Counseling People Living With HIV/AIDS

Contributors:
Brandon Hunt, Georgia Southern University

HIV/AIDS is a chronic illness that consists of three stages: acute HIV infection, chronic HIV infection, and AIDS (AIDS Info, 2014). AIDS is the most advanced stage of HIV infection and it is diagnosed by a physician based on a person having a compromised immune system with a CD4 count of less than 200 and/or one of a variety of opportunistic infections that result from a compromised immune system. For comparison, the CD4 count for a healthy person is between 500-1,600. See http://aidsinfo.nih.gov/guidelines/html/4/adult-and-adolescent-oi-prevention-and-treatment-guidelines/0 for a current list of opportunistic infections and cancers (AIDS Info, 2014; Centers for Disease Control and Prevention [CDC], 2014).

HIV works by attacking and destroying CD4 cells (also known as T cells) so the body can no longer fight off infections. According to the CDC (2015b)

Only certain fluids—blood, semen (cum), pre-seminal fluid (pre-cum), rectal fluids, vaginal fluids, and breast milk—from an HIV-infected person can transmit HIV. These fluids must come in contact with a mucous membrane or damaged tissue or be directly injected into the bloodstream (from a needle or syringe) for transmission to possibly occur. Mucous membranes can be found inside the rectum, the vagina, the opening of the penis, and the mouth. (para. 2)

In the United States, HIV is typically transmitted through sexual activity or sharing needles with
someone who is HIV infected. There is currently no cure for HIV/AIDS but medical treatment
protocols, called antiretroviral therapy, can effectively help people stay healthier and improve their quality of life (AIDS Info, 2014; CDC, 2014, 2015b). Counselors who work with people living with HIV/AIDS need to stay current in understanding advances in medical care and treatment protocols.

The only way to know if a person is HIV infected is through a blood test. The CDC (http://www.cdc.gov/hiv/basics/testing.html) provides a list of testing centers across the United States. Counselors can help clients determine if they are at risk for infection based on their behaviors and the activities in which they engage, as well as educating clients about how to more safely engage in those behaviors if they do not want to change their behavior, while decreasing their risk of infection (e.g., safer sex, safer needle sharing). The Substance Abuse and Mental Health Services Administration (SAMHSA; 2005) has developed a brief HIV/AIDS risk behavior assessment tool for mental health professionals: http://store.samhsa.gov/shin/content//SMA12-4033/SMA12-4033.pdf.

According to the CDC (2015a), 1.2 million people living in the United States are living with HIV/AIDS but 14% of them do not know they are infected. The rate of new infections has remained steady over the past 10 years; about 50,000 people in the United States become infected each year (CDC, 2014, Kaiser Family Foundation [KFF], 2014). It should be noted that rates of infection are not consistent across the United States, with some groups having proportionally higher rates of infection. Men who have sex with other men account for the highest incidence of HIV/AIDS (54%), and the rate of infection has started to increase in this group. Injection drug users represent 15% of people living with HIV/AIDS. Racial and ethnic minorities continue to be disproportionately affected by HIV/AIDS, with African Americans, who represent 12% of the U.S. population, accounting for 44% of people living with HIV/AIDS (CDC, 2015a; KFF, 2014). Hispanics/Latinos, who represent 16% of the U.S. population, account for 20% of people living with HIV/AIDS (CDC, 2015a). These numbers are significant in terms of developing and providing culturally relevant outreach and prevention, education, and treatment that reflects the needs of each group.

Intervention Strategies

Psychosocial History and Treatment Planning
A thorough psychosocial assessment should include information about a person’s physical and mental health; social support system; work, education, and recreation history; alcohol and other drug use; sexuality and sexual behaviors; spirituality/religion; coping skills and strategies; knowledge of community resources and supports (e.g., local AIDS organizations, drug trials), and potential barriers to services (Frame, Uphold, Shehan, & Ried, 2005). Counselors working in urban areas may be able to refer clients to AIDS Services Organizations (ASO) for case management services, but counselors in rural areas will often have to help clients access services.

Clients may engage in drug and alcohol use/abuse or sexual activities that may compromise their health or their ability to engage in treatment (Frame et al., 2005). Discussion of those issues should be included as part of the treatment plan, particularly if these involve a need for complex changes in client behavior. Use of strengths-based approaches with a focus on wellness and coping strategies can help clients be active in their treatment, life planning, and decisions.

Medication and Treatment
Counseling interventions can help people living with HIV/AIDS to: (a) better understand their illness, including symptoms and treatment plans, (b) become active participants in their treatment, and (c) learn how to advocate for themselves with medical and human services professionals. Education can help clients understand the importance of medication adherence and managing their physical and mental health in general. Not taking medications as prescribed can result in an increase in viral load and may cause some medications to become ineffective (CDC, 2014). Barriers to medication adherence include complexity of medication regimens/protocols (e.g., drug resistance, drug interactions, short- and long-term side effects) and costs of and access to medications (Britton, 2000). The Affordable Care Act provides people living with HIV/AIDS with increased access to health care, including prevention and treatment services (KFF, 2014). Other programs that provide medical services and housing support can be found at https://www.aids.gov/federal-resources/ and include the Ryan White HIV/AIDS Program and the Housing Opportunities for People with AIDS Program (HOPWA).

Living with a chronic, potentially fatal, illness can result in a variety of counseling issues. People need to make decisions about whether, how, and to whom disclosure of HIV status is made (e.g., partners, family, friends, employers). Counselors can work with clients to determine if, when, and how they want to let people know their HIV/AIDS status, including whether to disclose how they became infected. Counseling should also include a discussion about what do to if people react negatively, and how to maintain confidentiality in the workplace.

Depending on people’s physical and mental health status, living with HIV/AIDS may affect their ability to work and engage in meaningful life activities (for career counseling specific content see Dahlbeck & Lease, 2010; Doughty Berry & Hunt, 2005; Hunt, Jaques, Niles, & Wierzalis, 2003). Clients may need to learn ways to address stigma and assumptions about how they became infected. Clients may also need to process grief reactions related to loss of one’s health and potential loss of work, relationships, and identity as a healthy person.

Mental Health and HIV/AIDS
HIV infection not only affects people’s physical health, it also affects their mental health. Some opportunistic infections can affect the brain and nervous system, leading to changes in behavior and cognitive functioning, including dementia (National Institute of Mental Health, 2011). In addition, people living with HIV/AIDS are at increased risk for depression, post-traumatic stress disorder, and anxiety, as well as cognitive disorders (Office on Women’s Health, 2011; Reif et al., 2011). Depression is twice as common in people living with HIV/AIDS, which means people have medical issues that need to be treated separately and concurrently. There is also evidence that depression can speed up the progression from HIV to AIDS. Some HIV symptoms and medication side effects may be similar to symptoms of depression (e.g., fatigue, low sex drive, little appetite, confusion, nightmares, nervousness, weight loss), making diagnosis of depression a challenge (Office on Women’s Health, 2011).

Co-existing disorders can affect a person’s ability to make and keep physical and mental health appointments and maintain medication adherence, make use of support networks, engage in healthy behaviors (e.g., getting enough sleep, exercise, avoiding risky behaviors), and it may impair a person’s ability to cope with daily stress (AIDS.gov, 2014; Reif et al., 2012). To address these challenges, Reif et al. (2012) assessed the effectiveness of a treatment program designed for people living with HIV/AIDS and a mental disorder. CHAMP (the Collaborative HIV/AIDS Mental Health Project) staff provided nine months of in-home services based on an evidence-based program (Illness Management and Recovery) developed for people with HIV/AIDS. Licensed professional counselors and psychologists provided mental health counseling using nine modules focused on “education, increasing motivation, and building skills for coping and positive change” (Reif et al., p. 656), and 34 people completed the program. All participants experienced a decrease in psychiatric symptoms at the end of the study, and an increase in adaptive coping and social support. Participants also said they would be more willing to participate in outpatient counseling as a result of being in the program (Reif et al.).

 

Counseling strategies and interventions helpful when working with people with HIV/AIDS are similar to strategies used with people with chronic illness. Counselors should assess client competence with decision-making, communication, and problem solving skills, as well as assertiveness training and self-advocacy, to help people manage their physical and mental health. Clients can also benefit from learning stress management skills because stress can increase physical symptoms and reduce a person’s immune system. Counselors may also need to function as case managers by helping clients find physical and mental health service providers who are receptive to working with people with HIV/AIDS (Doughty Berry, & Hunt, 2005). Involving clients in group counseling, support groups, and family counseling can also expand support systems and decrease isolation and grief. Complementary therapies like accupuncture, music therapy, art therapy, and meditation can also benefit people living with HIV/AIDS.

Focusing on hope and empowerment can also benefit clients. Based on research that shows hope is key to survival for people with chronic illness, Zinck and Cutcliffe (2013) conducted a grounded theory study with 10 people living with HIV/AIDS. Based on their interviews they identified three counselor qualities that helped the participants feel more hopeful: (a) counselor self-awareness, including knowledge about their own views and beliefs about people who experience discrimination and marginalization; (b) current and accurate knowledge about HIV/AIDS; and (c) counselor hopefulness for clients. Zinck and Cutcliffe also listed possible interventions counselors can use to inspire and increase hope in people living with HIV/AIDS including witness hopelessness and re-storying client experiences.

Resources for current information about HIV/AIDS statistics, diagnoses, treatment, and resources:
AIDS Info: http://aidsinfo.nih.gov/
Centers for Disease Control and Prevention: www.cdc.gov/hiv/
The Henry J. Kaiser Family Foundation: http://kff.org/hivaids/

REFERENCES

AIDS.gov (2014). Mental health. Retrieved from https://www.aids.gov/hiv-aids-basics/staying-healthy-with-hiv-aids/taking-care-of-yourself/mental-health/

AIDS Info. (2014). HIV overview. Retrieved from http://aidsinfo.nih.gov/education-materials/fact-sheets/print/19/0/1

Britton, P. J. (2000). Staying on the roller coaster with clients: Implications for the new HIV/AIDS medical treatments for counseling. Journal of Mental Health Counseling, 22, 85–94.

Centers for Disease Control & Prevention. (2014). Living with HIV. Retrieved from http://www.cdc.gov/hiv/living/index.html

Centers for Disease Control & Prevention. (2015a). HIV in the United States: At a glance. Retrieved from http://www.cdc.gov/hiv/statistics/basics/ataglance.html

Centers for Disease Control & Prevention. (2015b). HIV transmission. Retrieved from http://www.cdc.gov/hiv/basics/transmission.html

Dahlbeck, D. T., & Lease, S. H. (2010). Career issues and concerns for persons living with HIV/AIDS. Career Development Quarterly, 58, 359–368.

Doughty Berry, J., & Hunt, B. (2005). HIV/AIDS 101: A primer for vocational rehabilitation counselors. Journal of Vocational Rehabilitation, 22, 75–83.

Frame, M. W., Uphold, C. R., Shehan, C. L., & Reid, K. J. (2005). Effects of spirituality on health-related quality of life in men with HIV/AIDS: Implications for counseling. Counseling and Values, 50(1), 5–19.

Hunt, B., Jaques, J., Niles, S. G., & Wierzalis, E. (2003). Career concerns for people living with HIV/AIDS. Journal of Counseling & Development, 81, 55–60.

Kaiser Family Foundation. (2014). The HIV/AIDS epidemic in the United States. Retrieved from http://kff.org/hivaids/fact-sheet/the-hivaids-epidemic-in-the-united-states/

National Institute of Mental Health. (2011). Depression and HIV/AIDS. Retrieved from http://www.nimh.nih.gov/health/publications/depression-and-aids/index.shtml

Office on Women’s Health. (2011). Mental health and HIV/AIDS. Retrieved from http://womenshealth.gov/hiv-aids/living-with-hiv-aids/mental-health-and-hiv-aids.html

Reif, S. S., Pence, B. W., LeGrand, S., Wilson, E. S., Swartz, M., Ellington, T., & Whetten, K. (2012). In-home mental health treatment for individuals with HIV. AIDS Patient Care and STDs, 26, 655–661. doi:10.1089/apc.2012.0242

Substance Abuse and Mental Health Services Administration. (2005). HIV/AIDS: Is your adult client at risk? Retrieved from http://store.samhsa.gov/product/HIV-AIDS-Is-Your-Adult-Client-at-Risk-/SMA12-4033

Zinck, K. E., & Cutcliffe, J. R. (2013). Hope inspiration among people living with HIV/AIDS: Theory and implications for counselors. Journal of Mental Health Counseling, 35, 60–75.

Published: February 2017
Updated: February 2017