• • Effective counseling to prevent sexually transmitted diseases (STDs), including HIV, comprises the following elements:
  
• • Conducting a thorough risk assessment using exploring, open-ended questions.
  
• • Addressing barriers to risk reduction and supporting preventive actions already taken.
  
• • Addressing misconceptions.
  
• • Selecting with the patient a high-risk behavior he or she is most willing and able to change.
  
• • Developing a step-wise risk reduction plan.
  
• • Providing referrals if needed.

Education and counseling have historically played a role in STD prevention activities, usually as an adjunct to testing, treatment, and partner notification services. However, it was not until the advent of the HIV epidemic that behavioral interventions, including counseling, became the focus of systematic efficacy research. A detailed review of this research and its underlying theoretical considerations is outside the scope of this chapter. However, arguably the single most important study that put counseling to reduce sexual risk behaviors on the map as an effective and feasible intervention for use in a variety of settings was Project Respect. This randomized controlled trial demonstrated that a specific type of counseling (subsequently referred to as prevention counseling), comprising two 20-minute counseling sessions, was significantly more effective in preventing subsequent STDs when compared with standard prevention messages.

The findings of this study have important consequences for STD prevention, especially because the effects of prevention counseling were shown to be particularly favorable for populations at highest risk for STDs, including individuals younger than 20 years of age and those with a baseline STD. Thus, there is a strong rationale to include counseling to reduce sexual risk behaviors when providing care for persons at high risk for STDs—that is, as long as the counseling process adheres to a number of critical elements. Subsequent sections of this chapter describe these elements and suggest ways in which prevention counseling can be incorporated into a busy practice setting where time and resources are important limiting factors.

Guidelines for HIV prevention counseling have been put forth by the Centers for Disease Control and Prevention (CDC) since 1986. Prevention counseling as evaluated in Project Respect (sometimes also referred to as client-centered counseling) was first described in 1993 and updated most recently in 2001. An adapted summary of these guidelines appears in Table 27–1, and a more detailed description follows.

General Counseling Guidelines

For prevention counseling to be most effective, an environment must be created that is conducive to an open dialog about the patient’s sexual risk behavior and ways to reduce these risks. A nonjudgmental attitude on the part of the provider is essential to avoid impediments to this process, including feelings of shame, guilt, and stigma by the patient. An open and inviting attitude and attentive listening will be perceived by patients as permission and encouragement to talk about these private issues. For example, an opening statement might be: “I realize that it may be difficult for you to discuss sexual matters, but it is important that I understand a bit better what’s going on in your life so that I can best help you.” The use of open-ended questions, discussed in greater detail below, is very helpful in the process of encouraging patients to talk freely about their sexual behavior. This is not to say that the provider should not be directive. Indeed, it is very important that counseling address personal risk behaviors of the patient and not be distracted by unrelated problems or theoretical discussions (eg, how likely it is that a certain STD will be transmitted from one person to another, or how long a person can remain infectious).

Risk Assessment

A thorough risk assessment is the first and most important step in the prevention counseling process, because all subsequent counseling actions naturally flow from it. Traditionally, risk assessments have followed a more or less standardized checklist approach, including questions on numbers of partners, gender of partners, types of sexual intercourse (vaginal, anal, oral), and condom use. Although such an approach may provide a quick gauge of the patient’s risk and repertoire of behavior, there are several important caveats when limiting the risk assessment to such “closed-ended” questions. Given the inherent sensitivity of questions related to sexual behavior, a patient may downplay or deny behaviors when these questions are not followed by further exploration. More importantly, these questions will not give answers to why this person is at risk or what the specific circumstances are that may lead to risky situations.

To explore these circumstances, and subsequently identify a specific risk behavior on which to focus the risk reduction phase of the counseling process, open-ended questions are very useful. For example, a provider may ask a female patient who has been diagnosed with chlamydia: “What do you think happened that put you at risk for this infection?” Answers to these questions generally determine the direction of the next steps of the counseling process. For instance, the patient just diagnosed with chlamydia may respond: “Well, usually I’m very careful and I always use condoms.” In fact, she tells her provider that she relies on condoms for both birth control and STD prevention. Further prompting (“So, what happened?”—another open-ended question), may reveal that she was in a bar and “got drunk and slept with a guy I didn’t know and we didn’t use a condom.” Alternatively, the patient may tell her provider that she is in a steady relationship with a man who has other partners but refuses to use condoms. Clearly, the circumstances in these two cases are very different. In the first example, the STD may be seen as the result of an isolated event, whereas the second example may indicate a more structural problem with a higher likelihood of recurrence. Thus, each of these cases represents its own particular issues and, consequently, risk reduction counseling should follow a different course for each.