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HIV counselling in the 1990s
950
HIV counselling in the 1990s
practices. Moreover, if HIV testing is to be promoted, there will have to be concomitant changes in the social conditions that patients may confront (eg, restrictions on employment, life insurance, and mobility). It is no longer possible to be completely neutral about HIV testing. Many patients are now well informed; they know the benefits of early testing and want to discuss the implications of a positive test result. We must develop brief but effective ways of addressing all these issues in pre-test sessions5 and initiate research into the efficacy of HIV counselling.
On World AIDS Day last December, Sir Donald Acheson, Chief Medical Officer at the Department of Health in London, stated that there are advantages for people who think they have been at risk of human immunodeficiency virus (HIV) infection in coming forward for HIV testing. The decision as to whether individuals should have a test has always been complex, but lately more positive views about testing have emerged. Why have attitudes shifted? First, advances in primary prophylaxis of Pneumocystis cariniz"1 and in antiviral therapy suggest that the outlook for those infected with HIV may have improved.2Additionally, the natural history of the infection is now better understood and regular monitoring of patients’ immune status enables them to make informed decisions. If patients decide to be tested, Sir Donald advises that they should first "be counselled, as now, about the implications of taking the test, and if it proves positive, what effect this may have on them". Many health care workers have discouraged their patients from being tested. The mystique surrounding counselling may have inhibited some doctors from discussing the test with patients, whereas, in the words of the General Medical Council, obtaining informed consent for HIV testing "should form part of the diagnostic process". Counsellors, acting as gatekeepers to HIV services, may have focused on the negative psychosocial sequelae of testing. Nevertheless, it is clear that an anti-testing position is at best self-defeating and at worst dangerous. It is self-defeating since only from patients can we learn more about the natural history of HIV infection so that we can plan for their care and treatment; it is potentially dangerous because patients are denied the benefits of treatment that may prolong life. The reality for most people with HIV infection is that symptoms will appear in time, even though the period of latency may be a decade or more.33 Dissuading people from having a test is, in effect, to collude with the position of denial. If people who are at risk of HIV are dissuaded, the worry about HIV never goes away completely and is exacerbated at times when they are psychologically and physically vulnerable. Conversely, a negative test can bring enormous relief and stability to those who have worried about their HIV status. HIV testing raises both ethical and social policy issues, as discussed in the latest World Health Organisation guidelines.4 Views about testing and social care will inevitably reflect local needs and resources, although the relevance of counselling in mass screening is unclear. An HIV test is only the
How should ophthalmologists and paediatricians counsel parents of apparently blind infants with normal eyes and normal retinal functions about the likely visual outcome? Beauvieux reported over 60 years ago that these infants may subsequently improve. He later described two broad groups: (a) those in whom delayed visual maturation was the only abnormality, with rapid improvement and complete recovery of vision within about 4 months; and (b) those whose delayed visual maturation was associated with other abnormalities such as squint, myopia, nystagmus, or mental retardation, in whom visual recovery was slower and less completed In 1961, Illingworth2 described two infants with delayed visual maturation whom he believed to be otherwise neurologically normal. He regarded these cases as examples of "normal" developmental dissociation. Subsequent reports3,4emphasised that the disorder could occur in infants without any overt neurological defects. Nevertheless, several researchers noted that a high proportion of these infants had had perinatal difficulties, and that some who seemed normal initially manifested abnormal signs later.5-7 These observations suggested that the abnormal vision might be a marker for a wider neurological impairment resulting from a prenatal or perinatal insult.7,8 Further understanding has been hampered because the condition cannot be diagnosed until vision becomes normal. Consequently, most reported series
beginning of an assessment process. From a baseline, doctors can give a more accurate and often positive message to the patient. They must also continue to counsel all patients about safer sex and drug injection
have been retrospective and have largely relied on historical data. Two groups9,10 have lately undertaken detailed prospective studies of infants who presented with absent visual responses and in whom the
1. Fischl M, Dickinson G, La Vioe L. Safety and efficacy of sulfamethoxazole and trimethoprim chemoprophylaxis for Pneumocystis carinii pneumonia in AIDS. JAMA 1988; 259: 1185-89. 2. Volberding P, Lagakos S, Koch M, et al. Zidovudine in asymptomatic human immunodeficiency virus infection: a controlled trial in persons with fewer than 500 CD4 positive cells per cubic millimeter. N Engl J Med 1990; 322: 941-49. 3. Biggar R. AIDS incubation in 1891 HIV seroconverters from different exposure groups. AIDS 1990; 11: 1059-66. 4. World Health Organisation. Guidelines for counselling about HIV infection and disease. Geneva: WHO, 1990. 5. Bayer R. Ethical and social policy issues raised by HIV screening: the epidemic evolves and so do the challenges. AIDS 1989; 3: 119-24.
Delayed visual maturation
HIV counselling in the 1990s
practices. Moreover, if HIV testing is to be promoted, there will have to be concomitant changes in the social conditions that patients may confront (eg, restrictions on employment, life insurance, and mobility). It is no longer possible to be completely neutral about HIV testing. Many patients are now well informed; they know the benefits of early testing and want to discuss the implications of a positive test result. We must develop brief but effective ways of addressing all these issues in pre-test sessions5 and initiate research into the efficacy of HIV counselling.
On World AIDS Day last December, Sir Donald Acheson, Chief Medical Officer at the Department of Health in London, stated that there are advantages for people who think they have been at risk of human immunodeficiency virus (HIV) infection in coming forward for HIV testing. The decision as to whether individuals should have a test has always been complex, but lately more positive views about testing have emerged. Why have attitudes shifted? First, advances in primary prophylaxis of Pneumocystis cariniz"1 and in antiviral therapy suggest that the outlook for those infected with HIV may have improved.2Additionally, the natural history of the infection is now better understood and regular monitoring of patients’ immune status enables them to make informed decisions. If patients decide to be tested, Sir Donald advises that they should first "be counselled, as now, about the implications of taking the test, and if it proves positive, what effect this may have on them". Many health care workers have discouraged their patients from being tested. The mystique surrounding counselling may have inhibited some doctors from discussing the test with patients, whereas, in the words of the General Medical Council, obtaining informed consent for HIV testing "should form part of the diagnostic process". Counsellors, acting as gatekeepers to HIV services, may have focused on the negative psychosocial sequelae of testing. Nevertheless, it is clear that an anti-testing position is at best self-defeating and at worst dangerous. It is self-defeating since only from patients can we learn more about the natural history of HIV infection so that we can plan for their care and treatment; it is potentially dangerous because patients are denied the benefits of treatment that may prolong life. The reality for most people with HIV infection is that symptoms will appear in time, even though the period of latency may be a decade or more.33 Dissuading people from having a test is, in effect, to collude with the position of denial. If people who are at risk of HIV are dissuaded, the worry about HIV never goes away completely and is exacerbated at times when they are psychologically and physically vulnerable. Conversely, a negative test can bring enormous relief and stability to those who have worried about their HIV status. HIV testing raises both ethical and social policy issues, as discussed in the latest World Health Organisation guidelines.4 Views about testing and social care will inevitably reflect local needs and resources, although the relevance of counselling in mass screening is unclear. An HIV test is only the
How should ophthalmologists and paediatricians counsel parents of apparently blind infants with normal eyes and normal retinal functions about the likely visual outcome? Beauvieux reported over 60 years ago that these infants may subsequently improve. He later described two broad groups: (a) those in whom delayed visual maturation was the only abnormality, with rapid improvement and complete recovery of vision within about 4 months; and (b) those whose delayed visual maturation was associated with other abnormalities such as squint, myopia, nystagmus, or mental retardation, in whom visual recovery was slower and less completed In 1961, Illingworth2 described two infants with delayed visual maturation whom he believed to be otherwise neurologically normal. He regarded these cases as examples of "normal" developmental dissociation. Subsequent reports3,4emphasised that the disorder could occur in infants without any overt neurological defects. Nevertheless, several researchers noted that a high proportion of these infants had had perinatal difficulties, and that some who seemed normal initially manifested abnormal signs later.5-7 These observations suggested that the abnormal vision might be a marker for a wider neurological impairment resulting from a prenatal or perinatal insult.7,8 Further understanding has been hampered because the condition cannot be diagnosed until vision becomes normal. Consequently, most reported series
beginning of an assessment process. From a baseline, doctors can give a more accurate and often positive message to the patient. They must also continue to counsel all patients about safer sex and drug injection
have been retrospective and have largely relied on historical data. Two groups9,10 have lately undertaken detailed prospective studies of infants who presented with absent visual responses and in whom the
1. Fischl M, Dickinson G, La Vioe L. Safety and efficacy of sulfamethoxazole and trimethoprim chemoprophylaxis for Pneumocystis carinii pneumonia in AIDS. JAMA 1988; 259: 1185-89. 2. Volberding P, Lagakos S, Koch M, et al. Zidovudine in asymptomatic human immunodeficiency virus infection: a controlled trial in persons with fewer than 500 CD4 positive cells per cubic millimeter. N Engl J Med 1990; 322: 941-49. 3. Biggar R. AIDS incubation in 1891 HIV seroconverters from different exposure groups. AIDS 1990; 11: 1059-66. 4. World Health Organisation. Guidelines for counselling about HIV infection and disease. Geneva: WHO, 1990. 5. Bayer R. Ethical and social policy issues raised by HIV screening: the epidemic evolves and so do the challenges. AIDS 1989; 3: 119-24.
Delayed visual maturation