Lecture | Quiz | Learning Exercise | Answer Key

Developed by JHPIEGO’s Training in Reproductive Health Project with funding from USAID.

Lesson 4: Counseling the HIV Positive Client About Family Planning
Instructor: Emmanuel 'Dipo Otolorin, MD

Objectives

In this lesson, we shall be reviewing the counseling process for clients living with HIV/AIDS. By the end of this lesson, participants will be able to:

1. Describe the importance of counseling for informed choice of contraceptive method
2. List 10 characteristics of a good counselor
3. List 6 elements of the counseling process
4. Greet clients in a welcoming manner that encourages openness in communication
5. Describe how to encourage clients to talk about themselves
6. Talk to clients about available methods of contraception
7. Assist clients to choose an appropriate method of contraception for themselves
8. Explain to clients how to use their chosen methods of contraception
9. Work with clients to plan for follow-up or return visits.

In the last few lessons, you learnt about the importance of voluntary counseling and testing (VCT) as an entry point to prevention, care of HIV-infected persons and those at high risk for HIV, and prevention of sexual transmission of HIV. Regrettably, because of the inequitable access to VCT services, most HIV-infected individuals in the developing world are unaware of their HIV-serostatus. Yet, at the very least, every woman, whether infected or uninfected with HIV, has the right to decide if and when she wants to become pregnant, to continue a current pregnancy and/or utilize evidence-based prenatal practices to reduce the risk of mother-to-child-transmission of HIV. 

As health professionals, we have the responsibility to assist any client, male or female, who wants to prevent an unintended pregnancy to do so with safe and effective methods of contraception. 

In this lesson we shall share information about how to counsel such clients so that they make informed choices about family planning.

Characteristics of a Good Counselor

A good counselor: 

• Understands and respects the client’s rights.
• Earns the client’s trust. 
• Understands the benefits and limitations of all contraceptive methods. 
• Understands the cultural and emotional factors that affect a woman’s (or a couple’s) decision to use a particular contraceptive method. 
• Encourages the client to ask questions. 
• Uses a nonjudgmental approach that shows the client respect and kindness. 
• Presents information in an unbiased, client-sensitive manner. 
• Actively listens to the client’s concerns. 
• Understands the effect of nonverbal communication. 
• Recognizes when s/he cannot sufficiently help a client and refers the client to someone who can. 

Elements of Counseling

Family planning providers are familiar with the acronym GATHER that describes the six elements of counseling, namely:

G - Greet clients
A - Ask clients about themselves
T - Tell clients about their family planning choices
H - Help clients choose an appropriate method of contraception
E - Explain what clients need to do after they have made a choice
R - Return for follow-up

Greeting Clients

When you meet clients, greet them and give them your full attention. Do not be distracted by other staff or activities. Do not discriminate against them because they are HIV-positive. Be polite, friendly and respectful. Introduce yourself and offer them seats. When they have settled down, ask them how you can help and assure them that you will not tell others what they say to you. To demonstrate this, shut the door or pull a curtain to provide them with visual and auditory privacy. If there are still concerns about privacy, you may decide to take the client outside to talk. Whatever you do, it is important to gain the confidence of the client so that she may feel free to discuss her intimate concerns with you.

Asking Clients About Themselves

Once the client has settled in, ask them about their reproductive and family planning experiences and help them to decide what decisions they face. These may include decisions about the timing or prevention of pregnancy, continuation of a current pregnancy, prevention of HIV transmission to or from others including acceptance of measures to prevent mother-to-child-transmission (MTCT) of HIV.

Help clients to express their feelings, needs, wants and any doubts, concerns or questions about family planning or other reproductive health services. Keep your questions open, simple and brief and look at your client as you speak. Listen attentively to what the client has to say and follow the direction where the client leads the discussion. Show your interest and understanding at all times. Express empathy and avoid judgments and biased opinions. Do not forget to ask for any information needed to complete the clients’ records such as age and how many children they have had.

Telling Clients About Their Contraceptive Choices

If the decision of your client is to defer or cease childbearing, you need to tell them about their contraceptive choices. In order to make an informed choice clients need clear, accurate, specific information about the range of their choices. These choices include barrier methods (condoms and diaphragms, spermicides), hormonal methods (combined oral pills, progestin-only pills, injectable contraceptives, implants), intrauterine devices (IUDs), permanent contraception (voluntary surgical contraception), fertility awareness methods, and lactational amenorrhea method (LAM).

If clients are choosing a contraceptive method, ask them which methods interest them, and what they know about these methods. Correct any misconceptions that they may have about any method. If there are no medical reasons to prevent it, clients should get the methods they want. However, if the client’s choice will not help her to achieve all of her objectives, she should be so advised. For example, a client who chooses to use the oral contraceptive pills to prevent both pregnancy and HIV transmission needs to be informed about the fact that oral pills will not prevent the transmission of HIV to others or to herself, even though it will prevent unintended pregnancy. She will need to add the use of a barrier method of contraception to achieve the latter objective. (We shall be discussing, in greater detail, the effectiveness of different contraceptive methods in the next two lessons).

While telling clients about contraceptive methods, briefly describe the client’s preferred method, providing information about method effectiveness, how to use the method, advantages and disadvantages of the method, possible side-effects and complications. Mention other available methods that might interest the client and ask if the client wants to learn more about them. Use contraceptive samples and other audiovisual materials to explain about the methods. 

Helping Clients Choose a Method

Once you have provided the necessary information about different methods of contraception, emphasize to the client that the final choice is hers. Only offer advice as a health professional but avoid making the client’s decision for her.

To help the client choose her preferred method, remind her to think about her future plans and family situation. Help her to think about the results of each possible choice. For example, if she and her spouse want to have one or two more children in the future, a permanent method of contraception (e.g. tubal ligation) will be inappropriate for them. Similarly, if the client is currently breastfeeding, it may not be safe for her to use the combined oral contraceptive until the baby is 6 months old or she has discontinued breastfeeding. Every family planning practitioner must be up-to-date on the medical eligibility criteria for the use of contraceptive methods in order to advise the client appropriately. 

To gauge the risk of STIs, you may ask if your client or her partner has sex with anyone else. This question is relevant if the client wants to choose the IUD, for example. A woman who has unprotected sexual intercourse with multiple partners or whose spouse has unprotected sexual intercourse with multiple partners is certainly not a good candidate for the IUD because of the increased risk of pelvic inflammatory disease.

Finally, explain that some contraceptive methods may not be safe for certain medical conditions. For example, a woman over the age of 35 years who smokes more than 15 cigarettes a day, is diabetic and hypertensive, should not use the combined oral contraceptive pill because of increased risk of cardiovascular disease. At the end of the session, check whether the client has made a clear decision. To confirm this, you may specifically ask, “What have you decided to do?” and wait for an answer.

Explaining What The Client Has To Do

Once the client has made a clear informed choice of contraceptive method, proceed to provide the method or refer the client to where she can get the method if you do not have it. If the method cannot be given at once (e.g. voluntary surgical contraception), tell the client how, when and where the method can be provided. 

For voluntary surgical contraception, the client may have to sign a consent form, which confirms that the client wants the method and has been given full information about the it and that she fully understood the information given. Help the client to understand the consent form before she signs it.

For all chosen methods:

1. Explain how to use the method or how to follow other client instructions
2. Describe the possible side effects and what to do if they occur
3. Explain when to come back for routine follow-up or supplies, if needed. 
4. Explain about any medical reasons for returning to the facility and ask the client to repeat the instructions to you to ensure she fully understands. If possible, give the client some printed materials to take home. 
5. Remind the client that she is welcome to come back whenever she wishes or if side effects bother her. 

Returning for Follow Up

When the client returns for follow up, ask her if she has any questions or any other concerns to discuss. Treat all concerns seriously. Ask if the client is satisfied with the method and if there have been any problems. Check if she is using the method correctly. It is important to find out if the client wants to continue the method or choose another method. Where necessary, refer clients who need care for health problems.

If the client is not satisfied with her temporary contraceptive method and wants to change, help her choose another method and explain how to use it. Changing methods is not unusual because no one can decide on a method without first trying it. Besides, the client’s situation may change, making another method a better choice.

It is not uncommon for clients to present with other reproductive health problems (e.g. STIs, domestic violence, breast lumps, abnormal cervical smear etc). The family planning provider should help refer such clients for additional care.

Summary

Counseling of HIV-positive clients for family planning should focus on individual client’s needs and situation and should assure confidentiality, voluntary choice, informed consent, respect for client’s rights and empowerment. When properly conducted, the benefits of counseling will include increased contraceptive acceptance, enhanced effectiveness, improved continuation rates with the chosen method, increased client satisfaction and reduced misconceptions and rumors. The GATHER acronym helps the provider to counsel clients in a systematic manner that leads to informed choice of a preferred method.

Next Week's Lesson: Barrier Methods of Family Planning, Dual Protection and Emergency Contraception

References and Suggested Additional Reading

1. Improving access to quality care in family planning. Medical eligibility criteria for contraceptive use. Second edition. 
   http://www.who.int/reproductive-health/publications/
   RHR_00_2_medical_eligibility_criteria_second_edition/  
   medical_eligibility_criteria_table_of_contents.en.htm
2. ReproLine: Family Planning Counseling – Presentation Graphics 
3. ReproLine: Model Service Delivery Guidelines – Counseling
4. Reproductive Health Outlook: Family Planning Program Issues
   http://www.rho.org/html/fp_program_issues.html