A consultation for an STI provides an opportunity for the health worker to discuss and explore with the patient, on a one-to-one basis, his or her risk factors for HIV/STI and other issues related to prevention and treatment. Frequently this consists of the provision of information about STI and their prevention, condom use and partner notification. This is education for prevention and is an essential part of an STI consultation.
However, just providing information is usually not sufficient to allow patients to accurately assess their own risk of infection or to deal with the challenges of informing a partner/partners, of preventing future infections or dealing with complications of STI. Some issues, which arise during an STI consultation, may provoke emotional reactions in the patient. Therefore, to deliver more than just education counselling is needed.
Counselling is defined here as an interactive confidential process where a care provider assists a patient in reflecting on these issues and in exploring possible lines of action. There often is a need for skills building and practising different behaviours and all this may require multiple visits. Counselling is much more time-consuming than more traditional means of information provision and requires from health care workers more empathy and understanding of the social and economic situation of a patient, as well as an ability to overcome their own judgmental attitudes.
Issues that should be addressed in a counselling session include:
• informing the partner(s) or spouse about the STI diagnosis (options: either the patient or the health care provider informs the partner(s) or spouse);
• assessing the patient's own risk for HIV and deciding whether or not to undergo testing for HIV;
• learning about, and coming to terms with, worrisome complications of STI, such as infertility, congenital syphilis, etc;
• dealing with an incurable STI such as herpes genitalis which may be transmitted to the partner(s) or spouse;
• symptoms suggesting HIV-related disease
• prevention of future infections, including strategies to discuss and introduce condom use with a partner
• confidentiality, disclosure and the risk of violence or stigmatizing reactions from spouse, partner, family or friends
Before offering counselling to STI patients, the care provider needs to:
• identify the need of the client which may relate to stress or anxiety about a particular aspect of the STI, or may be a special need for confidential risk assessment and planning for risk reduction;
• have the counselling skills, the privacy, and the time (usually 15-20 minutes), including the availability for follow-up discussions, as appropriate.
These resources are usually not available at a busy STI or general outpatient clinic. It is, therefore, suggested that when a counselling need is identified, the patient should be referred to a nearby counselling service, if this is available. If it is not, then a health or social worker may be designated to provide the counselling. This person should receive the relevant training and be accorded the necessary space and time off from other duties to provide the counselling. While not all adolescents will need to be referred for counselling, they have a well-recognized need to be able to talk to someone they can trust and who is well-informed. Having links to local support groups involved with young people can reinforce the clinical advice given at the clinic and encourage them to return to the clinic for future needs.
In many developing countries where health resources are scarce, counselling services are not always generally available. However, it is recognized that some of the ingredients of counselling - compassion, sensitivity and communication skills - are qualities that many health workers already possess and apply on a daily basis during all interactions with patients. Even in the absence of formal training in counselling, health workers should be encouraged to engage their patients in a dialogue about STI to explore risk assessment, personal behavioural options and to identify those requiring further emotional support, if such support is available.