**7.1 Counselling before and after testing HIV/AIDS**

The counselling before and after testing HIV/AIDS has phenomenal emotional, practical, psychological and social implications for each client. This type of counselling has some specifications:


The counselling before the examination is focused on providing information regarding the technical side of screening, but also the possible personal, medical, social, psychological and legal implications of diagnosis, whether it is positive or negative. Information should be given in an appropriate form and must be based on actual information. The process of child counselling has specific differences. It is necessary to explain to them every act of procedure that will reduce the initial fear.

Interview before the inquiry should focus on two main areas:


The initial interview should include discussion and assessment of the client's attitude, appraisal of psycho-social factors and knowledge about HIV/AIDS issues.

People who have been confirmed as being infected with HIV must be informed about it as soon as possible. The first interview should be confidential and the client should get some time to deal with this report. After that, he should be very clearly and factually informed about the importance of the diagnosis. At this time, devoid of different speculations about the forecast or consideration of how much time remains the affected person has to live. It is a time period, when a person has to deal with the new reality and overcome the *shock*. It's also time to provide security support and assistance. It is a time of hope for resolving personal and practical problems that may arise. If there are real possibilities of such support, it is appropriate to talk about possible ways of therapy in case of some HIV / AIDS symptoms, as well as the effectiveness of treatment.

Whether the client will or will not accept the diagnosis is usually determined by the following factors: (Bar, 2000)

• Current state of health. Persons, who are already sick, may have a prolonged reaction time. Their actual response occurs, only when they are physically stronger.

Psychosocial Aspects of People Living with HIV/AIDS 197

way people react to test results depends to a large extent on how thoroughly the counsellor

Clients' responses to the news usually vary from one person to another. Reactions may include shock, crying, agitation, stress, guilt, withdrawal, anger and outrage - some clients may even respond with relief. The counsellor should allow clients to deal with the news in their own way and give them the opportunity to express their feelings. The counsellor should show empathy, warmth and caring, maintain neutrality and respond professionally to outbursts. Because the loss of health is equated with bereavement, it manifests with all the components of denial, anger, bargaining, depression and acceptance. The counsellor

People's needs, when they receive an HIV positive test result, vary, and the counsellor has to determine what those needs are and deal with them accordingly. Fear of pain and death are often the most serious and immediate problems and these can be dealt with in various ways. Talking to clients about their fears for the future is one of the most important therapeutic interventions that the counsellor can make. Often it is enough for the counsellor just to be "there" for the client and to listen to him or her. One of the major concerns for HIV positive people is whom to tell about their condition and how to break the news. It is often helpful to use role-play situations in which the client can practise communicating the news to others. In responding to a client's needs, an attitude of non-judgmental and empathic attentiveness is more important than doing or saying specific things. Listening is more important than

Crisis intervention is often necessary after an HIV positive test result is given. The counsellor must be sure that the person has support after he or she leaves the office. A person in crisis should never be left alone: he or she should have somebody with whom to share the burden. If the client shows any suicidal tendencies, emergency hospitalisation should be arranged if a friend or family member cannot be with the client. Follow-up visits are therefore necessary to give clients the opportunity to ask questions, talk about their fears and the various problems that they encounter. Significant others, such as a partner, spouse or other members of the family may be included in the session. During the follow-up visits,

If health care professionals are not in a position to do follow-up counselling, information about relevant health services should be given. If there is a concern that the person might not return for follow-up counselling, information about available medical treatments such as anti-retroviral therapy, treatment of opportunistic infections, and social services for financial

The counsellor should inform the client about support systems such as the "buddy system" that is usually available at the nearest Aids centre or from the offices of non-governmental

It is necessary to convey information about safer sex, infection control, health care in general and measures to strengthen the immune system. It is very important also to encourage clients to go for regular medical check-ups to the health clinic. Infections and opportunistic

The *main goal* is to analyse the psycho-social aspects of people coming to the Voluntary Counselling and Testing Centre in Nairobi, Kenya. The study is realized in order to acquire

talking; being with the person more important than doing some specific action.

has educated and prepared them both before and after the test.

must respect the personal nature of an individual's feelings.

clients should be offered a choice concerning their treatment.

and on-going emotional support should be given.

organisations who work in the community.

diseases can be prevented if treated in time.

**8. Research study, objectives, methodology** 


Pre- and post-test counselling should preferably be done by the same person because the established relationship between the client and counsellor provides a sense of continuity for the client. The counsellor will also have a better idea of how to approach the post-test counselling because of what he or she experienced in the pre-test counselling. The counsellor should always ask the client if he or she is prepared to receive the results. In the case of the rapid HIV antibody test - where the results are available within minutes - the client should be asked if he/she is ready to receive the results immediately. Some clients need time to prepare for the results. For both the client and the counsellor, a negative HIV result is a tremendous relief. A negative test result could however give someone, who is frequently involved in highrisk behaviour, a false sense of security. It is therefore extremely important for the counsellor to counsel HIV-negative clients in order to reduce the chances of future infection. Advice about risk reduction and safer sex must therefore be emphasised. The possibility that the client is in the "window period" or that the negative test result may be a false negative should also be pointed out. If there is concern about the HIV status of the person, he or she should return for a repeat test after about three months and ensure that appropriate precautions are taken in the meanwhile. To communicate a positive test result to a client is a huge responsibility. The

• Readiness to accept the situation. People, who are not ready, may respond differently than those who expect such a result. Unexpected reactions may appear even if the

• Real or potential support of the environment. Factors such as satisfaction at work, harmonic family cohesion, as well as opportunities for recreation and sexual relations, may act as very positive support mechanisms. Conversely, those, who are socially isolated, have little money, scant employment perspective, poor family support and inadequate housing, react much worse. HIV positive parent, who learns that his child is infected, usually accepts the news very badly. An HIV positive parent knows his own

• Personality of tested before testing and the psychological health. If there was any mental stress before the test, the response may be more or less complicated and require a different strategy compared with those who did not have such problems. Management after such information should take into account personal psychological or psychiatric problems of clients. The stress of possible HIV positivity may cause a recurrence of previous conditions. In some cases, information about HIV positivity may unearth some unresolved issues and concerns. These often complicate the process of coping with the diagnosis. Therefore, this situation is to be handled very sensitively and

• Cultural and spiritual values related to disease and death. In many cultures people believe in an afterlife or fatality, so they receive the report of their HIV infection in a much calmer way. On the other hand, there may be a region where AIDS is seen as a punishment for antisocial and immoral behaviour, and therefore it is associated with feelings of guilt and resistance. Counselling and support are very important when reporting the news about the disease. Some reactions can be initially very turbulent. One has to realize, however, that this is a normal reaction to the report, which for the individual represents life threatening condition and that they often do not want to

• Although the post-HIV test counselling interview is separate from the pre-test counselling interview, both are inextricably linked. The pre-test counselling interview

should have given the client a glimpse of what to expect in post-test counselling. Pre- and post-test counselling should preferably be done by the same person because the established relationship between the client and counsellor provides a sense of continuity for the client. The counsellor will also have a better idea of how to approach the post-test counselling because of what he or she experienced in the pre-test counselling. The counsellor should always ask the client if he or she is prepared to receive the results. In the case of the rapid HIV antibody test - where the results are available within minutes - the client should be asked if he/she is ready to receive the results immediately. Some clients need time to prepare for the results. For both the client and the counsellor, a negative HIV result is a tremendous relief. A negative test result could however give someone, who is frequently involved in highrisk behaviour, a false sense of security. It is therefore extremely important for the counsellor to counsel HIV-negative clients in order to reduce the chances of future infection. Advice about risk reduction and safer sex must therefore be emphasised. The possibility that the client is in the "window period" or that the negative test result may be a false negative should also be pointed out. If there is concern about the HIV status of the person, he or she should return for a repeat test after about three months and ensure that appropriate precautions are taken in the meanwhile. To communicate a positive test result to a client is a huge responsibility. The

individual is prepared for the situation.

carefully as soon as possible.

admit it.

situation and knows about the chances the child may wait.

way people react to test results depends to a large extent on how thoroughly the counsellor has educated and prepared them both before and after the test.

Clients' responses to the news usually vary from one person to another. Reactions may include shock, crying, agitation, stress, guilt, withdrawal, anger and outrage - some clients may even respond with relief. The counsellor should allow clients to deal with the news in their own way and give them the opportunity to express their feelings. The counsellor should show empathy, warmth and caring, maintain neutrality and respond professionally to outbursts. Because the loss of health is equated with bereavement, it manifests with all the components of denial, anger, bargaining, depression and acceptance. The counsellor must respect the personal nature of an individual's feelings.

People's needs, when they receive an HIV positive test result, vary, and the counsellor has to determine what those needs are and deal with them accordingly. Fear of pain and death are often the most serious and immediate problems and these can be dealt with in various ways. Talking to clients about their fears for the future is one of the most important therapeutic interventions that the counsellor can make. Often it is enough for the counsellor just to be "there" for the client and to listen to him or her. One of the major concerns for HIV positive people is whom to tell about their condition and how to break the news. It is often helpful to use role-play situations in which the client can practise communicating the news to others. In responding to a client's needs, an attitude of non-judgmental and empathic attentiveness is more important than doing or saying specific things. Listening is more important than talking; being with the person more important than doing some specific action.

Crisis intervention is often necessary after an HIV positive test result is given. The counsellor must be sure that the person has support after he or she leaves the office. A person in crisis should never be left alone: he or she should have somebody with whom to share the burden. If the client shows any suicidal tendencies, emergency hospitalisation should be arranged if a friend or family member cannot be with the client. Follow-up visits are therefore necessary to give clients the opportunity to ask questions, talk about their fears and the various problems that they encounter. Significant others, such as a partner, spouse or other members of the family may be included in the session. During the follow-up visits, clients should be offered a choice concerning their treatment.

If health care professionals are not in a position to do follow-up counselling, information about relevant health services should be given. If there is a concern that the person might not return for follow-up counselling, information about available medical treatments such as anti-retroviral therapy, treatment of opportunistic infections, and social services for financial and on-going emotional support should be given.

The counsellor should inform the client about support systems such as the "buddy system" that is usually available at the nearest Aids centre or from the offices of non-governmental organisations who work in the community.

It is necessary to convey information about safer sex, infection control, health care in general and measures to strengthen the immune system. It is very important also to encourage clients to go for regular medical check-ups to the health clinic. Infections and opportunistic diseases can be prevented if treated in time.

#### **8. Research study, objectives, methodology**

The *main goal* is to analyse the psycho-social aspects of people coming to the Voluntary Counselling and Testing Centre in Nairobi, Kenya. The study is realized in order to acquire

Psychosocial Aspects of People Living with HIV/AIDS 199

Age 15-19 20-24 25-29 30-34 34-39 40-44 45-49 50-54 55+ Total Male 2 24 64 103 88 62 31 7 9 390 Female 27 149 216 162 118 47 39 7 10 775 Total 29 173 280 265 206 109 70 14 19 1165

Table 2. Number of HIV positive clients at Mary Immaculate VCT Nairobi, Kenya in years

An exploratory qualitative research study using in-depth interviews was conducted by the 6 counsellors in voluntary counselling and testing centre in Nairobi, Kenya. The interviews were carried out using semi-structured questions, open and closed questions. The counsellors collected data from their client´s record for the last 5 years (2005-2009). Data were assessed using content analysis, the study of the documentation of clients, observation,

The first objective is to discover the typical reactions of clients to their HIV/AIDS positivity. Based on the research study 60% of clients felt *fear, anxiety,* 30% of them *anger,* 25% of them indicated *distress*, 15% *cried.* Clients spoke about *grief,* feelings of sadness of loss they experienced, or are expecting. Obviously, almost all, clients confirmed positive for HIV felt *sadness* because of their status (89%). Many clients feel this way when referring to close relatives, who had suffered and died of HIV/AIDS. Only clients who are confirmed

Identification of clients' way of feeling´ *anger and aggression* after being tested differs according to gender. We came to conclusion, that many male clients who are tested positive openly show anger, disbelief, as opposed to their female counterparts. Some became aggressive (5%) towards a counsellor and demanded a repetition of the tests. The female clients tested positive for HIV tended to cry, go into shock, swallowed big lumps of air, saliva subconsciously, shook both their hand in refusal and blame the others almost

The results, if clients were to speak with counsellors were with regard to the *loss,* loss of life, their ambition, physical performance and potency, sexual relations, position in society, financial stability and independence are still challenging area for counsellors, 89% of clients are not ready to discuss the issue of loss. What they want to hear is the assurance that there is treatment, that they will live as long as any other person, or curing miracles happen and therefore one day they will be cured and be able to lead a normal life like others. It is very evident in most sessions that the magnitude associated with this status is depends on how well prepared a client is during a pre-test session. Very few clients talk about the loss of sexual relations (2%). Most of the clients register fears relating to loss of position in the

Another psycho-social issue that was discovered by the clients is a *hopelessness and helplessness* syndrome. It includes elements of giving up and leaving. It is interesting, that in years 2005 to 2007, many clients felt hopeless because of the lack of immediate elaborate

2005 to 2009 by age and gender (Okoth & Namulanda, 2010)

negative of HIV feel free to continue talking of this *topic-(grief).*

**Methodology and realization of the research study** 

**8.1 Summary of results from research study** 

comparison and interview.

immediately.

society.

support structures or mechanisms.

feedback information about psycho – social aspects in practices. The *main objectives* are follows:


#### **The target group and place of research study.**

Counsellors of VCT collected the data in the years from 2005 to 2009. They have provided counselling to 12 685 clients altogether; out of them 1165 were tested positive, which were included into the research study.

The clients were mostly from Mukuru slums, South B, South C, Nairobi West, Mugoya and from the industrial area in Nairobi. The VCT centre has a total staff included of six trained VCT counsellors, who have background trainings in public health (degree level) and psychological counselling (degree level) with vast experiences since the centre was started (2003) VCT for Mukuru slums was initiated with the aim to raise awareness about the spread of HIV/AIDS and to prevent the spread within the Mukuru population and its environment.

Being the entry point to HIV/AIDS prevention and care, the service has the specific objectives to achieve: to offer voluntary counselling and testing to the clients for HIV positivity; to provide information and education about HIV/AIDS ; to offer referral services for further management to designated referral points; to increase couple counselling and testing of VCT.

Any testing at the site must be accompanied by pre-test information and post-counselling information as prescribed in the National HIV counselling and testing guidelines. 70% of clients of VCT are coming to VCT based their own decision; this means they are not sent by doctors or nurses from any clinic or hospital.


Table 1. Number of clients at Mary Immaculate VCT Nairobi, Kenya by gender (Okoth & Namulanda, 2010)

Table shows clients in Voluntary Counselling and Testing Centre at Mary Immaculate Clinic in Nairobi, in Kenya. Out of 12 685 tested clients were 1165 positive. From the total number 775 were female and 390 male.

feedback information about psycho – social aspects in practices. The *main objectives* are

• To discover the percentage of clients in VCT, who have certain behavioural features

Counsellors of VCT collected the data in the years from 2005 to 2009. They have provided counselling to 12 685 clients altogether; out of them 1165 were tested positive, which were

The clients were mostly from Mukuru slums, South B, South C, Nairobi West, Mugoya and from the industrial area in Nairobi. The VCT centre has a total staff included of six trained VCT counsellors, who have background trainings in public health (degree level) and psychological counselling (degree level) with vast experiences since the centre was started (2003) VCT for Mukuru slums was initiated with the aim to raise awareness about the spread of HIV/AIDS and to prevent the spread within the Mukuru population and its

Being the entry point to HIV/AIDS prevention and care, the service has the specific objectives to achieve: to offer voluntary counselling and testing to the clients for HIV positivity; to provide information and education about HIV/AIDS ; to offer referral services for further management to designated referral points; to increase couple counselling and

Any testing at the site must be accompanied by pre-test information and post-counselling information as prescribed in the National HIV counselling and testing guidelines. 70% of clients of VCT are coming to VCT based their own decision; this means they are not sent by

Year 2005 2006 2007 2008 2009 Total

Male 1079 93 1128 82 1218 94 1367 59 1672 62 6464 390

Female 1011 208 1056 162 1132 145 1264 145 1758 115 6221 775

Total 2090 301 2184 244 2350 239 2631 204 3430 177 12685 1165

Table shows clients in Voluntary Counselling and Testing Centre at Mary Immaculate Clinic in Nairobi, in Kenya. Out of 12 685 tested clients were 1165 positive. From the total number

Table 1. Number of clients at Mary Immaculate VCT Nairobi, Kenya by gender (Okoth &

tested positive tested positive tested positive tested positive tested positive tested positive

• To identify the sources of stigmatization and discrimination of PLWHA in Nairobi,

• To discover whether or not clients of VCT are able to speak about spiritual issues, • To analyse the meaning of regular counselling session in order to change the behaviour

(anger, fear, anxiety, distress, shock and so on)

**The target group and place of research study.** 

doctors or nurses from any clinic or hospital.

included into the research study.

• To analyse the most problematic social issues of PLWHA,

• To analyse the psycho-social factors that affect PLWHA in Nairobi,

follows:

of PLWHA.

environment.

testing of VCT.

Namulanda, 2010)

775 were female and 390 male.


Table 2. Number of HIV positive clients at Mary Immaculate VCT Nairobi, Kenya in years 2005 to 2009 by age and gender (Okoth & Namulanda, 2010)

#### **Methodology and realization of the research study**

An exploratory qualitative research study using in-depth interviews was conducted by the 6 counsellors in voluntary counselling and testing centre in Nairobi, Kenya. The interviews were carried out using semi-structured questions, open and closed questions. The counsellors collected data from their client´s record for the last 5 years (2005-2009). Data were assessed using content analysis, the study of the documentation of clients, observation, comparison and interview.

#### **8.1 Summary of results from research study**

The first objective is to discover the typical reactions of clients to their HIV/AIDS positivity. Based on the research study 60% of clients felt *fear, anxiety,* 30% of them *anger,* 25% of them indicated *distress*, 15% *cried.* Clients spoke about *grief,* feelings of sadness of loss they experienced, or are expecting. Obviously, almost all, clients confirmed positive for HIV felt *sadness* because of their status (89%). Many clients feel this way when referring to close relatives, who had suffered and died of HIV/AIDS. Only clients who are confirmed negative of HIV feel free to continue talking of this *topic-(grief).*

Identification of clients' way of feeling´ *anger and aggression* after being tested differs according to gender. We came to conclusion, that many male clients who are tested positive openly show anger, disbelief, as opposed to their female counterparts. Some became aggressive (5%) towards a counsellor and demanded a repetition of the tests. The female clients tested positive for HIV tended to cry, go into shock, swallowed big lumps of air, saliva subconsciously, shook both their hand in refusal and blame the others almost immediately.

The results, if clients were to speak with counsellors were with regard to the *loss,* loss of life, their ambition, physical performance and potency, sexual relations, position in society, financial stability and independence are still challenging area for counsellors, 89% of clients are not ready to discuss the issue of loss. What they want to hear is the assurance that there is treatment, that they will live as long as any other person, or curing miracles happen and therefore one day they will be cured and be able to lead a normal life like others. It is very evident in most sessions that the magnitude associated with this status is depends on how well prepared a client is during a pre-test session. Very few clients talk about the loss of sexual relations (2%). Most of the clients register fears relating to loss of position in the society.

Another psycho-social issue that was discovered by the clients is a *hopelessness and helplessness* syndrome. It includes elements of giving up and leaving. It is interesting, that in years 2005 to 2007, many clients felt hopeless because of the lack of immediate elaborate support structures or mechanisms.

Psychosocial Aspects of People Living with HIV/AIDS 201

up-to-date information; they can discuss issues like prevention, getting infected with HIV, how to stop spreading HIV, and where to seek appropriate medical and psychological assistance and access to appropriate home based care. The self-support groups are often the instrument within which to accept the status and accept the comprehensive care services. It is also rare, to see the "AIDS picture" in public, thanks to the devoted involvement of ARVs, the HIV issue starts to be discussed more in families, at workplaces and in the media. A lot of PLWHA in Kenya wish to fight the stigma and to give HIV positive people hope and to encourage those who have not been tested yet to get tested and get the treatment. As a result of self-help support groups and better edification of the public, less and less *depressive* cases seem to be recorded in VCT. In the study less than 1% of clients have tried to commit suicide*.* There were clients, who came get tested for HIV positivity already decided, that if confirmed positive, they would commit suicide, however with the help of counselling they changed their decision. In one case the client brought poison in VCT, just in case, he

A situation in which one must face loneliness, loss of control and subsequently the inevitability of death, can lead to *spiritual questions* and seeking assistance in faith. Concepts of sin, guilt, forgiveness and reconciliation may be the subject of spiritual and religious discussions. There are a number of similar moments in life for the HIV positive patient. 35% of clients wish to discuss these spiritual issues. In their prayers they often express a wish for a so called miraculous curing. The counsellors have never seen even one client with a negative approach after so called miracle healing. The strong belief in God helps them to hope that God can heal at his own time, using his own ways and for his own reasons. In Kenya, especially in the slums, there are a great number of people living with HIV/AIDS communities seeking divine healing. This fact was of significant meaning for greedy pastors, who misuse the faith of believers and make them, in their hope for healing, to deliver offerings, tithing and to plant the seed of healing in the church. So people sell their properties, go and plant the seed of healing in the church (church business).The counsellors discourage client from dropping or even stopping the use of ARVs after "prayers" and remind them that it is not all right, when they are asked for money for a "prayer". They try politely without wanting to influence one´s spirituality and make clients understand, that the love of God is the same to all people, whether positive or negative, Muslim or Christian,

The issues of *grief bereavement* and issues related to *death and dying* found to be taboo issues during counselling for a large number of clients. Based on our results, only 5% felt free to speak openly about these matters. The clients, who come to be tested for HIV, do not know whether the result is going to be positive or negative. In this case should the result of the test be confirmed as negative, they state their plan to change their behaviour to reduce risk of

If the result is confirmed to be positive, most of the clients perceive themselves as if they were already dead (walking corpses). They imagine their funeral and its realization and they visualise their grave. People regret their failures and they are not ready to discuss such an issue as the death. Most clients tend to avoid this topic. It takes a lot of encouragement and

The counsellors need to encourage the clients to understand that the dying process either their own or the one of someone they know, for a HIV positive person or with some other

assurance form the counsellor to help them open up and to talk about these matters.

comparable disease or sickness, is an issue that can be openly discussed.

would be confirmed positive, and so he would be able to commit the suicide.

one tribe or another.

getting infected.

However as time has passed, the level of awareness increased, and the level of stigma decreased. These facts were expressed in the faces of most clients, who feel hope. Information on the availability of subsequent services (comprehensive care) has boosted the morale and thus an increase in VCT service uptake. Most of the clients responded to the following question "How would you accept the fact, if you turned out to be positive for HIV" with more confidence. "There are available drugs nowadays, many people take them, and so I will be able to join the support groups, start my medication and move on with my life".

By the analysis of issues, many of these were related to *guilt.* Very few people would feel guilty about the way, in which they were infected with HIV – they got infected because of their lifestyle. The majority would blame their partners or the environment, because most of them claim to have been true to their partners. (62%).In a stable relationship (marriage) the individual will feel guilt with regard to infecting the spouse. But in instable relationships (not married), the culprit will not feel guilt, so they are both guilty.

Almost all clients seeking voluntary HIV testing services have a reason for their visit, based on some form of one´s own or partner's failure, accidental happenings or poor health background and work/professional related commitments. More than half of these blame themselves subconsciously whilst up to 30% do it consciously. This is then transformed into guilt, though it is not easy to point it out openly or state it in sessions. We ask a direct question to help the client address guilt and help him accept guilt, when necessary, for example: "Do you know the direct impacts of your actions on your health when you engage yourself in unprotected sexual relationships with somebody whose state of health you do not know? "

Based on results of the research study HIV positive clients are exposed to *stigmatization* and *discrimination* which is communicated by their spouse, family members, friends, colleagues, employers, medical staff and the church. There is the complicated situation in some churches, as it is still believed, that HIV can only be spread via promiscuous way of life and they spread this message in information when preaching. The situation is really difficult, when the people living with HI/AIDS wants to get married; some religious leaders in Kenya still have a lot to say against it.

Back in 2005 to 2007 incidents of stigmatisation were higher in comparison to recent years in Kenya. 5% of women have been sent away from the husband's homestead, after his death. This was done in the belief that only women can spread HIV virus. This situation seems to be gender biased, as most of complainers were women. Some of them were helping out in houses; they were discriminated against by their employers. Mostly women from rural areas experienced discrimination from the husband's relatives.

Only a few discrimination cases are reported because it could be perceived as an offence according to some legal matters changed in Kenya and it is punishable by both jail and a fine. Clients were made redundant by an employer, who believed, that HIV positive people can become an insurance-liability issue for the company. Some companies revoked the insurance of particular employers, because they feared of overrunning of annual medical insurance costs based on misuse or on continuous illnesses treatment. It can be concluded, that stigma fades slowly away from Kenya.

The people living with HIV/AIDS themselves suffer from self-stigma, which presents an obstacle in the progress of acceptance and the consequence is low *self-esteem*.

The best way how to support PLWHA is to ask him to join *self-help support groups*. The clients who agree to join support groups and work within these groups develop internal relationships. This shows the importance of supporting one another. They have access to

However as time has passed, the level of awareness increased, and the level of stigma decreased. These facts were expressed in the faces of most clients, who feel hope. Information on the availability of subsequent services (comprehensive care) has boosted the morale and thus an increase in VCT service uptake. Most of the clients responded to the following question "How would you accept the fact, if you turned out to be positive for HIV" with more confidence. "There are available drugs nowadays, many people take them, and so I will be able to join the support groups, start my medication and move on with my

By the analysis of issues, many of these were related to *guilt.* Very few people would feel guilty about the way, in which they were infected with HIV – they got infected because of their lifestyle. The majority would blame their partners or the environment, because most of them claim to have been true to their partners. (62%).In a stable relationship (marriage) the individual will feel guilt with regard to infecting the spouse. But in instable relationships

Almost all clients seeking voluntary HIV testing services have a reason for their visit, based on some form of one´s own or partner's failure, accidental happenings or poor health background and work/professional related commitments. More than half of these blame themselves subconsciously whilst up to 30% do it consciously. This is then transformed into guilt, though it is not easy to point it out openly or state it in sessions. We ask a direct question to help the client address guilt and help him accept guilt, when necessary, for example: "Do you know the direct impacts of your actions on your health when you engage yourself in unprotected sexual

Based on results of the research study HIV positive clients are exposed to *stigmatization* and *discrimination* which is communicated by their spouse, family members, friends, colleagues, employers, medical staff and the church. There is the complicated situation in some churches, as it is still believed, that HIV can only be spread via promiscuous way of life and they spread this message in information when preaching. The situation is really difficult, when the people living with HI/AIDS wants to get married; some religious leaders in

Back in 2005 to 2007 incidents of stigmatisation were higher in comparison to recent years in Kenya. 5% of women have been sent away from the husband's homestead, after his death. This was done in the belief that only women can spread HIV virus. This situation seems to be gender biased, as most of complainers were women. Some of them were helping out in houses; they were discriminated against by their employers. Mostly women from rural areas

Only a few discrimination cases are reported because it could be perceived as an offence according to some legal matters changed in Kenya and it is punishable by both jail and a fine. Clients were made redundant by an employer, who believed, that HIV positive people can become an insurance-liability issue for the company. Some companies revoked the insurance of particular employers, because they feared of overrunning of annual medical insurance costs based on misuse or on continuous illnesses treatment. It can be concluded,

The people living with HIV/AIDS themselves suffer from self-stigma, which presents an

The best way how to support PLWHA is to ask him to join *self-help support groups*. The clients who agree to join support groups and work within these groups develop internal relationships. This shows the importance of supporting one another. They have access to

obstacle in the progress of acceptance and the consequence is low *self-esteem*.

(not married), the culprit will not feel guilt, so they are both guilty.

relationships with somebody whose state of health you do not know? "

Kenya still have a lot to say against it.

that stigma fades slowly away from Kenya.

experienced discrimination from the husband's relatives.

life".

up-to-date information; they can discuss issues like prevention, getting infected with HIV, how to stop spreading HIV, and where to seek appropriate medical and psychological assistance and access to appropriate home based care. The self-support groups are often the instrument within which to accept the status and accept the comprehensive care services.

It is also rare, to see the "AIDS picture" in public, thanks to the devoted involvement of ARVs, the HIV issue starts to be discussed more in families, at workplaces and in the media. A lot of PLWHA in Kenya wish to fight the stigma and to give HIV positive people hope and to encourage those who have not been tested yet to get tested and get the treatment.

As a result of self-help support groups and better edification of the public, less and less *depressive* cases seem to be recorded in VCT. In the study less than 1% of clients have tried to commit suicide*.* There were clients, who came get tested for HIV positivity already decided, that if confirmed positive, they would commit suicide, however with the help of counselling they changed their decision. In one case the client brought poison in VCT, just in case, he would be confirmed positive, and so he would be able to commit the suicide.

A situation in which one must face loneliness, loss of control and subsequently the inevitability of death, can lead to *spiritual questions* and seeking assistance in faith. Concepts of sin, guilt, forgiveness and reconciliation may be the subject of spiritual and religious discussions. There are a number of similar moments in life for the HIV positive patient. 35% of clients wish to discuss these spiritual issues. In their prayers they often express a wish for a so called miraculous curing. The counsellors have never seen even one client with a negative approach after so called miracle healing. The strong belief in God helps them to hope that God can heal at his own time, using his own ways and for his own reasons. In Kenya, especially in the slums, there are a great number of people living with HIV/AIDS communities seeking divine healing. This fact was of significant meaning for greedy pastors, who misuse the faith of believers and make them, in their hope for healing, to deliver offerings, tithing and to plant the seed of healing in the church. So people sell their properties, go and plant the seed of healing in the church (church business).The counsellors discourage client from dropping or even stopping the use of ARVs after "prayers" and remind them that it is not all right, when they are asked for money for a "prayer". They try politely without wanting to influence one´s spirituality and make clients understand, that the love of God is the same to all people, whether positive or negative, Muslim or Christian, one tribe or another.

The issues of *grief bereavement* and issues related to *death and dying* found to be taboo issues during counselling for a large number of clients. Based on our results, only 5% felt free to speak openly about these matters. The clients, who come to be tested for HIV, do not know whether the result is going to be positive or negative. In this case should the result of the test be confirmed as negative, they state their plan to change their behaviour to reduce risk of getting infected.

If the result is confirmed to be positive, most of the clients perceive themselves as if they were already dead (walking corpses). They imagine their funeral and its realization and they visualise their grave. People regret their failures and they are not ready to discuss such an issue as the death. Most clients tend to avoid this topic. It takes a lot of encouragement and assurance form the counsellor to help them open up and to talk about these matters.

The counsellors need to encourage the clients to understand that the dying process either their own or the one of someone they know, for a HIV positive person or with some other comparable disease or sickness, is an issue that can be openly discussed.

Psychosocial Aspects of People Living with HIV/AIDS 203

influential belong to issue pertaining to sexual practices, rate of partner change, prevalence

On the micro environmental level there are determinants as urbanization, mobility, access to health-care services, and status of women, violence issues, stigmatization and

The macro environment determinants influencing the daily life of people living with HIV

All these aspects should be taken into account by analysing the psychological and social living of HIV positive people. Psychological mechanisms such as denial, avoidance, grief, discrimination, etc. are encouraged by practices and gender-dominant relationships in the African culture, which increases women's and children vulnerability to HIV infection. It is very important to create a positive environment and positive mind-set for people living with

The stigma can be minimized through campaigning, so that people can continue to lead a life, which is productive and full-valued. For a wider outreach of actions, programs cannot be restricted to massive information diffusion but the psycho-educational strategies need to be applied on a small number of target groups. There is the need, not only to increase the

Culture, values, traditional norms and taboos are lost as a consequence of too many HIV/AIDS deaths. The support groups seem to be a very positive way in supporting people how to cope with the situation. The services provided to the families are needed very much and also the wider family should be well–informed and educated in order to provide basic

A great amount of special care must be given to HIV positive children and children, who became orphaned due to HIV/AIDS. Education and support is the most effective tool that helps people living with HIV/AIDS to live a psychologically well-balanced life. Proper support will also help people with HIV/AIDS to move through the appropriate stages and to reach the acceptance of their status and to cope with all the psycho-social issues in their

HIV positive people can use the educational activities to learn the way of how in order to be in charge of their own medical care, and how to protect themselves as well as those around them. They can also disseminate this education to others and help to reduce the stigma within their communities. Through the many changes and challenges, it the support of family, friends, communities, and health care professionals which are essential to overall

Bar R. et.al. (2000). *Counselling in Health Care Settings,* Casell, ISBN 0-304-33986-5, London,

Botek, O. & Kovalcikova, N. (2008). *Particularities of building institutional services for* 

*Cambodia.* In: Collection contributions of the 3rd International conference on Hospice and Palliative Care, Faculty of Health Care and Social Work, Trnava University,

*HIV/AIDS suffering children in South-Eastern Asia,* In: Assessing the "Evidence-base"

Bastecky, J. et al. (1993). *Psychosomatic medicine,* Grada Avicenum, Praha, Czech Republic Botek, O., Zakova, M. & Docze, A. (2005). *Palliative care of HIV/AIDS suffering children in* 

medical knowledge but also to enhance the awareness about HIV/AIDS in general.

are culture, religion, governance, income distribution as well as wealth.

of partners, condom usage and so on.

emotional and psycho-social support.

discrimination and so on.

HIV/AIDS.

lives.

well-being.

**10. References** 

England

ISBN 80-88949-84-x, Trnava, Slovakia

The following outlines the *most problematic social issues* of people living with HIV/AIDS in Mukuru slums, Kenya want to discuss with counsellors in VCT:


The clients of VCT mentioned also some other issues, which they face, for example poor supplies of ARVs; how the available treatment is not available for all; corruption, which allows receiving treatment only in the case of some acquaintances and contacts with higher positioned staff in rural clinics. Clients have also financial problems. Some of them have a long way to travel from home to the treatment centres.

The service providers, who always seem to have "permanent issues" with anybody who has HIV/AIDS constantly breach confidentiality. Some clients start to drink alcohol and turn into heavy drinkers / drug users in order to avoid stress.

On the side of counsellors in VCT the challenging issues are often linked with the poor level of education of the clients and strong traditional beliefs. There is usually a high level of conflict that some clients find themselves in, for example conflict between religious beliefs and traditional African beliefs.

Another issue is the high expectation referring to the dependency syndrome, depending too much on guidance and not being able to be self-dependant or self-sufficient. There is an increase of the threshold for starting ARVs by the government from CD4 counts of below 250 to CD4 counts of below 350. This is very important and positive for a third-world country; it is not only practical but also realistic. It easily caused a shift of half a million people to be immediately put on ARVs yet the stock, stores, staff, infrastructure, expertise and counselling staff were not present and available.
