scientific research and national HIV guidelines.
  • Confidentiality: Trust is the most important factor in the counsellor-client relationship. It enhances the relationship 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 with HIV may have to face, it is all the more important to guarantee confidentiality. Where the counsellor 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.
  • Sociocultural considerations: Effective and ethical counselling must recognize the impact of culture on a client’s perception of the world. Counsellors should take a holistic view of clients and their sociocultural background, including beliefs about HIV, sexual mores, traditional healing practices, gender inequalities, marriage practices (e.g., monogamy, polygamy), customs, and social practices. Counsellors should keep in mind that culture and tradition shape attitudes and beliefs, particularly regarding illness and death. Thus, they should be sensitive to and respect cultural differences. A counsellor should refer clients to another counsellor if differences of gender, race, ethnicity, religion, sexual orientation, disability, or socioeconomic status interfere in any way with counselling

Importance of HIV/AID counselling

From the minute a person decides to take the HIV test, a counsellor’s role begins. Their job, however, does not stop at telling someone about the results of the test. FMOH (2012) stated that counselling is important before, during and after tests are done by stressing that counselling helps patients accept their status.  The counsellors are the ones the patients consult with about their fears, their dreams and their expectations of their status. They are the ones who help the patient through HIV testing and treatment.  The counsellors give their patients and the confidence to live positively and to become strong within themselves when the disease and medicine might make them feel weak.

Before HIV testing, one-on-one talk with the counsellors about the expectations of the patient about the test, whether they think they are positive or negative, and what they plan on doing in both situations helps the counsellor to have a fore knowledge on the perception of the patient and how to effective manage the outcome of the test result (Sebudde & Nangedo, 2013). After that, the counsellor observes the client and their training gives them proper knowledge about how to tell with everyone’s different type of coping.  After being diagnosed with HIV, persons can be referred to a clinic where they are counselled and started on antiretrovirals (ARVs) drug if they qualify. Oshi et  al. (2013) stated that effective counselling assist patients to adhere to HIV management procedures by encouraging patient to take their drugs according to specifications.

Problems of HIV/AIDS counselling in Nigeria

In Nigeria, there are several factors that may limit what the counsellor can do. This include ethical, legal, psychological and social issues that are challenging and at times frustrating to the counsellor involved in HIV/AIDS counselling. There are fundamental problems in ensuring privacy and confidentiality.

Iyaniwura and Oloyede (2011) stated that the Nigerian culture accepts that everyone in the neighbourhood takes an interest in what is happening in the lives of their neighbours. As positive as this may be at other times, it has been a hindrance in counselling patients with HIV/AIDS. The problem is that the counsellor may be inhibited in visiting clients at home to avoid bringing upon them suspicion and the associated stigma, possible ridicule and even possible homicide by non-supportive family members who may see the client as a disgrace. While the few people working in this area may still be able to help through anonymous counselling, Onyeonoro (2011) noted that they lack facilities and resources to do this most of the time.

National Agency for the Control of AIDS (NACA) (2010) stated that it is uncertain whether appropriate and adequate counselling is provided through screening facilities provided by the government. Some people go without counselling before and after screening, except for the general health information that health practitioners give. Many health practitioners are as ignorant and as afraid as members of the general public, if not more so. The general pretence that anyone can do counselling and the poor attention given to the need to train people for this job may prove to be expensive for the country in the long run.

Daniyam and Agaba (2014) identified an acute problem of non-availability of trained counsellors to handle most of the sensitive issues that often arise, to help the untrained persons who are forced to take responsibility and to give the time required to meet the needs of the people affected. Making use of any untrained available person to do HIV/AIDS counselling may be doing more harm than good.

Measures to promote effective HIV/AIDS counselling

To ensure adequate and effective HIV counselling, the following measures were suggested by Ikechebelu et al. (2014):

  • To start with, counselling should be a fundamental right of the client in healthcare, irrespective of the nature of the disease or health needs that bring the client in contact with the system.
  • There is a need to see how this old phenomenon of kinship can be improved upon to help the family cope with the disease.
  • It is necessary for health practitioners to build scheduled counselling sessions into care regimens for all clients.
  • As a matter of urgency, there is a need for anonymous counselling facilities. These for a start could be in the big cities and towns and possibly linked to all health units.
  • The government, philanthropic organizations and individuals should help existing counselling groups to train more people to expand the scope of coverage to reach many more people affected, not only by HIV or AIDS, but by other terminal diseases.

References

Abebe, A. (2014). Perception of students towards voluntary HIV counselling and testing using health belief model in Butajira. Ethiop J Health Dev, 23, 148-52.

Aniebue, P.N. & Aniebue, U. U. (2011). Voluntary counseling and willingness to screen among Nigerian long distance truck drivers. Niger Med J, 52, 49-54

Daniyam, C.A. & Agaba, P.A. (2010). Acceptability of voluntary counselling and testing among medical students in Jos, Nigeria. J Infect Dev Ctries, 4, 357-61

FMOH (2012). National HIV/AIDS Reproductive Health Survey (NARHS). Abuja: FMOH

Ikechebelu, I.J., Udigwe, G.O. & Imoh, L.C. (2014). The knowledge, attitude and practice of voluntary counselling and testing (VCT) for HIV/AIDS among undergraduates in a polytechnic in Southeast, Nigeria. Niger J Med, 15, 245-9.

Iyaniwura, C.A. & Oloyede, O. (2012). HIV testing among youths in a Nigerian local population. West Afr J Med, 25, 27-31

NACA (2010). National HIV/AIDS Strategic Plan (2010-2015). Abuja: NACA

Onyeonoro, U. U. (ed.) (2011). Abia State HIV/AIDS Epidemiology, Response Policy Synthsis (ERPS). Umuahia: Abia State Agency for Control of AIDS (ABSACA).

Oshi, S. N., Ezugwu, F.O., Dimkpa, U., Korie, F.C. & Okperi, B.O. (2013). Does self-perception of risk of HIV infection make the youth to reduce risky behaviour and seek voluntary counselling and testing services? A case study of Nigerian youth. J Soc Sci, 14, 195-203.

Sebudde, S. & Nangedo, F. (2013). Voluntary counselling and testing services: Breaking resistance to access and utilization among the youths in Rakai district of Uganda. Educ Res Rev, 4, 490-7.

World Health Organisation (WHO) (2012). Guidance on provider-initiated HIV testing and counselling in health facilities. Geneva: WHO.

Wusu, O. & Okoukoni, S. (2011). The role of HIV counselling and testing in sexual health behaviour change among undergraduates in Lagos, Nigeria. Tanzan J Health Res, 13, 27-32.

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