A. Risk counseling sessions

The basic model for risk counseling sessions should be client centered prevention counseling, which was found to be effective in reducing HIV/STD-related risk behaviors in Project RESPECT⁶. At a minimum, prevention counselors should be trained in basic client centered pre- and post- test prevention counseling before conducting CRCS.

Additionally, the overall model for risk counseling may be described as client centered. That is, within the component ‘risk counseling’ in CRCS, a menu of options exist, the basic one being client-centered prevention counseling described above. However, at all times, you will be choosing the kinds of counseling approaches and scenarios that best fit the needs of each client, and at times you may include other intervention approaches to address particular needs.

Some components of risk counseling in CRCS may be structured, unstructured, or a combination of the two.

• Structured sessions follow previously developed, standard protocols for each client. For example, prevention counselors may use structured sessions from interventions such as CLEAR⁷ or some of the other individual-level DEBI interventions⁸.
• Unstructured sessions are more flexible, allowing you to address the specific risk issues raised by your clients in a manner that seems most appropriate. For example, you can arrange sessions to help clients build skills or learn prevention strategies when those needs become apparent in the course of your counseling relationship.
• In unstructured sessions, risk reduction counseling should be theory-based and tailored to the clients’ circumstances. The Prevention Training Centers (PTCs) provide theory-based intervention trainings⁹.
• CRCS is an individual level intervention, but a client may bring in a partner for risk counseling where appropriate. You should offer or refer all clients to Partner Counseling and Referral Services (PCRS), which is usually provided through local health departments.
• While individual sessions are the essence of CRCS, group sessions or group-level interventions can be used as an additional resource, not only for recruiting to CRCS, but also to support behavior change.

For example, you may think that it would be helpful for a client to participate in a group or individual level intervention that directly addresses a particular risk issue (for example, couples counseling on disclosure issues). In this case, you would be ‘monitoring’ your client’s participation to make sure that you can help him or her to benefit from the experience.

Client needs determine selection of approaches or combination of interventions

Menu or toolbox of risk reduction interventions

HIV client centered prevention counseling (standard CTR) Other, less structured sessions that rely primarily on assessment of client prevention needs to drive content of session More structured sessions or interventions that address specific risk reduction needs and that are standardized (for all clients), such as some of the DEBIs Combination of structured and unstructured interventions, such as CLEAR

Lessons from the field

A PCM demonstration project for HIV-positive persons found that the following topics were the focus of prevention counseling for more than 50% of the participants: Relationship building Coping with being HIV-positive Psychosocial issues and risk Condom use Medical care and adherence Substance use and sexual behavior

When your client first enters CRCS, you should try to hold weekly risk reduction counseling sessions with the client – more or less often, as appropriate. As the client makes progress, you can have sessions less frequently

Getting CRCS clients to return to risk reduction sessions may be difficult at first. There are a number of strategies you can use to help with this. Agencies in previous PCM programs have found that early engagement of clients in risk reduction discussions, from the clients’ perspectives and in terms of the clients’ own interests, may encourage clients to return.

Lessons from the field

In our program, risk reduction actually begins the very moment clients enroll, and each contact with the client is used as an opportunity to provide risk reduction counseling. Clients right away write something up about what they want out of the program, and this is used to construct the first risk-reduction plan. Mobile advocates – who provide the first contact with the program – also know the community well enough that they can introduce the topic of risk reduction, in their own terms, during their first contact with the potential client. Our approach to risk reduction is that it begins right away and gradually uncovers clients’ risk issues and provides opportunity for small steps and successes. This helps build the clients’ confidence in their ability to make the changes they want to make to live healthier. Your first session may be as much about relationship-building as anything else, but you should always be prepared to follow-up your clients’ comments and questions with your queries that will help you get to your clients’ risk reduction needs quickly.

Go to section 2 part 4B

⁶http://www.cdc.gov/hiv/topics/research/respect and Rotheram-Borus MJ, et al. (2004). Prevention for substance-using HIV-positive young people: telephone and in-person delivery JAIDS 37(suppl 2):S68-S77.
⁷http://chipts.ucla.edu/interventions/manuals/intervclear.html
⁸http://www.effectiveinterventions.org
⁹http://depts.washington.edu/nnptc