![](media/image1.jpeg){width="3.0479166666666666in"
height="4.1305555555555555in"}Couples HIV Counseling and Testing (CHCT)

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# Participant's Manual {#participants-manual .COVER-SH1}

# November 2007 {#november-2007 .COVER-SH1}

Couples HIV Counseling and Testing Intervention and Curriculum

**Centers for Disease Control and Prevention**

**National Center for STD HIV Viral Hepatitis and TB Prevention,**

**Global AIDS Program**

+-----------------------------------+-----------------------------------+
| Michele Evering-Watley, MS        | Beth Dillon, MSW, MPH             |
|                                   |                                   |
| Instructional Designer            | Intervention Design and Technical |
|                                   | Content                           |
+-----------------------------------+-----------------------------------+
| Alison Surdo, MPH                 | Janet Moore, PhD                  |
|                                   |                                   |
| Research and Technical Content    | Technical Advisor                 |
+-----------------------------------+-----------------------------------+
| Task Force for Child Survival and | Susan Allen, MD, MPH, DTM&H       |
| Development                       |                                   |
|                                   | Technical Advisor                 |
| Curriculum Designers              |                                   |
+-----------------------------------+-----------------------------------+

# Acknowledgements

**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

Dr. Susan Allen, a Professor at Emory University, with her colleagues
and field staff in Rwanda and Zambia, conducted the sentinel research
that clearly documented the critical importance of couples HIV
counseling and testing services. The counselors on these studies from
the Rwanda-Zambia HIV Research Group (including Project San Francisco
\[PSF\] in Kigali, Rwanda, and the Zambia-Emory HIV Research Project
\[ZEHRP\] in Lusaka, Zambia) pioneered approaches to delivering HIV
counseling and testing services to couples. Dr. Allen and her staff
provided ongoing guidance and support throughout the conceptualization
and consultation process of developing this curriculum. Dr. Allen's
research has been supported by the US National Institutes of Health,
including the Institutes of Allergy and Infectious Diseases, Mental
Health, and Child Health and Development, as well as the International
AIDS Vaccine Initiative (IAVI).

Dr. Rebecca Bunnell from the Global AIDS Program in Uganda provided
technical content, guidance, and conceptual contributions to this
curriculum based on her research and work in Uganda.

Dr. Connie Celum from the University of Washington, through a grant from
the Gates Foundation, coordinated and provided resources to support two
initial pilots of the curriculum materials: April 2004 in Johannesburg,
South Africa, and May 2004 in Nairobi, Kenya. Counselors and staff from
the Partners in Prevention study sites provided valuable feedback during
these pilot tests.

Dr. Miriam Taegtmeyer, Director of Liverpool VCT in Kenya, in December
2003 coordinated a one and a half day consultation of counselors from
Liverpool VCT, PSF, and ZERPH to share their wealth of experience in
providing services to couples and to provide input and feedback on the
draft document. Dr. Alan Haworth, Director of the Ministry of Health
Counseling Unit, Lusaka, Zambia, was a key contributor to this workshop.
The following persons also participated in this consultation:

+-----------------------------------+----------------------------------+
| **Liverpool VCT, Kenya**          | # University of Washington       |
|                                   |                                  |
| Jane Karongehati                  | Shana Sniffen                    |
|                                   |                                  |
| Youniter Mutsungah                |                                  |
+-----------------------------------+----------------------------------+
| **Project San Francisco, Rwanda** | **ZEHRP, Zambia**                |
|                                   |                                  |
| Dvora Joseph                      | Lucy Banda                       |
|                                   |                                  |
| Mechtilde Mukankuku               | Steven Dunham                    |
|                                   |                                  |
| Vestine Mutarabayire              | Elias Gudo                       |
|                                   |                                  |
|                                   | James Mubonde                    |
+-----------------------------------+----------------------------------+
| **Tebelopele VCT, Botswana**      |                                  |
|                                   |                                  |
| Mary Grace Alwano                 |                                  |
+-----------------------------------+----------------------------------+

Dr. Elizabeth Marum, June Odoyo, and Jane Tipton from CDC-Kenya
coordinated a consultation of counselors from Kenyan

VCT sites in December 2003 to share their experiences and present case
studies. The following persons in Kenya shared their expertise:

+-----------------------------------+-----------------------------------+
| **Baraka Clinic**                 | **Kibera Community Self-Help      |
|                                   | Program**                         |
| Chrisphen Simbiri                 |                                   |
|                                   | Fillet Darizu                     |
|                                   |                                   |
|                                   | Phyllis Kitavi                    |
|                                   |                                   |
|                                   | Evlyn Wasonga                     |
+-----------------------------------+-----------------------------------+
| **Eastern Deanery AIDS Relief     | **Tivoli VCT**                    |
| Program**                         |                                   |
|                                   | Maurice Abuodha                   |
| George Otieno Owiso               |                                   |
|                                   | Pamela Menya                      |
+-----------------------------------+-----------------------------------+
| **Kenyatta National Hospital**    |                                   |
|                                   |                                   |
| Francis Kathambana                |                                   |
|                                   |                                   |
| Christine Otieno                  |                                   |
+-----------------------------------+-----------------------------------+

Vel McKleroy, Ben Bellows, Megan Thorley, and Walker Tisdale from CDC
facilitated a one-week workshop in September 2002 at the AIDS
Information Center (AIC) in Kampala, Uganda, to outline a couples HIV
counseling and testing framework. The following persons participated in
this workshop:

+-----------------------------------+-----------------------------------+
| **Tebelopele VCT, Botswana**      | **Liverpool School of Tropical    |
|                                   | Medicine, Kenya**                 |
| Nkopane Mfolwe                    |                                   |
|                                   | Youniter Mutsungah                |
| Monkie Morake                     |                                   |
+-----------------------------------+-----------------------------------+
| **CDC Uganda**                    | **Ministry of Public Health,      |
|                                   | Thailand**                        |
| Margaret Achom                    |                                   |
|                                   | Kanyarat "Toom" Klumthanom        |
| Humphrey Masaba                   |                                   |
|                                   | Suporn Koetsawang                 |
+-----------------------------------+-----------------------------------+
| **MACRO, Malawi**                 | **Kenyatta National Hospital,     |
|                                   | Kenya**                           |
| Tamara Phiri                      |                                   |
|                                   | Christine Magambo                 |
| S. William                        |                                   |
+-----------------------------------+-----------------------------------+
| **Project San Francisco, Rwanda** | **AIC/TASO/Ministry of Health,    |
|                                   | Uganda**                          |
| Mechtilde Mukankuku               |                                   |
|                                   | Janet Bahizi                      |
| Vestine Mutarabayire              |                                   |
|                                   | Alice Berigija                    |
|                                   |                                   |
|                                   | Kellen Tumuhairwe                 |
+-----------------------------------+-----------------------------------+

+-----------------------------------+----------------------------------+
| **National DOH, South Africa**    | **ZEHRP, Zambia**                |
|                                   |                                  |
| Cleopatra "Cleo" Sehloho          | Lucy Banda                       |
|                                   |                                  |
| Nosimilo "Milo" Zama              | Elias Gudo                       |
|                                   |                                  |
|                                   | James Mubonde                    |
+-----------------------------------+----------------------------------+

Michael Iatesta and the VCT Team identified the important role that
Couples HIV Counseling and Testing (CHCT) could play in HIV prevention.
He convened a consultation of experts and researchers in Atlanta,
Georgia, in August 2002 to review the scientific basis for couples
counseling and to identify the critical issues to be considered in
developing a counseling and testing intervention for couples. The
following persons contributed to this meeting:

+-----------------------------------+----------------------------------+
| **CDC**                           | **University of                  |
|                                   | Alabama--Birmingham**            |
| Mary Kamb                         |                                  |
|                                   | Leslie Clark                     |
| Janet Moore                       |                                  |
|                                   | Joseph Telfair                   |
| Ann O'Leary                       |                                  |
|                                   |                                  |
| Tom Painter                       |                                  |
|                                   |                                  |
| Kathy Parker                      |                                  |
|                                   |                                  |
| R.J. Simonds                      |                                  |
|                                   |                                  |
| Megan Thorley                     |                                  |
+-----------------------------------+----------------------------------+
| **HRSA**                          | **University of North Carolina   |
|                                   | at Chapel Hill**                 |
| Beth Dillon                       |                                  |
|                                   | Priya Satow                      |
+-----------------------------------+----------------------------------+
| **Emory University**              | **University of Zambia**         |
|                                   |                                  |
| Susan Allen                       | Alan Haworth                     |
+-----------------------------------+----------------------------------+

# Foreword

**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

The *Couples HIV Counseling and Testing (CHCT) Intervention and Training
Curriculum* was developed in response to increased demand from field
partners for interventions and training that would help them address the
complex issues related to HIV counseling and testing (HCT) with couples.
The materials are intended to guide trainers and participants through a
general course covering essential topics and activities for the CHCT
provider. By addressing CHCT technical content, and counseling and
communication skills through learning exercises and hands-on practice,
the materials aim to increase the skills of counselors who provide HCT
to couples. Working with couples can be challenging and complex, even
for the most experienced counselor. This manual was developed to address
the challenges faced by these counselors in the field.

The goal of this manual is to provide reference materials and course
documents to HCT providers who are being trained in CHCT. The modules
outlined in the curriculum will build upon the existing counseling
skills of these providers so that they may help individuals in a couple
understand the results of their HIV tests, as well as the importance of
preventing all of their partners from becoming infected with HIV.

CHCT has emerged as an important intervention aimed at preventing the
transmission of HIV between sex partners, and cohabiting or married
couples. HIV prevention counselors can assist couples by:

1.  Providing clear and accurate prevention messages tailored to the
    couple's life stage and reasons for seeking HCT services

2.  Mitigating tension and diffusing blame

3.  Dispelling myths about HIV transmission

4.  Creating an environment that is safe for disclosure of HIV status
    among partners; and

5.  Discussing options for disclosure of HIV status to the couple's
    children, and thinking through appropriate next steps for testing
    children, when necessary.

The materials found in this intervention and curriculum package were
designed for experienced HIV prevention counselors currently working in
HCT sites, regardless of whether they have prior experience counseling
couples or not. This manual is not intended for HCT providers in health
facilities such as prevention of mother-to-child transmission (PMTCT)
sites or tuberculosis (TB) clinics. Couples HIV counseling and testing
is an important intervention in these settings, however, and an
abbreviated version of the CHCT intervention found in this manual will
be optimal for those who will provide HCT services in these sites and
settings.

The materials, instructional design, and formatting of this training
package were field tested in South Africa, Kenya, and Botswana in 2004.
In January 2006, the final field test was conducted in Kenya. These
materials were also used in CDC-led trainings conducted in Botswana,
Malawi, and Ethiopia in 2005, in Namibia in 2006, and in Nigeria in
2007. Local co-trainers and participants in early pilot tests of this
manual provided valuable feedback that was used to strengthen these
training materials.

As with any training package developed for use in a variety of
countries, it will be necessary to review this document and tailor it
based on the country's HIV counseling and testing policies and
guidelines; current treatment availability; local and regional
realities; cultural norms of couples seeking HCT services; and current
and future foreseeable trends in HIV prevention, care, treatment, and
support.

Several countries have introduced policies and HCT guidelines supporting
and promoting CHCT. As a response to the growing demand for these
services, some countries have already met with key local partners,
adapted earlier drafts of these materials, and begun implementing CHCT
trainings.

+-----------------------------------------------------------------------+
| Michele Evering-Watley, MS                                            |
|                                                                       |
| Master Trainer/Instructional Designer                                 |
|                                                                       |
| Health Education Specialist, CDC-Atlanta                              |
+-----------------------------------------------------------------------+

# Table of Contents

**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**Acknowledgements**

**Foreword**

**Abbreviations**

**Module One: Background and Discordance**

> Module Overview 1
>
> Facilitating a Shared Vision: Goals and Objectives 2
>
> CHCT: Characteristics and Advantages 5
>
> Importance of CHCT 7
>
> Discussing Discordance with Couples 8
>
> HIV Knowledge among CHCT Clients 9
>
> Facts about Discordance 10
>
> Wrap-up 11

**Module Two: Introduction to Couples Counseling Skills**

> Module Overview 12
>
> Basic Counseling Skills 13
>
> Essential Skills and Attributes of the Couples Counselor 14
>
> Self Awareness Exercise 16
>
> The Importance of Counselor Self Awareness 17
>
> Other Issues Affecting Couples Counselor's Ability to Provide Quality
> Service 18
>
> Additional Couples Counseling Skills 19
>
> Forming an Alliance between the Counselor and the Couple 20
>
> Directing Communication in Couples Counseling 22
>
> Mediation Skills for Easing Tension and Diffusing Blame 24
>
> Solution-Focused Model of Couples Counseling 28
>
> References 29

**Module Three: Initial Session of the CHCT Intervention**

> Module Overview 30
>
> Conditions for Receiving CHCT Services 31
>
> Realities of CHCT 32
>
> Using a Protocol: Terms and Definitions 33
>
> The Initial Session 34
>
> Component I: Introduce Couple to CHCT and Obtain Concurrence 35
>
> Types of Couples Seeking HIV Counseling and Testing 37
>
> Component II: Explore Couple's Life Stage and Reasons for Seeking CHCT
> Services 40
>
> Johari's Window for Couples 42
>
> Discussion of Couples Abstract HIV Risk Issues and Concerns 43
>
> Limitations in Conducting an Individual Risk Assessment in the Context
> of CHCT 44
>
> Component III: Discuss of Couple's HIV Risk Issues and Concerns 45
>
> Component IV: Prepare for Testing and Discuss Possible Results 47
>
> Considerations for Delivering HIV Test Results to a Couple 49
>
> References 50

**Module Four: Providing Concordant Negative Results**

> Module Overview 51
>
> Component V-A: Provide Concordant Negative Results 52
>
> Component VI-A: Discuss Risk Reduction 54

**Module Five: Providing Concordant Positive Results**

> Module Overview 56
>
> Component V-B: Provide Concordant Positive Results 58
>
> Component VI-B: Discuss Coping and Mutual Support 59
>
> Component VII-B: Discuss Positive Living and HIV Care and Treatment 60
>
> Fundamentals of Antiretroviral (ARV) Treatment of HIV Infection 61
>
> Component VIII-B: Discuss Things to do at Home to Keep Healthy 62
>
> Component IX-B: Discuss Risk Reduction 63
>
> Component X-B: Discuss Children, Family Planning and PMTCT Options 64
>
> Basic Information about PMTCT 65
>
> Universal PMTCT Messages 66
>
> References for PMTCT Section 69
>
> Component XI-B: Discuss Disclosure and Getting Support 70
>
> Review Essential Counselor Attributes and Skills 74
>
> References 76

**Module Six: Providing Discordant Results**

> Module Overview 77
>
> Factors that Influence Transmission of HIV 79
>
> Essential Counselor Responsibilities 82
>
> Component V-C: Provide Discordant Test Results 83
>
> Component IX-C: Discuss Protecting the Negative Partner from HIV 84
>
> Potential Differences: Concordant Positive and Discordant Couples 86

**Module Seven: Support and Prevention Services**

> Module Overview 87
>
> Support Services and Resources for Couples 88
>
> Prevention with Positives 89
>
> Care and Support Services for HIV Affected Children 90
>
> Fundamentals of Referrals and Linkages 91
>
> Community Mobilization Basics 92
>
> References 92

**Module Eight: Outreach and Recruitment**

> Module Overview 93
>
> Why is Outreach Important? 94
>
> Community Outreach 94
>
> Door to door Outreach 95
>
> Media Outreach 95
>
> Outreach through Fictional Drama 96
>
> Outreach through Antenatal Clinics and PMTCT Programs 96
>
> Outreach in the Workplace 96
>
> Closing Exercise 98
>
> References 99

# Abbreviations

**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

AIC AIDS Information Center

AIDS acquired immune deficiency syndrome

ARV antiretroviral (drug)

CDC United States Centers for Disease Control and Prevention

CHCT couples HIV counseling and testing

CITC client-initiated testing and counseling

FP family planning

HCT HIV counseling and testing

HIV human immunodeficiency virus

IAVI International AIDS Vaccine Initiative

IGA income generating activity

LSTM London School of Tropical Medicine

PEPFAR United States President's Emergency Plan for AIDS Relief

PITC provider-initiated HIV testing and counseling

PMTCT prevention of mother-to-child HIV transmission

PSF Project San Francisco (Rwanda)

PWP Prevention with Positives

RZHRG Rwanda-Zambia HIV Research Group

STI sexually transmitted infection

TB tuberculosis

VCT voluntary counseling and testing

ZEHRP Zambia-Emory HIV Research Project (Zambia)