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HCET Home > On-line Training > HIV Risk Assessment in Women > 8. Incorporating Risk Reduction Counseling into Family Planning

8. Incorporating Risk Reduction Counseling into Family Planning

Risk reduction counseling provides an opportunity for the client to discuss and explore ways to reduce the chance of HIV infection or pregnancy. The provider should promote and reinforce safe behaviors that the client is already using and assist the client in building skills and abilities to implement healthy behavior change.

Counseling must be both interactive and individualized to be effective and is more than giving information or reading a list of do's and dont's to the client. Clients who set their own goals for behavior change are more likely to achieve the goals than clients who are told what to do (e.g., “You should use a condom every time!”).

The goal of risk reduction counseling is to help the client to formulate a realistic plan for reducing her particular risks for HIV infection.

Important Principles in Risk Reduction Counseling

  • Incremental changes and small steps in risk reduction need support and reinforcement.

  • Personalized discussion that addresses the individual client's concerns is more effective than general advice or written information.

  • The negotiated risk reduction plan must be a realistic and attainable strategy.

  • Periodic review of the client's risk reduction plan is necessary.

  • Assist the client in building skills and abilities to implement behavior change.

Harm Reduction

Behaviors that eliminate all risk may not be realistic or desirable for every client; therefore, providers should be aware of possible alternatives that will reduce risk. The concept of Harm Reduction is to change behavior even if initially the changes are very small, with the goal of reduce the chance of becoming infected and gradually moving towards safer behaviors. This approach does not eliminate all risk and may not be acceptable for all providers. This information is provided in order to include a wide range of options.

Options for Reducing Risk

  • Monogamy with an uninfected partner.
  • Limiting the number of sex partners.
  • Not engaging in anal or vaginal sex.
  • Using extra lubrication if engaging in anal or vaginal sex (extra lubricant will help decrease tears and abrasions).
  • Always using condoms (male or female, latex or polyurethane).
  • Not using spermicides with nonoxynol-9 (it can cause irritation and increase risk).
  • Not engaging in oral sex.
  • If engaging in oral sex, always using latex condoms, dental dams, or plastic wrap.
  • Not brushing, flossing or using mouthwash prior to or just after performing oral sex. This can cause tears, cuts and irritation to the mucous membranes.
  • Avoiding ejaculation inside the mouth, vagina or rectum.
  • Avoiding swallowing ejaculate.
  • Not using needles.
  • Only using clean needles and “works.”
  • Cleaning needles/syringes/"works" before and after use with bleach.
  • Not sharing inkwells or piercing equipment.
  • Limiting the number of needle sharing partners.

Depending on the individual’s chosen risk reduction measure, the counseling session might focus on such issues as:

  • Delaying/avoiding sexual activity
  • Methods for avoiding unsafe sex and negotiating safer sex
  • Techniques to avoid sharing injection drug paraphernalia
  • Referrals to alcohol and/or drug abuse treatment programs
  • Referrals to HIV prevention programs

Behavior Change Models

Several models for predicting and supporting behavior change exist. These models have proven useful in different areas of disease prevention and behavior change. They can provide the health care provider with a framework for planning interventions and for better understanding risk-taking behavior. Following are brief descriptions of several such behavior change models that may be used in HIV risk reduction counseling.

Centers for Disease Control and Prevention Model for Prevention Counseling

The CDC has developed six steps of counseling designed to support individual risk-reduction planning during a client visit. The framework can be used in family planning settings and can be combined with a family planning visit. It provides a general guideline for prevention and can be used to help clients reduce risk in any aspect of life, such as pregnancy prevention, wearing seat belts, or weight reduction. (26)

  1. Introduce and orient a client to the session (This is done as part of the visit).
    1. Introduce yourself
    2. Describe purpose and duration of session
    3. Reiterate confidentiality

  2. Identify client's personal risk behaviors and circumstances (This information is gathered as part of the family planning visit, just make sure all risks are covered in your existing risk assessment).
    1. Identify specific pregnancy/STI/HIV risk behaviors
    2. Maintaining an open and nonjudgmental attitude is vital
    3. Consider possible triggers and vulnerabilities
    4. Make referrals when appropriate

  3. Identify a safer goal behavior to protect client from pregnancy, STI and HIV (Ask, “What can you do to reduce the risk of HIV/STI?”)
    1. Identify behaviors that prevent or greatly reduce transmission that the client is willing to adopt
    2. Allowing the client to create her own safer goal behavior increases success in making a behavior change
    3. Harm reduction techniques may be considered
    4. Offer options not directives

  4. Develop client risk-reduction plan (Ask, “What kind of things would make it easier to achieve the safer goal behavior?”)
    1. Development of the plan is crucial
    2. Help the client develop specific incremental steps to help reach the safer goal behavior
    3. Establish how and when the client will implement the plan
    4. Identify persons who will provide support for the safer goal behavior

  5. Make referrals and provide support (Make sure you have a referral list available for your area).
    1. Help client define priorities
    2. Discuss and offer options
    3. Determine which referrals the client is willing to accept
    4. Offer referral
    5. Develop a follow-up plan

  6. Summarize and Close (Review this with the client at the same time you review the birth control option chosen).
    1. Review the risk reduction plan and confirm choices the client has made.

Stages of Change

This behavior change model explains the process of behavior change, ranging from not being aware of negative effects of a behavior to adopting and maintaining safer behaviors. People do not necessarily pass through the stages sequentially and may repeat stages. Different types of intervention are most successful at different stages.

  1. Pre-contemplation
    • Client is not aware of risks, denies risks or is not planning to change behavior.
      • Help client to start to think about behavior change.
      • Provide education and leave the door open for when the client is ready.

  2. Contemplation
    • Client is thinking about changing behavior but doesn't have a plan.
      • Help client to think concretely about a plan for changing behavior.

  3. Preparation
    • Client begins to actively plan for change.
      • Assist client with making plan and setting a target date for action.

  4. Action
    • Client implements behavior change.
      • Provide reassurance and support.

  5. Maintenance
    • Client maintains behavior change over the long term.
      • Continue to provide reassurance and support. (27)

For more information on behavior change models, go to:

 

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 Last update: 03/05/08