Revised Guidelines for HIV Counseling, Testing and Referral in Non-Clinical Settings
Steering Committee Teleconference
Counseling
Minutes
October 29, 2008
1. Attendees:
a. CDC: Sam Dooley, Angela Hutchinson, Paul Farnham, Jason Craw, Susan
Shewmaker, Cindy Lyles, Jessica Gardom, Veronica McCants, Heather Joseph
b. Non-CDC: Martin Fishbein, Carlos del Rio, David Holtgrave, Jacques Normand,
Laura Cheever, Liisa Randall, George Rutherford, Walt Senterfitt, Catherine
Hanssens, David Munar
c. Guideline Development Team: Gail Janes, Rebecca Morgan
2. Welcome and overview of call objectives:
a. Call was called to order at 1pm EDT
b. Attendance was taken
c. Minutes from October 6th (Targeting/Recruitment) call were accepted without
amendments
d. Goals of call were briefly reviewed.
3. Provision of Information definition was reviewed and the call was opened up for
discussion:
a. The American Medical Association has a legally accurate definition of
informed consent posted on its website (see below). It was proposed that we
continue to distinguish between Provision of Information and Prevention
Counseling as separate and distinct concepts.
i. AMA definition of Informed Consent (http://www.amaassn.org/ama/pub/category/4608.html): “It is a process of
communication between a patient and physician that results in the
patient's authorization or agreement to undergo a specific medical
intervention.”
ii. According to the AMA definition, the following should be disclosed:
1. The patient's diagnosis, if known;
2. The nature and purpose of a proposed treatment or procedure;
3. The risks and benefits of a proposed treatment or procedure;
4. Alternatives (regardless of their cost or the extent to which the
treatment options are covered by health insurance);
5. The risks and benefits of the alternative treatment or
procedure; and
6. The risks and benefits of not receiving or undergoing a
treatment or procedure.
b. Keep topics separated, as it is in line with the clinical HIV guidelines
c. Include reportability of positive tests in the informational definition.
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d. Have the text (under provision of information) include clarification of the
difference between anonymous and confidential testing, particularly where
both are available.
e. Barriers to providing all of this information in non-clinical settings (i.e. bars,
parks, etc) should be addressed
f. General discussion: Definition should specify minimum requirements for the
types of information that must be provided
g. Clients might need different information, depending on their testing history
(have they tested before?), and the location of testing. Information should
also be understandable (language, literacy level).
h. How should programs handle underage adolescents who present for testing,
but are under the minimum age of consent? This should be explicitly
addressed in guidelines.
i. Age of consent varies by state (and by other factors such as mental capacity)
and resources should be referenced in guidelines or associated implementation
materials.
4. Prevention Counseling definition was reviewed and the call was opened up for
discussion:
a. Both definitions were still on target, but should emphasize the importance of
explaining the risks and consequences of testing to the client
b. The definition could be broader since it now essentially describes the Project
RESPECT model, and other models should also be discussed.
5. What is the spectrum of state and local statutes and regulations?
a. Illinois regulations and law require more prevention counseling and provision of
information in non-medical settings than in clinical settings; it also hinges on the
funding source.
b. Governing law include common and case law, particularly as regards liability.
Information on this issue will be forwarded, as it varies by state.
c. State laws can be very fluid over time.
d. General discussion: Is there an accurate compendium of state laws (other than
National HIV/AIDS Clinicians’ Consultation Center site
(http://www.nccc.ucsf.edu/StateLaws/Index.html))?
e. Seldom to come across any that are completely accurate, but the guidelines
provide a link to a complete (and updated) listing of state regulations, as well as a
directory of legal service organizations.
f. Service providers should review their local laws and regulations and communicate
these to clients.
6. What approaches to HIV counseling have been demonstrated to be effective at
encouraging clients to understand and accept HIV testing? There were no suggestions on
this topic.
7. What approaches to HIV counseling have been successful in eliciting behavior
change? Is prevention counseling recommended for all clients? Should prevention
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counseling always take place in conjunction with HIV testing?
a. General consensus: Counseling should be tailored to the client - “client-centered
counseling” – although the guidance document should be clear what this means
b. Project RESPECT is still the “gold standard” on the CDC’s site.
c. The provider or program should have flexibility in deciding how and when to
couple or uncouple testing and prevention counseling. There should always be
some counseling at the point of testing, but there should also be the flexibility to
vary the approach from client to client. In addition, counseling should be
regarded as a way to link clients to other services, in addition to providing a
prevention message. Program designers should be able to contextualize their
approach in different communities.
d. Need more research on the importance of temporally linking testing to counseling,
but the guidance should allow programs the flexibility to accommodate client
needs, in determining whether to counsel on-site or not
e. Some counseling should be provided with results, but clients should then be
linked to more intensive counseling, either on-site or at another time or place, if
on-site counseling is not feasible (or desired).
8. Call for literature on counseling
a. There have been no PRS (Prevention Research Synthesis) reviews to date on the
efficacy of preventive counseling. Referenced an older Cochrane protocol on the
behavioral benefit of preventive counseling by Mike Sweat; he found there was
very little research on this topic. Need more trials/evidence to make
recommendations for one model over others.
b. What is our main goal? Is it just to increase testing? There is research on
building trust between the test taker and the tester.
c. Should define whether we’re looking at testing and counseling, counseling alone,
or testing alone. Most studies examine the effect of counseling and testing vs.
control group of testing alone, with no counseling. Few address the benefits of
counseling alone.
d. Hard to generalize to a single test-taking population. CDC will need to discuss
the potential uncoupling of counseling and testing in the context of specific
populations and settings.
9. Other business
a. There was a brief discussion of the feasibility of a website to share documents.
CDC staff confirmed that they are working on this.
11. Meeting was adjourned at 2pm EDT.
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