Posttest discussion points when giving an HIVpositive result

1. Inform the patient of the nature of the HIV result clearly, and what this result means.

2. Give the patient the opportunity to read the result, pointing out the clinic number and date of birth.

3. Clarify the patient's understanding of the result.

4. Address the patient's immediate reactions. Each patient will receive the news in his or her own way. Ensure there is time for discussion of immediate concerns. Find out what the patient will be doing in the next 24-48 hours.

5. Offer further support if the patient requires it.

6. Carry out an assessment of any social or mental health issues.

7. Discuss the need for further blood tests to assess health status and a repeat test for confirmation.

8. Refer for specialist management, including treatment where appropriate. Depending on your clinic's practices this may involve an HIV appointment with a specialist HIV doctor and clinical nurse specialist to discuss the results of further tests and give the patient an appointment card confirming the dates and times.

9. Check if the patient has any immediate medical problems. In the event of any symptoms, an immediate link with a doctor is indicated.

10. Offer follow-up appointments and ongoing support for the patient, partner and/or family.

11. Find out who the patient may tell, and clarify available support systems.

12. Clarify transmission issues, and how patients can minimise risk to themselves and others.

13. Give details of support services and resource material.

14. Give the patient written details of the ways s/he can contact the health adviser, and help-line numbers, for example the National AIDS Helpline.

15. Raise partner notification. It may be appropriate to address partner notification issues in the immediate post-test session. Patients will often raise partner notification at this point themselves.

RECOGNISING PATIENTS' ANXIETIES

Most patients who test positive for HIV are likely to have a high degree of anxiety, even before getting their results. The reasons for this may be varied, but generally they may involve knowing people who have already died from AIDS-related illnesses, misconceptions about the facts of HIV infection, and anxieties about informing close family and partners.

While giving a result, you should be aware that the anxiety and emotion that accompany a positive result are likely to have a significant effect on the patient, and they normally need some time to absorb the initial result before you give them any further information. With most patients, it is generally advised not to give small amounts of information about specific areas (e.g. viral loads and CD4 counts), and to focus more on how the patient is, who they are going to inform about the result and who will be able to give them some emotional support if needed. At a follow-up appointment in a week's time, normally when they return for the confirmatory second HIV test and other blood-test results, it may be more appropriate to go into further details about the infection.

TALKING ABOUT PATIENTS' PROGNOSES

When discussing HIV infection with newly diagnosed patients, it can be difficult to work out a balance between giving factual and practical information, whilst simultaneously giving the patient hope for the future.

It is common for patients to ask questions such as 'How many years will I live for?' after learning of the infection. Honesty and pragmatism are essential when discussing a patient's prognosis, but a realistic optimism should be applied whenever appropriate.

Whilst recognising the seriousness of the diagnosis, you should avoid speculating about a patient's life expectancy, stressing that each individual case is different and that strategies to extend survival and new treatment therapies are being developed and tested at a rapid pace. The fact that they are diagnosed in a first world country will mean that treatment options are readily available and expert care is available.

REFERRAL TO AN HIV SPECIALIST DOCTOR AND ASSOCIATED SPECIALISTS IF HIV-POSITIVE

Now that the HIV result has been given and confirmed, the next step in working with this patient is to refer them appropriately. Most GUM clinics have specialist services such as HIV physicians, and other associated specialists in HIV. Depending on the area in which you work you may be able to refer newly diagnosed patients directly into these services, or you may need to contact them and refer in another way. Some patients may prefer to have their HIV care moved to another clinic, which in most cases can be organised by your service by means of writing a referral letter once a confirmatory HIV test has been reported. A policy should be set up in every area that takes and gives HIV results. It should detail the steps that need to occur in dealing with a new positive diagnosis and onward referral. If such documentation does not exist it is a good idea to contact a GUM clinic near to your service and ask for some guidance.

REFERRAL FOR COUNSELLING AND OTHER SERVICES IF HIVPOSITIVE OR -NEGATIVE

Newly diagnosed patients may require immediate assistance in attaining additional counselling for emotional distress, peer support, assistance with financial concerns, future planning, child-care issues, housing, or other practical concerns. Such patients may also require referrals to services related to family planning. Where available, you should refer patients to appropriate community organisations, social agencies, peer support groups, and other resources near to the area in which they live or work. However, some patients may wish to travel further afield.

Patients who test negative may also require referrals to family planning, healthcare, counselling, or social services. All patients, positive and negative, should be provided with condoms, counselling on prevention, and information about where to obtain additional condoms.

HIV PRE- AND POST-TEST DISCUSSION

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