What you can do

You don’t have to be an expert in HIV to conduct a risk assessment or provide advice and guidance to someone with HIV infection.  But as someone on the frontline of health care, you are in a position to be the first to recognise the signs and symptoms of HIV infection or risk factors in a patient or client.

As you work through this section, consider whether you feel you have the training and experience to effectively provide these services.  If you do, that’s great. If you don’t feel confident to undertake these tasks, act as a ‘link’ and refer your patient or client to a more experienced colleague or HIV specialist. The information in this section will still be important in helping you recognise when HIV may be a consideration.

Risk assessment

Risk assessment is the first step in identifying people who are HIV positive but are undiagnosed, and those who are engaging in behaviours that are putting themselves at risk of HIV infection. A risk assessment will help you to:

• evaluate a person’s risk for HIV infection
• provide early intervention through HIV testing
• educate about behaviour modification
• provide access to treatment and support for those who have HIV infection.

Here are some questions that cover topics included in a risk assessment for HIV. For each question, read the two versions and decide which phrasing would help you get the most accurate information. Select the question mark to see which one turns green to indicate it is the better model for asking these sensitive questions.

As this exercise shows, how a question is phrased can have a real impact on the accuracy and quality of the information you receive.  An effective risk assessment involves:

• adopting an open and non-judgemental manner
• not making assumptions
• asking the right questions
• taking care with the choice of words and terms –  a man might have sex with another man but not identify himself as gay or bisexual, others may not consider oral sex a form of sex at all
• listening actively, and
• using effective communication techniques.

Explore the question marks in this next activity to learn some additional tips from two nurses about undertaking an HIV risk assessment.

There are many resources that provide more detailed information about conducting a risk assessment for HIV. Some of these are listed in the ‘Useful resources’ section. In general, when conducting a risk assessment for HIV infection:

Step One: Raise the topics of intravenous drug use and sexual practices.

• Determine if the person is engaging in behaviours that put them at risk such as having unprotected sex or sharing needles.
• Pay particular attention to any clues that might indicate a sexually transmitted infection or intravenous drug use.
• Men who have sex with men, black African migrants newly arrived in the UK, and people from countries with a high HIV prevalence should also be considered to be at higher risk. All pregnant women are offered an HIV test as part of their routine antenatal care.

Step Two: If any ‘red flags’ are raised, continue with a clinical assessment to determine if the person has any symptoms of HIV infection. The 'UK National Guidelines for HIV Testing', listed in the ‘Useful resources' section provides an extensive list of clinical indicators for HIV.

Step Three: If your assessment raises any concerns, encourage HIV testing.

Carys, a general practice nurse, was conducting a HIV risk assessment with one of her patients and thought that testing was in order. She raised the issue with her patient in this way: "Your symptoms sound like they may be caused by a virus. There are a couple of viruses that might be the cause, flu is one example, but some less common viruses such as HIV could be at play too. In these sorts of situations we routinely test for HIV. Is that okay with you?" Just as normalising high risk behaviours helps to encourage open and effective communication, normalising HIV testing by presenting it as routine helps reduce concern and remove the stigma that is often attached to the test.

Prevention, early intervention, and health promotion

HIV prevention and safe behaviours should be a natural part of any health promotion message. Practicing safe sex can sit comfortably aside messages about diet, exercise, smoking, and alcohol use. This includes:

• Educating your patients and clients about safe sexual and IV drug use behaviours. Never assume that because you’ve given the message once that it doesn’t need to be raised again.
• Urging your clients or patients not to become complacent. A person who is negative now will only remain so if the good practices continue. As with many long-term behaviours, it is easy to ‘slip’ so regular reminders of healthy behaviours is important.
• Signposting your patients or clients to the specialised sources they need. For example, know where the HIV testing centres are in your community and which type of test they offer. Remember that not everyone will have access to the internet so be sure your lists contain up tp date address and telephone contact details.

Counselling patients with HIV

The stigma surrounding HIV makes the way you approach the issue more difficult than for many other health topics. HIV is linked to subjects that many people, patients, and health care workers alike, consider personal and private. HIV and AIDS counselling is often provided by specialist counsellors but nurses are often well-positioned to provide advice, information, and support. Effective counselling has real benefits for patients or clients with HIV by helping them make informed decisions, manage their medical needs, keep themselves healthy, and prevent transmission of the virus to others. Counselling someone with HIV involves:

• promoting a healthy way of life
• reinforcing the message to practice safe behaviours - in addition to possibly transmitting the virus to someone else, unprotected sex can lead to secondary infections and other sexually transmitted diseases
• provide information about support groups – they can help people feel less alone and also provide a forum for sharing coping strategies or for discussing concerns and fears.

One in five people with HIV develop some type of mental illness, most often depression. It is natural for someone with HIV to experience sadness and grief, but it’s important that it is recognised when this crosses into clinical depression. Depression in someone with HIV can lead to them adopting risky behaviours, failing to adhere to medication regimes, and substance abuse. Any counselling or discussions you have with someone with HIV should consider their mental health. Raising the topic need not be awkward or overly complicated. A simple sentence can do the trick, for example: I’m concerned about all of you – your mental health as well as how you’re feeling physically. Do you mind if I ask you a few questions? A couple of quick questions then can indicate if further assessment or referral to a mental health professional is needed. For example:

• In the past month have you felt down or hopeless?
• Have you lost interest or pleasure in doing things you usually enjoy?

Depending on your training, experience, and the needs of the person sitting across from you, sometimes the best thing for you to do is provide signposting to other resources. But if you are confident in your skills, use this opportunity to provide information and guidance to your patient or client.

Colleagues with HIV infection

It can be difficult for colleagues who have disclosed their HIV positive status. The stigma and discrimination that exists in other workplaces is found in health care working environments too. Some nurses who told colleagues of their HIV status reported that they were treated differently, made to feel isolated, and often excluded from social events (Santry, 2009). Look at the graphic below and as you do, consider how can you make sure this doesn’t happen where you work. You may wish to create an action plan to capture the ideas you come up with in response to this question or write a reflective statement. Templates are available in the 'Taking action' section. You may wish to save this document to your computer and upload it to your e-portfolio as evidence of your continuing professional development. You may wish to share or discuss your action plan with your colleagues or line manager.

Tips for dealing with HIV postive colleagues

• Know the facts so you don’t mistakenly assume their HIV infection puts you, other colleagues, or patients at risk.
• Provide support and consideration.
• Remember, HIV is only one part of the person. They are foremost a nurse, a health care worker, a nursing student, and your colleague. They just happen to have HIV infection.

It is important for HIV positive health care workers who disclose their status to be treated with respect and understanding. When this doesn’t happen, not only does the individual suffer but other health care workers with HIV infection will be discouraged from disclosing their status. And those who have concerns about their status won’t get tested for fear of the reaction a positive diagnosis might bring. This puts their health at risk but also may pose a risk to their patients or clients.

The confidentiality about a person’s HIV status that applies to patients applies to health care workers too. If you are aware of the HIV status of a colleague, unlike the nurses in the scenario above, you should not share that information with anyone without their permission. If, however, you believe the person's actions put patients, other colleagues, or the public at risk, you may need to breach confidentiality. In these cases, seek advice from your human resources advisors, occupational Health advisors or your professional body before you take any further action. It would also be advisable to speak to the individual concerned to allow you to discuss your concerns with them to make sure that you are not misunderstanding any situations.

Helping patients, clients and colleagues decide who to tell

For many people, one of the most difficult and emotional parts of having HIV is telling other people. Whether it is friends or family, sexual partners or employers, telling someone you’re HIV positive is never easy. For most, the decision to share their HIV status is beneficial – it can bring support and lessen the stress that living with a secret can bring. But there may be times when sharing HIV status can cause problems – it can tap into other peoples’ own fears, misconceptions, or prejudices about sex, sexuality, drug use, and HIV itself.

The decision of who to tell is a personal one and will depend on each person’s individual situation.  How can you help? Take a moment to think about how you might feel if you had to make the decision about who to tell - what questions and concerns would you have? Work through the activity below to see what people in that situation have said.

If your patient or client is thinking about disclosing his or her HIV positive diagnosis or is wondering how to go about it, there are some things you can encourage them to think about such as:

• Know what they want to tell. Is it that they have HIV or will other issues such as sexual orientation or drug use need to be discussed?
• Get support before they tell others. There are a number of HIV support organisations that provide information on their websites as well as free and confidential telephone numbers where they can speak to someone and receive advice and tips on telling others.
• Be prepared for reactions they don’t expect.
• Recognise that people may need some time to digest the information. Your patient or client may have been living with their HIV diagnosis for days, weeks, months, or years. It may take others some time to absorb what they’ve been told.
• Have information and telephone numbers handy. The people they tell may have misconceptions or want to learn more about HIV and AIDS.  They too may feel that they want to talk to someone and receive support.
  For the most part, it is a personal decision whether to disclose an HIV diagnosis. However, as touched on earlier in this learning programme, there may also be legal reasons for telling a sexual partner of an HIV diagnosis, and, if you work in health care you will need to inform your employer if you have HIV.

In 2012, Brian made the decision to tell his parents of his HIV diagnosis. Work through the activity below to see what he has to say about how he delivered this news.

Benefits and drawbacks of disclosure

When discussing disclosure with your patient or client, consider the following possible benefits and drawbacks.

The benefits are:

• Provides an opportunity for support.
• Some legal rights are only available if a person’s HIV status is known . For example, an employer is only required to make reasonable adjustments, such as flexi-time, if they have been told of their employees HIV diagnosis.
• Informing sexual partners may encourage them to receive treatment should they be exposed to the virus during sex (for example, if a condom tears or breaks) - something they might not do if they are unaware of their partner’s HIV status.

Some possible drawbacks are:

• rejection
• ending of a relationship
• loss of a home
• threats of or actual violence.

The issues surrounding disclosing HIV status are difficult, emotional and can carry significant effects. In addition to any support and information you provide, there is good, detailed advice available from HIV support organisations for guidance on disclosing HIV status which you may want to read or provide to your patients or clients. The contact information and web links for some of these organisations are available in the ‘Useful resources’ section.