Materials in this module will help you:

List your key responsibilities as an HIV test counsellor
Recall the meaning of the acronym ARCCH, and how it applies to HIV testing activities
Consider the perspectives and experiences of clients that may shape the testing experience
Speak with clients about the risks and benefits of testing to allow them to make an informed decision (consent)

Your Role as an HIV Test Counsellor

Learn about the client’s needs. This is accomplished both through talking to the client and by learning, in advance, about needs and challenges faced by the communities you serve.

Offer support and referral to needed services including prevention, HIV care and testing for other sexually transmitted and blood-borne infections.

Explain the test and provide information about HIV risk and transmission, addressing client needs. Make sure the client consents to HIV testing before it happens.

Provide complete and accurate information on all test requisitions. When conducting rapid HIV testing, perform the procedures correctly and carefully.

Provide initial emotional, social and medical support when people test positive.

In Ontario, HIV Testing is

Ontario’s testing guidelines specify that all HIV testing services (including point of care) are:

Adapted – Each testing interaction responds to the needs of the client and is shaped around their concerns and questions

Respectful – Each testing interaction engages with clients with respect and honesty, exploring issues of risk in non-judgement and non-stigmatizing ways

Consenting – People who test for HIV must choose to take the test and have considered how a reactive test might impact their life

Confidential – People who test for HIV are confident that their privacy will be respected

High Quality – People who test for HIV are accessing a continuum of high-quality services including accurate HIV testing, but also referral to other needed prevention and care services

The Test Appointment

In Ontario, each testing appointment should be adapted to the needs of the client. Each testing appointment has five steps:

Introducing the testing conversation
Assessing risk and the client’s service needs
Explaining the test and obtaining consent
Performing the test
Providing follow-up care and support around the test results and referral to services

Steps 1-3 are often called pre-test counselling. It is essential that each pre-test counselling session lead to the informed consent of the client.

Informed Consent – What a Client Needs to Understand to Give Consent

Informed consent is a requirement of all HIV testing in Ontario. Clients can decide not to test at any time and can decline follow-up, such as confirmatory standard testing of a reactive rapid test result.

Make sure that all clients to be tested understand that:

What living with HIV means, they have a chronic condition that will need ongoing treatment; with treatment they can live a long and healthy life. If the test is reactive, you will connect them to care.
The rapid test takes only a few minutes. At the end of that time they will know if their test was reactive. Although this result needs to be confirmed, in almost all cases a reactive result will mean they have HIV..
The client has thought about how they might respond to knowing they have HIV., and has an idea about who in their life they can turn to for support.
Knowing their status will mean that they are legally required to disclose their status to past partners. If a person tests positive nominally (using their name), Public Health authorities have a responsibility to contact them, and will contact their past partners, while protecting their identity.
The Supreme Court of Canada has ruled that people who have HIV are required to tell their sexual partners that they have HIV if they engage in activities where there is a realistic possibility of transmission of HIV. The Ontario government has further clarified this ruling stating that: A person living with HIV who is on ART and has a viral load of under 200 copies/ml blood for at least six months does not have a duty to disclose their status before anal, vaginal or oral sex. This is the case whether or not a condom is used.

Minors (clients under 18) and people with diagnosed mental health conditions can make the decision to test for HIV if they understand these points. if a client is too impaired or disoriented to make an informed choice, testing should be delayed until this circumstance changes.

Confidentiality

The evidence shows that concerns around privacy are a major barrier to HIV testing.

Talk to clients about why and how information is collected and stored.
If your site does not offer anonymous testing, tell concerned clients the location of the nearest anonymous testing location if they prefer.
Explain what information is sent to the Public Health Labs and to local public health authorities
The Canadian HIV/AIDS Legal Network has an excellent resource for care providers, Reducing stigma and discrimination through the protection of privacy and confidentiality (May 2017). At: https://bit.ly/2Wv0kZr

Biomedical Prevention

Condoms remain a central tool for both HIV prevention, and for the prevention of other sexually transmitted and blood borne infections (STBBI). However, pre-exposure prophylaxis (PrEP) has also emerged as a valuable prevention tool, that may be helpful for many of the clients you see. Immediately after a high-risk exposure, post-exposure prophylaxis (PEP) can also be an important option. Here is some basic information about PrEP and PEP. More information is provided by the resource sites listed below.

Pre-Exposure Prophylaxis (PrEP) is the ongoing use of antiretroviral drugs to prevent HIV infection.

Consistent use of PrEP virtually eliminates the risk of HIV infection through sexual activity and reduces the risk of infection through needle sharing by nearly half.
Clients who regularly engage in high risk practices or who have used PEP more than once are appropriate clients for PrEP.
Family physicians can prescribe PrEP and specialty clinics are beginning to emerge in some urban centres; if you site does not prescribe PrEP refer clients to local providers that do.
Substantial information about PrEP is now available online; try to have resource information available for your clients.
The costs of a PrEP prescription will be covered by most private insurance, for those on ODSP and Ontario Works, and for people under 25. PrEP is also covered by federal plans for Canadian First Nations peoples, people with refugee status, and Canadian Armed Forces personnel.
Costs have decreased substantially in the past year to $200-300 a month; many providers can now help clients arrange drug coverage within their means

The Ontario HIV PrEP website provides comprehensive resources about PrEP for HIV test counsellors, health care professionals and people at risk who are interested in exploring this option. www.ontarioprep.ca

Post-Exposure Prophylaxis (PEP) is the use of antiretroviral drugs to prevent HIV infection after a high-risk exposure has occurred.

Clients can effectively use PEP in the first 72 hours after a high-risk exposure. For these clients, the risk of HIV infection is reduced by 80%, if they continue to take the drug consistently for 28 days. If your site does not provide PEP, suggest clients go to a hospital emergency room to get PEP.
Clients must have a prescription for PEP. Often an emergency room will provide pills for a couple of days, after that they will have to fill the prescription they are given.
The cost of a PEP prescription is covered for people who have been sexually assaulted and may be covered by private insurance.
For clients without these forms of coverage, PEP may cost $750 or more. In some cases, local HIV clinicians may be able to help clients in this circumstance arrange low or no cost coverage. Learn about the possibilities for PEP coverage in your area.
For more information on assessing for PEP, see an example PEP algorithm in the Ontario Guidelines for Providers Offering HIV Testing. Also, see the recommendations on HIV testing PEP on pg. 11 of the Guidelines).

A practical overview of post-exposure prophylaxis including where and how to get it, and how to pay for has been created by the AIDS Committee of Toronto. At: https://www.actoronto.org/health-information/hiv/pep/

Learning More about Client Needs

Being an effective HIV test counsellor means listening and responding to a client’s concerns and to their assessment of their needs. It means relating to clients in a human way, not as an authority on their needs. Talk to your HIV testing colleagues about the people and communities you site serves, and learning about the resources available to clients in your community. Here are some basic resources to help you better understand the challenges your clients may face, and relevant issues for the communities you serve:

Trauma Informed Care training – Alberta Health Services has created this e-learning module for anyone providing health services and interested in understanding more about trauma-informed care and responding appropriately to clients who have experienced trauma. At: https://www.albertahealthservices.ca/webapps/elearning/TIC/Mod01/story_flash.html
HIV Resources Ontario – is a collaborative of resource programs and capacity building organizations that serve the HIV sector and create trainings, workshops, and materials to support HIV workers. Some specific resources on this site are included below, and this site is regularly updated with new training and resources. At: http://www.hivresourcesontario.ca/
CATIE – is Canada’s official knowledge broker for HIV and hepatitis C information. They connect healthcare and community-based service providers with the latest science, and promote good practices for prevention and treatment programs. At: https://www.catie.ca/

Population Specific Resources

Gay, Bisexual and other Men who have Sex with Men (GBMSM)

The Gay Men’s Sexual Health Alliance (GMSH) is a network of HIVAIDS Service Organizations who work together to improve responses to GBMSM needs. At: http://www.gmsh.ca/
The Sex You Want – A resource created by GMSH to help GBMSM think through the sexual decisions that can impact their health. At: https://thesexyouwant.ca/
Re-centering our approach to gay and bisexual men’s health and HIV prevention – a CATIE resource about how the health of GBMSM may differ from heterosexual men. At: https://bit.ly/2JdF4FK
Rainbow Health Ontario provides a broad array of resources on 2SLGBT health in Ontario. At https://www.rainbowhealthontario.ca/

African, Caribbean, and Black communities

The African and Caribbean Council on HIV/AIDS in Ontario (ACCHO) provides leadership in the response to HIV/AIDS in African, Caribbean and Black communities in Ontario including workshops and resources for HIV workers to better understand community needs. At: https://www.accho.ca/
It Takes Courage is a campaign working with spiritual leaders in ACB communities to address antiHIV stigma and addressing some of the myths and challenges. At: http://ittakescouragenow.com/

People who Use Drugs

The Ontario Harm Reduction Network (OHRN) supports harm reduction efforts in Ontario by providing training and consultations to service providers and agencies. At: http://www.ohrn.org/
The Ontario Harm Reduction Distribution Program provides harm reduction supplies and education materials at: https://ohrdp.ca/supplies/. The OHRDP also has a short course on stigma at: https://bit.ly/2CuTawL
Understanding stigma: A free online course for healthcare providers and other frontline clinicians A course from CAMH on the stigmatization of people with mental health and substance use issues. At: https://moodle9.camhx.ca/moodle/?lang=en

Indigenous People

The Ontario Aboriginal HIV/AIDS Strategy (Oahas) provide culturally respectful and sensitive programs and strategies to respond to HIV/AIDS epidemic among Indigenous Peoples in Ontario. At: http://www.oahas.org/
Strong Medicine – a video about the experiences of Indigenous people testing for and living with HIV developed by CAAN and CATIE. At: https://www.catie.ca/en/strong-medicine
Indigenous People and HIV in Ontario: An Overview – information about the common HIV risks for Indigenous people in Ontario and the service gaps they experience. At: https://bit.ly/2W0b41G
Two-Spirited People of the First Nations provides resources about the lives and health of 2SLGBT Indigenous peoples including support for those living with HIV. At: http://www.2spirits.com/

Women Experiencing Increased Risk of HIV

Women and HIV/AIDS initiative (WHAI) – a community-based response to HIV/AIDS among cis and trans women in Ontario that takes into account the societal factors that increase women’s risk of HIV. WHAI offers training and resources about the needs of women at increased risk of HIV. At: http://www.whai.ca
Women, HIV & Stigma: A Toolkit for Creating Welcoming Spaces – A toolkit created to assist community organizations and their staff to work with women in Ontario who are living with or at elevated risk of HIV. At: http://www.whai.ca/ModuleFile?id=263
Supporting Mothers in Ways That Work – This is a toolkit for people who work with mothers living with HIV but it also explores many of the issues that complicate the lives of women seeking HIV testing. At: http://www.whai.ca/ModuleFile?id=115

Transgender People

Trans Inclusion Pocket Guide – A guide developed by WHAI about and through the shared lived experience of trans women living in Ontario and how they do (or don’t find services). At: http://www.whai.ca/ModuleFile?id=117.
Primed2: Sexual Health Guide for Trans Men – This guide was written by and for trans men who have sex with other men. It contains information on staying sexually, emotionally, and mentally safe and healthy. At: https://www.catie.ca/en/resources/primed-sex-guide-trans-men-men
Trans-PULSE Project – This community-based research project explored the health, service delivery, and policy of trans people in Ontario, and is an excellent resource about community needs. At: https://transpulseproject.ca/research/

Other Resources for More Information:

HIV Testing in Ontario – Data about testing, including the number of tests done, and the number of positive tests in each region is compiled by the Ontario HIV Epidemiology and Surveillance Initiative (OHESI). Detailed reports are available on the OHESI website at http://www.ohesi.ca/
- A brief overview, HIV testing and diagnosis in Ontario, 2017, is available at: http://www.ohesi.ca/documents/OHESI-WAD-2018-Fact-Sheet.pdf
HIV Test Counselling Checklist (standard practice) is included in this handout, and is available on the HIV Testing Ontario Program website.