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| HIV Post-Test Counseling and Delivering Test Results | | What should I discuss with the patient during HIV post-test counseling? | |
Post-test counseling includes delivering the test result and making appropriate plans based on the results. The specific elements of the discussion will vary based on the test result and also to the needs of the particular patient.
When counseling a patient who has received a negative test result, information should be given about the validity of the test result, especially if the patient has engaged in high risk behavior within 6 months of the test, as well as the need for possible retesting. It is also important to talk with the patient about how to decrease his or her risk for HIV.
When counseling a patient who has received a positive HIV test result, it is important to provide a referral for HIV care, to inform the patient about the importance of informing his or her spouse, and/or sexual or drug use partners, and provide information about how to avoid transmitting HIV to others.
Documentation of post-test counseling is required in VA and should include: the results of the test; a brief overview of the content of the counseling sessions; information about the patient's comprehension of and reaction to the results; and, information about follow-up referrals or services arranged. (June 2005)
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| Do I have to deliver the HIV test results in a face-to-face meeting with the patient? Sometimes our patients may not have another clinic visit scheduled in the immediate future and they may live several hours away from our medical center. Coming in for just the HIV test result may be a hardship for some while others do not show up for appointments that were scheduled to deliver the test results. | |
VHA policy has always been to deliver HIV test results in a face-to-face meeting with the patient whenever possible. This is even more important when the test result is positive as it is critical to make sure that the patient has all the information that he or she needs to answer any questions about HIV and to offer much needed support. It is also important to help get the patient into care for their HIV as soon as possible and to provide them with the information about how to prevent transmission to others.
However, there are times when it may be difficult or impossible after multiple attempts to get a patient in for post-test counseling. At those times, it is appropriate to try to reach the patient by phone and speak with him or her directly. This is more easily done over the phone when the provider is someone who already has a relationship with the patient. Post-test counseling information should still be given and the phone conversation and results need to be documented in the medical record. Another instance in which contacting the patient by phone may be acceptable is if the result is negative and it would represent an undue burden for the patient to return for a visit just to receive the test results. Again, post-test counseling still should be done and documented in the medical chart.
It is important to make sure that the patient's confidentiality is protected. If you need to leave a message with someone on the phone, please make sure that the reason for the call is not disclosed. It is not appropriate to leave a message on results on an answering machine or to inform a patient by email, as these are not secure means of communication. (June 2005)
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| What are the requirements for documentation of post-test counseling? | |
The delivery of test results and a description of post-test counseling should be documented in a progress note in the medical record. The note should document how and when the patient received the test result, the patient's understanding of the meaning of the result, and any arrangements for follow-up testing or referral for additional care. (June 2005)
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| Reviewed/Updated Date: October 16, 2008 |
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