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Manual on Advance Counselling for
ICTC Counsellors
Participant’s Manual
Manual on Advance Counselling for ICTC Counsellors
Page 1
HIV/AIDS Knowledge and Information
This section deals with providing updated knowledge essential to working in the field of HIV/AIDS.
The following topics are included under the section:
 Global/Regional/National profile
 NACP-IV
 Epidemiology updates
 Updates on ART & PPTCT
 Understanding prevalence
 Understanding High Risk Groups
[For the above topics please refer to
http://naco.gov.in/NACO/Quick_Links/Publication/Annual_Report/NACO_Annual_Report/
Annual_Report_2012-13/]
Manual on Advance Counselling for ICTC Counsellors
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Use of ‘Self’ in the Counselling Process
Self awareness
Self awareness is viewed as knowledge of one’s perceptions and experiences. The cognitive
understanding that individuals have about the self, that comprises an understanding of one’s value
system and relational processes and an awareness of feelings and bodily sensations. The counselor
needs to be aware of this dynamic relationship between cognitive understanding and affective
reactions. Self awareness is a state of being conscious of one’s thoughts, feelings, beliefs, behavior,
values and attitudes and knowing how these factors are shaped by important aspects of one’s
development and social history.
Self awareness training is for the counselor to develop the ability to identify their personal
reactions and to understand and possibly utilize these reactions within the counseling relationship.
The focus on self awareness development emphasizes the role and function of the counselor’s self
in an effective counseling.
Self awareness is central to the therapeutic process in counseling. The importance of self awareness
in the therapeutic process is very important. The development of the counselor’s self awareness
must carry as much importance in his/her professional training as the assimilation of knowledge of
theories.
The counselor works closely with the client, understanding, empathizing with the client. The
counselor helps the client to understand his/her situation and problems, encouraging the client to
take decisions and supporting in behavior change. This requires that the counselor be aware of
his/her own self.
Self awareness is having a perception of one’s own personality, including their strengths,
weaknesses, thoughts, beliefs, motivation, attitudes, emotions and feelings. Self awareness allows
us to understand other persons, how they perceive us, our thoughts and our responses to them.
Self awareness is our capacity to introspect, the ability to recognize ourselves as an individual,
separate from the environment and other individuals. Self awareness means we compare the self
with standards of correctness that specify how the self needs to think, feel and behave. This is a
process of comparing the self with standards helping us to change our behavior and to experience
pride or dissatisfaction with one selves.
In the self awareness training the counselor often experience a range of emotional reactions to their
clients in the counseling process. The counselor comes across their previously held values and
views to be questioned. The counselor is encouraged to develop greater cognitive flexibility and are
required to understand how their own identities might influence the counseling process. For
example in the counseling process a counselor coming from a religious background where his/her
Manual on Advance Counselling for ICTC Counsellors
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religion prohibits consumption of liquor cannot accept alcoholism. That counselor has problem
counseling a client having an alcohol addiction. The counselor needs to be aware of his/her biases
so as to control his/her emotions in counseling that client.
To be aware of one’s own strengths and weakness helps us to be an effective counselor. The
counselor needs to be aware of one’s own values, morals, attitudes and prejudices when working in
the field of HIV counseling. Counseling in the field of HIV/AIDS means dealing with highly sensitive
and personal issues of sexuality. Sexuality requires that the counselor themselves are aware of
what is in their own mind and then they will be able to understand other’s mind.
Use of self in the counseling
process
Fostering the development of the therapeutic use of self in counseling is done by increasing the
capacities for empathy, attunement and counseling skills by the counselor. After the first activity
the counselor is now conscious of his/her values/belief, attitudes which is very important in the
field of HIV counseling, especially when the counselor is addressing various diverse sexual
practices. The counselor is aware of his/her values/beliefs and attitudes and is careful that he/she
is not biased in dealing with the client
The counselor presents themselves therapeutically to the client this requires a range of skills and
abilities including the intentional and disciplined use of the counselors self that is his/her
experience, identity, relational skills, moral awareness, knowledge and wisdom.
Viewing the counseling relationship as intended to serve as empowering role in the lives of people,
we believe that the nature of power calls for attention and understanding. The counselor
consciously uses the counselor-client relationship to bring about behavior change empowering a
CSW to negotiate the use of condom to protect themselves or their client from HIV transmission.
There are also situations in the counseling process that counselors express their own life aspects
without being aware of it. These expressions could have ill-effects and cause hindrances in the
counseling. A women counselor having a teenage daughter, in the counseling with a teenage client
becomes moralistic when hearing about the client’s sexual relationship.
The choices we make regarding the aspects of self that we bring into the particular counseling
relationship should be a function not only of what is authentic about ourselves but also crucial of
what we can offer that addresses the psychological needs of the client. For example if the counselor
is not comfortable or clear about issues in homosexuality. The counselor must be true to the client,
explore more about the issue, be open to change of personal views, control their values and learn to
deal with challenges of homosexuality. The counselor has to make an initiative to learn about
diversities in sexual orientations.
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Counselor’s personal growth and development
The use of “self as instrument” initiate both a respect for individual development and the meeting of
the counselor’s responsibility as a professional. When we say “self as instrument” we mean
facilitating the counselors self awareness, reflection and understanding of themselves within their
socio-cultural context and the application of this knowledge in service of their client. The
encouragement of personal growth and perspective transformation is stabilized with the
counselor’s responsibility of the self assessment and evaluation of counselor’s competence. Hence
the counselor in his/her journey of self awareness is also going to help themselves to personal
development. Looking into what are the bottle necks in the counselor’s performance and how to
deal with these bottle necks to emerge as an effective counselor.
Effective counseling training emphasizes the development of self so the counselor becomes a
competent practitioner who can feel, think and act according to each counseling situation. The
counselor’s feeling competence means the ability to relate and attune to the client using empathy
and relational connection. The counselor’s thinking competence means the ability to think critically,
conceptualize the client in theoretical terms and to demonstrate academic and research skills, oral
and writing presentations. The counselors acting competence is the professional ability to conduct
the counseling with the client.
Are you in control of yourselves?
In our life we have success and failures. These success and failures we can attribute to factors in our
control and to some factors in the environment, which are outside our control. This is called the
locus of control. Those factors that are in our control we say are “internal locus of control” for
example a counselor is not very confident in counseling as she feels she/he lacks knowledge, this is
the control of the counselor as she/he can make efforts and increase their knowledge and become
more confident. Those factors we cannot control are called “external locus of control” for example a
counselor has ailing parents who need medical attention; this is a situation that is not in our
control. Persons who develop an internal locus of control believe that they are responsible for their
own success. Those with an external locus of control believe that external forces, like luck, destiny
plays an important role in their life.
Manual on Advance Counselling for ICTC Counsellors
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Understanding Counseling Skills and
Core Competencies
Interpersonal Relationship
Skill
Greets clients
Description of the skill
The counsellor warmly and
genuinely welcomes the client
into the counselling room while

looking at him/her as opposed to

being pre occupied with filling

the registers/forms of previous
clients.
Demonstration of the particular
skill
 As the client enters into the
room
Co: (verbal) Good morning! Come
in. Please have a seat.
(Non verbal) Nods head, gives
smile that the client is being
noticed
 If the counsellor is preoccupied with completing the
earlier clients details, the
counsellor can tell the client
the same
Co: (verbal) Please give me five
minutes to complete a few
details from this form. After
that we can begin our
discussion.
(Non-verbal) indicates to sit by
using hands to show chair
(Please observe that counsellor is
not just giving a plain stare for the
sake of establishing eye contact as it
cannot be considered a welcoming
gesture. Also in all verbal
communication it is noteworthy to
observe the voice modulation, pitch
etc. because sometimes just saying
something doesn’t mean that it is
conveying the same thing.)
Introduces self
Counsellor tells the client his/her
name, a brief description about
Manual on Advance Counselling for ICTC Counsellors
Co: I am Sarita Sovani, appointed as
an ICTC counsellor in this centre.
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the center and its functions and
the counsellor's role in that
particular center.
Engages the client
in conversation
Listens
actively(both
verbally and non
verbally)
It implies that there should not be
awkward
silence
between
conversations which may hinder
smooth dialogue between the
counsellor and the client.
Therefore, the counsellor must be
able to use probes, open and
closed ended questions as and
when required. The counsellor
may use some light talk in
between to ease and make the
client continue the conversation
rather ending it abruptly.
The counsellor listens for total
meaning i.e. focuses both on the
content as well as the feeling or
attitude underlying the content
and responds appropriately and
sensitively to the client
This centre primarily aims to
provide
HIV/AIDS
related
counselling and testing services in
free of cost. Keeping in view the
sensitivity of the HIV testing and
related concerns all information
shared between you and me along
with the test results will be kept
completely confidential.
Co: May begin the conversation by
asking the client to talk about
themselves, for example what do
you do for a living, his/her familial
details, marital status and other non
HIV related information.
(The skill can also be demonstrated
by using appropriate verbal and non
verbal interjections like yes, ok,
hmmm, makes continuous eye
contact, nods and leans towards the
client during the conversation.)
Cl: I told my partner about my HIV
status
Co: What were you feeling when
you disclosed your HIV status
Cl: Finally I told my partner about
my HIV status
Co: I can see that you are feeling
relieved by disclosing your HIV
status
The content of both the statements
is same. However if the counsellor is
listening actively, he will recognize
the two different feeling attached to
the statements, i.e. a feeling of
anxiety in the first and the feeling of
being relief in the second and
respond accordingly.
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Is supportive and
Non judgmental
The counsellor frequently asks
clients about their feelings and
thoughts.
The counsellor reflects these
feelings back to the client so that
the client knows that s/he is
being understood.
The counsellor is patient and
does not try to get a word in
when the client is talking.
(The counsellor is aware that not all
communication is verbal and that a
client’s words alone don’t tell us
everything
he/she
is
communicating. For e.g. The way in
which a client hesitates in his
speech can tell us much about
his/her feelings so, too, can the
variation of his/her voice. S/He may
stress certain points loudly and
clearly and may mumble others. The
counsellor should also note such
things as the person’s facial
expressions, body posture, hand
movements, eye movements, and
breathing. All of these help to
convey the client’s total message.)
Co: Now that you have decided that
you want to take the test, how are
you feeling or what are your current
thoughts?
Co: It seems that you feel anxious
about your test result, because you
do now know what is the result.
Co: You are not alone in this. This is
a center where persons test
themselves for HIV and I work with
a lot of persons who are HIV+.
The counsellor does not become
“the expert” and offers premature Co: I am glad you trusted me with
advice.
this information. I understand it can
be difficult discussing you HIV
status and other intimate details
with me.
Cl: I also want to tell you that I am
physically intimate with my wife’s
best friend and she doesn’t know
about it.
Co: hmm….I understand your
situation. Let’s try to find out some
Manual on Advance Counselling for ICTC Counsellors
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way so that your sexual partners do
not get infected.
The counsellor does not pass any
judgment (whether critical or
favorable).
Gathering Information
Skill
Uses appropriate
balance of open
and closed
questions
Description of the skill
The counsellor does not use
close ended questions in quick
succession, as the client may
feel like s/he is being
interrogated and will become
defensive.
The counsellor
intersperses
open ended questions with a
few closed ended questions to
allow the counsellor to decide
in what direction they want to
take the conversation
The counsellor uses adequate
close ended questions to collect
facts pertaining to the client’s
problem as well as the basic
details like the clients name,
age, and marital status, where
s/he resides and information
about his family members close
ended questions.
As the session progresses, the
counsellor begins to use more
open ended questions. These
questions seek out client’s
thoughts,
emotions,
and
Manual on Advance Counselling for ICTC Counsellors
Demonstration of the particular skill
Open-ended questions:
An open-ended
question
requires more than a oneword answer, e.g.
 ‘What difficulties do you
experience in practising safe
sex?’
 ‘How do you think you would
react if you received an HIVpositive test result?’
 ‘When do you think would be
the right time to disclose your
test result to your spouse?’
These cannot be answered by a
simple ‘Yes’ or ‘No’
These questions invite the
client to continue talking and
allow the counsellor to decide
in what direction they want to
take the conversation.
Closed Questions:
• A closed question limits the
response of the client to oneword answers, e.g.
 ‘Do you practice safe sex?’
 ‘Do you know how to use a
condom?’
• Closed questions do not give
the opportunity to a client to
think about what they are
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experiences and invite
client to continue talking.
Uses silence well
to allow for self
expression
the
saying
• Answers to such questions can
be very brief, hence noninformative.
This
often
necessitates
further
questioning.
• However please note that
closed ended questions are not
bad and they will have to be
used in certain situations,
• e.g.
 Are you willing to take ART
medicines?
 Does your spouse know about
your HIV status?
In the course of counseling,
counsellor is supposed to show
patience until the client is able
to provide additional input and
responds
further.
It
is
important for the counsellor to
allow the client to gather
thoughts
and
regain
composure.
The counsellor either pauses or keeps
quiet for a few minutes, after asking
the client certain questions that
require the client to share their
personal experiences, feelings or
thoughts.
The counsellor uses statements like
“You can take your time” and “I
understand you need some time to
think about this, before you answer
this question”
During this time, the counsellor
appears patient and makes eye
contact with the client. The counsellor
does not fidget or appear
uncomfortable.
The counsellor does not allow for the
silence to continue for very long.
Seeks clarification
about information
given by the client.
The counsellor asks the client
questions about the
information shared by the
client.
Questions to seek clarification
are often worded differently
Manual on Advance Counselling for ICTC Counsellors
Cl: I used condom but, I think it did
not work.
Co: Ok. Can you please elaborate more
on “it did not work………….” as I did
not get what you mean by it.
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Avoids premature
conclusions
Summarizes main
issues discussed
than the opening question
asked by the counsellor
Drawing appropriate and right
conclusion is important for the
counsellor failing which the
client may feel that the
counsellor
is
in-attentive,
biased and/or is judgmental
about
the
client.
To
demonstrate
the
skill
counsellor does not make a
conclusion based on incomplete
information and to use this skill
the counsellor listens actively to
all that the client has to share
without interrupting the client.
In summarizaing main issue,
the counsellor is doing a
paraphrasing at the end of the
session or wherever the
counsellor feels that during the
session
the
client
have
presented facts and important
Manual on Advance Counselling for ICTC Counsellors
 Drawing Premature conclusion:
Cl: Last night I went out with a few
friends and we got drunk
Co: So you visited a sex worker and
you had unprotected sex because you
were drunk.
 Leading to accurate conclusion:
Cl: Last night I went out with a few
friends and we got drunk
Co: ok, so what is bothering you right
now about that event?
Cl: nothing much, we just freaked out
and wanted to have some fun.
Co: so what type of fun you had?
Cl: we tried a new drug in the market
Co: hmm …….so how did you feel
about it?
Cl: we were at the top but now I feel
guilty that I will become an drug
addict even if I have done it only once
Co: I can understand your feelings but
before we discuss more on it can you
tell me did you injected it and shared
the needle within the group or you
inhaled it?
Cl: no! No! We inhaled it through
smoking pipe.
Co: ok, so I can say that you are
feeling guilty about the act you did
last night and you are apprehensive
about being
a regular drug
inhaler…………………….
Cl: yes, that is right…………
Client : “Yes , how should I tell her I
am positive , I want to tell her because
I don’t want to infect her , and I have
to tell her because I cannot suddenly
start using condoms , but not now ,
she will get upset, I don’t know …”
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information woven in between
the underlying emotions and
works spoken and explicit
gestures. The sequence of
presentation also does not
progress as priority wise.
Amidst observing all the above
by “keeping eyes and ear open”
to make sense out of it and filter
the relevant information or
feeling is not easy for a
counsellor.
There
is
a
possibility of confusion and
being buzzed up with the
information
coming
all
together. Therefore, it is
important for counsellor to put
tighter key points of the
discussion in a few words.
Makes
proper The
counsellor
maintains
records
of descriptive
records
that
problem
explicate a client’s key issues,
formulation
for their feelings associated with
future reference
them and action points for the
future (if discussed).
Counsellor: “So can we summarise it
in this way. …“If you do not tell your
status, you fear infecting your wife.
On the other hand, you are finding it
hard to tell her as she may leave you.
Therefore, even though you want to
tell, it is very tough for you.”
(Please make sure that the summary
you provided to the client is checked
back with the client as presented
accurately or needs to be reframed).
Giving Information
Skill
Description of the skill
Gives information The counsellor uses the
in clear and simple language of the state to provide
terms
HIV related information to the
client.
The counsellor provides the
information in an appropriate
order and organized manner.
(for example information about
ART should be given only after
the client has understood the
Manual on Advance Counselling for ICTC Counsellors
Demonstration of the particular skill
Co: (in complicated terms) ELISA test
will be performed on you in the
adjacent lab to diagnose your serostatus. In case your test result is seropositive it means you have retro-virus
in your body which is cause of
acquired
immuno
deficiency
syndrome in human beings and once
you are tested sero-positive you have
potential of horizontal and vertical
transmission to others.
Page 12
modes of transmission as well
as facts about how the HIV (in simple and clear term) your blood
virus affects the immune will be tested for HIV in the lab
system)
situated opposite to the x-ray
department on the first floor. You will
be required to collect your report
result from me in the afternoon. I
would like to tell you that the if the
result is positive it means the HIV
virus is inside your body and if it is
negative it means you do not have
virus in your body. In case you have
positive result it doesn’t mean that
you have AIDS it is a condition which
develops after many years after the
virus has entered your body. You can
transmit the HIV only through the
following mediums………………….
Gives client time to The
counsellor
paces Co: Your test result is negative which
absorb
himself/herself while providing means that the virus is not inside your
information and to HIV related information.
body………………(silence)
respond
Cl: oh my God! I am so happy. I dint
S/he waits for a few minutes have sleep for the entire night.
after the providing the client Co: hmm, I can see that you are feeling
with necessary information.
quite relieved…
Cl: yes, I am very happy. I just want to
The counsellor is patient and go home and sleep
waits for the client to respond Co: you can ask me in case you are not
to the information provided
clear about anything….as you know
we have talked safe sex,.
The counsellor asks the client if Cl: yes, now I know the practices
s/he have any doubts or which I earlier used to consider safe
questions
about
the such as anal sex.
information provided to them.
Co: hmm….good…would you like to
once again summarise the safe
practices?
Has to up-to-date
knowledge about
HIV
The counsellor is aware of the
recent developments, treatment
regimes and research for their
own knowledge and in case the
client asks them. It is important
for a counsellor to be aware of
the current NACO guidelines for
treatment, care and support
Manual on Advance Counselling for ICTC Counsellors
Such as earlier the minimum CD4
count for initiating ART was 250 the
limit is recently being revised by
NACO……
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Repeats and
reinforces
important
information
The
counsellor
repeats
important
parts
of
the
information given to the client.
Repeating information should
not reflect that counsellor is
parroting the given information
rather it is for bringing more
clarity on the information
shared and in case counsellor
has listened incorrectly it can
be reprimanded then and there
only. The counsellor may add
additional information to help
the client gain an improved
understanding of the facts
provided.
 Illustration1:
Cl: I wanted to get rid of all my
miseries…you know life is just
miserable if my wife will leave me. I
thought I should either tell her or end
it.
Co: hmm…either ends it??????
Cl: yes, end this relationship without
telling her the truth
Co: hmm…I can understand how
difficult it is for you….
 Illustration 2:
Cl: Now I know there are three modes
of transmission, they are through
unsafe sexual intercourse, blood
For
example,
modes
of transfusion and from mother to her
transmission, the meaning of unborn child
CD 4, information about ART, Co: yes you are right, mother to her
etc.
unborn but it may also be transmitted
from mother to her new born child
through breast feeding.
Cl: ohh! I din’t know it
Checks for
It is important to check
understanding and whether “what is being said is
misunderstanding understood correctly by the
client and/or the counsellor?”
in order to minimize confusion
and ambiguity.
Summarizes main
issues
(The counsellor may
also use
relevant examples that help the client
gain a comprehensive understanding
of the information provided )
“Can you please tell me, what you
have understood from the
information I have just provided you?
(The counsellor may use open ended
questions or just repeat the important
information to gauge if the client has
.
understood the information given to
him or her. Based on the response
given by the client to the above
questions, the counsellor checks for
any misunderstanding. If any are
present, the counsellor clarifies the
same)
In summarizing main issues, the Cl: “I love my wife, but she will get
counsellor
is
doing
a very angry with me if she comes to
Manual on Advance Counselling for ICTC Counsellors
Page 14
paraphrasing at the end of the
session or wherever the
counsellor feels that during the
session
the
client
have
presented facts and important
information woven in between
the underlying emotions and
words spoken and explicit
gestures. The sequence of
presentation also does not
progress as priority wise.
Amidst observing all the above
by “keeping eyes and ear open”
to make sense out of it and filter
the relevant information or
feeling is not easy for a
counsellor.
There
is
a
possibility of confusion and
being buzzed up with the
information coming all tighter.
Therefore, it is important for
counsellor to put together key
points of the discussion in a few
words.
know that I am HIV positive, she will
hate me and leave me.”
Co: So can we summarise it in this
way. …“If you do not tell your status,
you fear infecting your wife. On the
other hand, you are finding it hard to
tell her as she may leave you.
Therefore, even though you want to
tell, it is very tough for you.”
“Please make sure that the summary
you provided to the client is checked
back with the client as presented
accurately or needs to be reframed.”
Handling Special Circumstances
Skill
Description of the skill
Demonstration of the particular skill
Talks about
sensitive issues
plainly and
appropriately to
the culture
When talking about sensitive
issues for example sexual
history or sexuality related
issues, the counsellor is
straightforward. For example
the counsellor makes his/her
intention clear at the beginning
of the discussion itself. An
example is given alongside.
“We will now discuss certain personal
details like condom use and your last
sexual encounter. I understand that
you may feel uncomfortable in
discussing it at first. However I need
to know this information, so that we
can proceed with the appropriate
course of action for your HIV testing
and treatment”
(The counsellor has the appropriate
The counsellor uses clear and knowledge of and is aware of the
Manual on Advance Counselling for ICTC Counsellors
Page 15
instantly recognizable language
in the discussion of sensitive
topics like safe sex or disclosure
related issues.
Prioritizes issues
to cope with
limited time in
short contacts
Keeping in mind the limited
time available for a counselling
session, the counsellor is able to
identify issues which are most
distressing to the client.
From amongst these issues, the
counsellor is able to identify
issues that fall within the
purview of counselling as
compared to issues that are
beyond counselling like poverty
alleviation
or
livelihood
options.
Uses silences well
to deal with
difficult emotions
The counsellor either pauses or
keeps quiet for a few minutes
when the client is expressing
emotions like excessive grief,
anger,
sorrow
or
even
Manual on Advance Counselling for ICTC Counsellors
client’s background details like
gender/class/caste/sexuality/age/fin
ancial status/marital status and
current cultural norms. While dealing
with sensitive topics, the counsellor
frames his/her statements based on
the same.)
Cl: I feel that my children will be
discriminated if they are tested
positive like us. I want to relocate
from this place because we have very
close
relationships
with
our
neighbors and they will come to know
that something is wrong with us.
Though they are supportive and will
not discriminate but do not want to
tell them.
Co: You have discussed two, three
important issues here. It seems there
is a lot going on in your mind. Taking
up the issues altogether will make the
situation complex and difficult to
handle. Therefore, what you can do is
note down all the issues which are
cause of your concern and arrange
them in ascending order depending
on the issues which needs immediate
action, which may be put on hold for
some time and which may be resolved
later on when situation is under
control…..
I can help you in identifying some
issues which you may put in order as
explained above such as your children
will be discriminated if they come
positive, secondly, you are concerned
about neighbors, thirdly you also feel
that they are close to you and are
supportive.
Co: “I have some bad news for you;
your test report is HIV positive”
Cl: “What”?? (Breaks down into tears
…)
Co: “It is ok, I understand you need
Page 16
happiness.
The counsellor uses silence
after the client has finished
expressing difficult emotions to
allow the client time to reflect
on what they have shared.
some
time
to
absorb
this
information…………”
(and
stops
talking for a few seconds )
Client: “I am sorry” (again breaks
down into tears …)
Counsellor: “You can take your
time……………”,
Manages client’s
distress
The counsellor pays attention
and
acknowledges
the
disturbing
thoughts
and
feelings of the client such as
feelings
of
loneliness,
hopelessness, anxiety, guilt,
helplessness etc. The counsellor
needs to address such concerns
and behavior of the client soon
after they are observed.
The counsellor emphasizes
upon the duration and intensity
of such feelings in order to
assess the need for any further
mental
health
related
intervention.
Co: Can you explain that how are
feeling right now, I can see that you
are sweating a lot… should I increase
the speed of fan…..have some water
first and tell me in detail….I am there
for you…you can hold my hand if you
wish so.
Handles client’s
defensiveness
sensitively and
well
It is possible for a client to be
defensive about her/his actions,
behavior and the information
and knowledge shared. It is
important that the counsellor is
patient and empathetic when
the client is trying to justify
his/her actions or is denying
certain emotions they may be
feeling.
Cl: I cannot take all ART medicines in
time. I have lots of other work to do.
Co: I understand it is not possible for
you to remember all the medicines
and you have quite busy schedule. But
as it is very important for your health
not to skip then….. Together we will
find out some way that it becomes
easy for you.
(When the client is being defensive
the counsellor does not attempt to
correct the client or tell the client that
he/she is wrong or lying.)
Manual on Advance Counselling for ICTC Counsellors
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Counselling Skills
Skill
Description of the skill
Demonstration of the particular skill
Active
listening
The counsellor listens for
total meaning i.e. focuses
both on the content and
the feeling or attitude
underlying the content and
responds
appropriately
and sensitively to the client
The counsellor is aware that not all
communication is verbal and that a client’s
words alone don’t tell us everything he/she is
communicating.
For eg. The way in which a client hesitates in
his speech can tell us much about his/her
feelings. So, too, can the variation of his/her
voice.
S/He may stress certain points loudly and
clearly and
may mumble others. The counsellor should also
note such things as the person’s facial
expressions, body posture, hand movements,
eye movements, and breathing. All of these help
to convey the client’s total message.
Paraphrasing
The counsellor restates or
repeats the client’s words
in a shortened and clarified
form. While doing so, the
counsellor ensures that
his/her words are in
congruence
with
the
client’s verbal and non
verbal language.
Cl: “I love my wife, but she will get very angry
with me if she comes to know that I am HIV
positive, she will hate me and leave me.”
Co: “What you are saying is that your wife will
be upset with you and you feel that after
knowing your status, her love for you will
become less and she may want to discontinue
the marriage”
Reflecting
Also the counsellor can
use some of his/her own
words to convey the real
meaning of what the client
is saying as well as feeling
and experiencing.
The counsellor is accurate
in
recognizing
the
emotions that lie beneath
the client’s verbal and non
verbal communication.
The counsellor reflects
Co: It sounds like you are worried about your
wife’s HIV status.
From what you have shared, it seems you may
be feeling anxious about your health.
Manual on Advance Counselling for ICTC Counsellors
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Confronting
Empathizing
back to the client with the
use of a different set of
words, the emotions that
the client seems to be
feeling.
The counsellor is able to "On the one hand you say you are not anxious
accurately identify mixed about the HIV test results but on the other
messages, discrepancies, hand, your behavior indicates otherwise”
and incongruities between
the content of what the
client is saying and his or
her non verbals, between
contradictory content and
between behaviors and
stated goals.
The counsellor points out
these discrepancies to the
client in a sensitive and
respectful manner
The counsellor is able to “I can feel that how hopeless you are feeling at
keep self in the client’s this moment because nobody is there to share
situation and feel the way your apprehensions.”
client is feeling.
The counsellor is able to
communicate empathy to
the client through both the
verbal and non-verbal
communication
Goal Setting
The counselor is able to
identify accurately assess
the client's problem(s) and
then assist him or her in
finding the workable and
realistic
option
or
solution(s).
Cl: I do not know how I can improve my health.
I am ignoring it constantly. There is no one to
take care of my routine. My husband comes
home late as he works hard. I do not want to
burden him to look after my ART medicine
schedule. I am also falling ill often. But I have no
choice, I think like is soon going to over. I am
worried who will take care of my husband after
The counsellor is able to me as he is very much attached to me.
assist the client in listing
goals that be specific, Co: if I am not mistaken, it is clear from the
measurable,
realistic, issues you discussed that you want to be with
psychologically
and your husband for many more years but you fear
emotionally healthful, and that you will die leaving him alone.
Manual on Advance Counselling for ICTC Counsellors
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arranged in their order of
importance.
Cl: Yes, you are right. I want to live healthy
Co: So let’s set a goal you want to achieve and
sub goals to achieve the main goal. Please set
such goals that can be achieved with the
available resources, services and support
Cl: hmm……ok.
Main goal: Living healthy life with my husband.
Sub-goals 1: Taking care of my health
2: adhering to ART
Co: Good, now write down the ways how you
can achieve it
Cl: ok, I can go to a dietician for diet chart. I can
put reminders for ART medicines based on the
T.V. shows timings.
Co: Yes, good, that will be great…now set
timeline for each goal that you…………………..
Facilitating
The counsellor is able to
smoothen
the
client’s
sharing
of
feelings,
ventilation of emotions,
discussing the concerned
issue, choosing among
workable options and goal
setting to achieve the set
goal
The counsellor is able to
ease and speed up the
intake of other related
services such as linking to
positive network, availing
other welfare services,
getting legal and ethical
help etc.
Unconditional Counsellor is able to give
positive
respect to the client
regard
irrespective of the gender,
sexual orientation, caste,
class, profession and creed
Co: I am giving you this referral slip, show it to
the PLHIV network head, I have already called
him up for the same.
You can cry, if you are feeling like….do not
press your emotions, just let them go.
“ offering seat to a female sex worker client like
other clients”
“Giving information to the illiterate clients in
simple language rather considering them
incapable of understanding anything.”
Manual on Advance Counselling for ICTC Counsellors
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of the client
Cl: though my wife is taking care of me and
loves me a lot still I want to divorce her because
the relationship is not sexually satisfying to me.
She hardly feels any need for physical intimacy
and is reluctant even if I pursue it.
Co: As we already have talked about it in detail
and based on all pros and cons of breaking up
this relationship you have arrived on this
conclusion. You have also taken up with your
wife, it is good that both of you have mutually
agreed for it. Therefore, I wish best to you for a
prosperous life ahead.
Summarizing
In summarizing main issue,
the counsellor is doing a
paraphrasing at the end of
the session or wherever
the counsellor feels that
during the session the
client have presented facts
and important information
woven in between the
underlying emotions and
words spoken and explicit
gestures. The sequence of
presentation also does not
progress as priority wise.
Amidst observing all the
above by “keeping eyes
and ear open” to make
sense out of it and filter the
relevant information or
feeling is not easy for a
counsellor. There is a
possibility of confusion and
being buzzed up with the
information coming all
together. Therefore, it is
important for counsellor to
put together key points of
the discussion in a few
Cl: “I love my wife, but she will get very angry
with me if she comes to know that I am HIV
positive, she will hate me and leave me.”
Co: So can we summarise it in this way. …“If you
do not tell your status, you fear infecting your
wife. On the other hand, you are finding it hard
to tell her as she may leave you. Therefore, even
though you want to tell, it is very tough for
you.”
“Please make sure that the summary you
provided to the client is checked back with the
client as presented accurately or needs t be
reframed.”
Manual on Advance Counselling for ICTC Counsellors
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words.
Disclosure
skills
The counsellor is able to
tell the client any sensitive
and/or
important
information which may
bring
apprehensions,
anxiety or distress in the
client in a non-threatening,
clear and correct way
personal to the client and
with
the
client’s
permission
to
the
significant others who are
related to the client
directly or indirectly.
Co: Your husband has brought you here
because he wants to share something important
with you. It is difficult for him to speak to you
about it so he wants me to share it with you.
Please be assured that whatever he has shared
with me is between us only and is not being
disclosed to anyone. It is important for you to
know it as it may affect you directly or
indirectly…….
One of the techniques that can be used is the
Sandwich Technique: It follows the physical
layout of a sandwich – two slices of bread with
a filling.
 Upper slice of bread:
“I have some bad news to give you. You may or
may not be expecting this.” Announcing that the
news is bad gives the parent a few seconds to
prepare themselves to actually hear the words
which are going to dash their hopes.
 Sandwich filling:
“The child’s test result is positive.” This is the
actual news of the test result.
 Lower slice of bread:
“I am here to help you absorb this shock.” This
is the offer of support from the counsellor. Just
as the bread supports the filling, so the
counsellor offers support for digesting the bad
news.
Manual on Advance Counselling for ICTC Counsellors
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Strengthening Service Linkages
Programmatic Linkages for the ICTC
Each ICTC must establish the following programmatic linkages with other health services.
Some of these services fall under the NACP umbrella. Some are within the general health
system. The performance of the ICTC in this area is visible in completed and accurate linelists, and good entries into the columns for in-referrals and out-referrals. The counsellor
must also be aware of the services available at each of these units and guide clients
appropriately.
Care Support
&Treatment
Treatment
for Sexually
Transmitted
Infections
Maternal
&Child
Health
ICTC
Positive
People’s
network
RNTCP
Targeted
Intervention
Projects
Manual on Advance Counselling for ICTC Counsellors
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Care and Support Services :
Care and support services are available through ART centres, Link ART centres, Centres of
Excellence and Community Care Centres. However, the primary linkage between the ICTC
and the Care and Support services will be through the ART centre whose functions are:
Prevention of Opportunistic Infections
Assessment and management of HIV-related illnesses
Assessment and management of other recurrent and chronic infections
Anti-retroviral therapy
Management of other recurrent and chronic infections
Counselling for drug adherence, nutrition, infant feeding
Early Infant Diagnosis and care of the child
STI Services:
STI clinics are branded as Suraksha Clinics. They offer the following services:
Screening for presence of STI signs and symptoms
Early diagnosis and treatment of STIs during pregnancy including routine syphilis
testing of pregnant women
Syndromic diagnosis and treatment where laboratory tests are not possible
RNTCP :
Manual on Advance Counselling for ICTC Counsellors
Page 24
Under the RNTCP, there are several facilities. They offer the following services:
 Screening for TB
 Early diagnosis & initiation of Anti-TB Treatment
 Cotrimoxazole prophylactic treatment (CPT)
Maternal and Child Health:
Linkages with Maternal and Child Health services are not just for those counsellors who are
attached to Antenatal or Gynaecology units in the hospital. Every counsellor should know
their services and how to link to them effectively:
 Essential antenatal care
 Family planning services
 Safer delivery practices
 Counselling and support for the infant feeding method opted by the woman
 Maternal Care: MCH postpartum care services help protect the mother‘s health by
providing medical and psychosocial supportive care
 Infant care: MCH postnatal care services offer assessment of infant growth and
development, nutritional support, immunizations, and early HIV testing.
 Family care: MCH services provide social support, testing and counselling for family
members; referrals to community-based support programmes; and assistance in
dealing with stigma
Positive People’s Network:
Positive people’s networks offer  Psycho-social support
 Support groups
 Legal support
 Socio-economic support
Manual on Advance Counselling for ICTC Counsellors
Page 25
 Nutritional support
Targetted Intervention (TI) Projects:
TI Projects provide:
 Behaviour change communication
 Referral for HIV testing
 STI education and management
 Condom promotion
 Community mobilization
 Enabling environment
Reference:- Refresher Training Programme for ICTC counsellors ( Second
edition)Trainee’s Handouts, April 2011
Manual on Advance Counselling for ICTC Counsellors
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Strengthening Service Linkages
Assistance Schemes for PLHIVs
As an ICTC counsellor, you may not always find it possible to address all the needs of your
clients within the health system. The Care and Support Programme has made provisions
for free treatment. But PLHIVs have other needs as well. Besides failing health, they face
two problems: First, their health problems often disrupt their employment leading to
breakdown in family finances. Second, they are often marginalized due to the stigma
associated with HIV/AIDS. Hence there is a need to develop linkages with other
government departments, non-HIV NGOs and the public sectors.
Types of Schemes:
HIV/AIDS affects people of all walks of life. But its impact is greatest on members of the
lower socio-economic classes. With HIV, the demand for living a healthier life is more
important than ever and the additional economic burden is the biggest barrier to accessing
the free care and support services.
There are various government schemes which a PLHIV can avail. These schemes differ
from state to state and sometimes from district to district. The information for such
schemes is available at the office of the District Collector/ District Magistrate. A partial list
is provided here. But counsellors can request this information from the office of the District
Collector or the District Magistrate or their State AIDS Control Society.
A) Social Security Schemes:
Manual on Advance Counselling for ICTC Counsellors
Page 27
Examples of such schemes are:
 Widow pension scheme
 Special pension schemes for PLHIVs
 Old age pension scheme
 Insurance schemes (government as well as private such as Star Insurance)
 Employment guarantee schemes
B) Free Transport to PLHIVs for Commuting
to ART Centres :
Concessions are sometimes provided for travelling to treatment centres by state transport
agencies or by the railway authorities. However in some places, this facility has been made
available even with private transporters.
C) Below Poverty Level
Status for PLHIVs:
Inclusion of PLHIVs in the BPL list, if eligible, helps PLHIVs to get nutritional support
through subsidized rations and livelihood support through benefits under rural
development and employment schemes. It also seeks to address stigma by encouraging
disclosure of status.
D) Nutritional Support for PLHIVs :
Some states have provided nutritional support to PLHIVs through the ICDS scheme or
Antyodaya scheme or through private donors. Chandigarh SACS has in fact developed a
pooled fund through private donations like Rotary Club for providing such support. Orissa
SACS has a nutrition supplement programme.
E) Safe Environment :
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Page 28
Some states have provisions for orphanages for CLHIVs and short-stay homes for women
affected with HIV.
F) Some states have made provisions for other schemes like animal loans, train passes,
educational loan/grant, etc.
Role of the Counsellor :
 Referral
 Managing Barriers
 Enhancing Linkages
Referral:
An effective ICTC counsellor will gather information on the locally available schemes and
seek to link people to the right resource. PLHIV networks generally are of great help in
ensuring that these schemes are made available. Hence they would be your first referral
link for all these activities. Various TI NGOs, Link Worker Scheme (LWS) NGOs and other
non-HIV NGOs are also of great help in providing these services. You should add them to
your list of referral agencies.
The ICTC counselor should ensure that the following details are displayed prominently in
the ICTC:
 List of various government schemes for PLHIVs
 Name and contact details of various HIV and non-HIV NGOs providing services for
PLHIVs (Services available at each NGO should be clearly written)
 A line indicating that they can ask you for more details
Managing Barriers:
Manual on Advance Counselling for ICTC Counsellors
Page 29
As a counsellor, you should be aware of the barriers that a PLHIV can face while trying to
avail a package of services. Based on experience you should explore solutions to these
barriers on a case-to case basis. Hence it is extremely important to obtain feedback from
clients for whom you have already made referrals. Providing information that is as accurate
as possible is critical. For instance, tell them how to reach there, draw a small map, etc.
Further, prepare your clients as to what to expect when they go to a particular office to
register for the scheme/ service. This is the skill of anticipatory guidance. If clients feel
uncomfortable with language or with speaking with someone more educated than them,
encourage them to talk with the District Level Network for a “buddy” who can accompany
them the first time. Other possible advocates are workers from the Link Worker Scheme.
Be sensitive to clients’ concern about being “outed” – that is having their status disclosed.
Remember it takes time for people to feel comfortable. Therefore, work with them at their
pace. But always present to them the need to get registered for treatment as soon as
possible as this is a lifesaving measure.
Prepare your clients as to what to expect when they go to a particular office to
register for the scheme/ service. This is the skill of anticipatory guidance.
Enhancing Linakges :
Developing linkages with the various government departments is extremely important for
the benefit of your client. A good rapport with your counterparts in these departments will
ensure timely and hassle-free services to your clients.
A “Thank You” note to the concerned officer will take you a long way ahead.
More Suggestions:
Manual on Advance Counselling for ICTC Counsellors
Page 30
Once you have successfully linked your client to a particular service, make a note of the
relevant details in your records for future use. Share and discuss these achievements with
your District ICTC supervisor and/or Nodal officers so that others can also benefit from
your experience. Use your records to analyse the emerging needs of your client population,
assess your success and improve your future performance
Check list for ICTC Counsellors :
Do you have the following information with you?
List of various government schemes available in the district
Name and contact address of the District Collector’s office
List of Tehsildars and their contact address
Name and address of contact persons of the District PLHIV network
Name and address of all HIV services
Name and address of the TI NGOs in the district, their area of coverage,
their typology of coverage, etc
Name and contact details of ORWs and Peer Educators in the district
and the areas covered by them in the district
Name and address of the LWS NGOs in the district
List of villages covered under the LWS in the district
Name and contact details of the link workers in the villages
Name and contact details of non-HIV NGOs in the district
Name and contact details of short stay homes for women in the district
Name and contact details of orphanages in the district
(This is a partial list that is ever-evolving)
Manual on Advance Counselling for ICTC Counsellors
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Reference:- Refresher Training Programme for ICTC counsellors ( Second
edition)Trainee’s Handouts, April 2011
Strengthening Service Linkages
Assistance Schemes at the State Level
Free Baseline Investigations:
 Baseline tests are provided free of cost to PLHIVs in most of the states. This includes
tests like CBC, ESR, Urine Routine, Micro, Bl.UREA, S. CREATININE, LFT, X-Ray, USG,
Lipid Profile, HBSAg, HCV, RBS, FBS, PPBS, etc
 Some states extend special services to CLHIVs. For instance, Kalawati Saran Children
Hospital in Delhi provides free diagnostic tests like CT scan and Ultra Sound for HIVpositive children.
Free Transport to PLHIV for
Commuting to ART Centres:
 The states of Assam, Gujarat, Rajasthan, West Bengal, Maharashtra, Goa and
Jharkhand have provisioned travel concessions to PLHIVs for travelling to ART
centers.
 In Rajasthan some private transporters are providing concessions to PLHIVs on
specific routes which cover ICTC, ART centres and TB hospitals.
Manual on Advance Counselling for ICTC Counsellors
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 In Gujarat, PLHIVs are receiving reimbursement of travel expenses with financial
support from Clinton foundation and NRHM. This programme was implemented
under the Jantan Project in October 2009. The government has earmarked Rs. 1.8
Crores for this purpose in the state health budget.
 In Karnataka, travel assistance is provided in two high-prevalence districts.
 In the states of Kerala, Chattisgarh and Andhra Pradesh, the proposal is under
consideration with the state transport departments.
BPL Status :
Inclusion of PLHIVs in the BPL list helps them to get nutritional support through subsidized
ration, livelihood support through benefits under rural development and employment
schemes. Currently, Orissa, Rajasthan, Assam and Gujarat have given BPL status to PLHIVs.
Nutritional Support for PLHIV :
 The states of Andhra Pradesh, Bihar, Delhi, Gujarat, Orissa, Haryana, Rajasthan, West
Bengal, Goa and Kerala are supporting nutritional care of PLHIVs, through ICDS,
Antyoday Anna Yojana or private donors.
 In Gujarat, the Social Justice and Empowerment Department declared support of Rs.
500 per month to PLHIVs for nutritional support under Medical Aid Scheme for
lifelong.
 In Kerala, the Social Welfare Department has sanctioned an amount of Rs. 49.64
Lakhs for nutrition support programme for WLHIVs and CLHIVs registered in ART
centres. Nutrimix powder (4 Kg p.m for WLHIVs, 2 Kg p.m for Pre ART and CLHIVs)
is provided through the ICDS. Besides, multi vitamin, folic acid and iron tablets are
Manual on Advance Counselling for ICTC Counsellors
Page 33
provided to children wherever required. Free nutritional kits are also provided,
through ICDS to all PLHIVs registered in DICs. This project is rolled out in 4 districts.
 In Andhra Pradesh, CLHIVs in 4 districts are provided a special nutrition package
every month under the Balasahayoga Program.
Social Security Schemes:
 Andhra Pradesh, Delhi, Gujarat, Orissa, Rajasthan, Tamil Nadu, West Bengal and Goa
have incorporated social security measures through widow pension, old age
pensions or special pension for PLHIV.
 Orissa is providing Madhubabu pension scheme for PLHIVs and provides financial
support of Rs 400 per month.
 In states where widow pensions were already being provided, the SACS have
advocated with the state governments to reduce the age bar for widows of PLHIV.
 In Andhra Pradesh, PSI has launched insurance for PLHIVs through Star Health and
Allied Insurance Company.
 In Rajasthan, the Department of Social Justice and Empowerment provides monthly
pension of Rs. 400 per month for all PLHIV widows.
 In West Bengal, a one-time widow pension of Rs. 10,000/- is provided.
Legal Aid :
Manual on Advance Counselling for ICTC Counsellors
Page 34
The states of Chattisgarh, Punjab, West Bengal, Rajasthan and Uttar Pradesh have
provisions of legal aid for PLHIV through different models.
 In Gujarat, an MoU regarding free legal aid to PLHIV has been signed between
GSNP+ and district legal aid authorities.
 The Bar Associations of Durg, Korba (Chattisgarh), Alwar (Rajasthan), Itawah, Mau,
Devaria (Uttar Pradesh), Alipore (West Bengal) have committed and are providing
free legal aid for PLHIVs
 In Punjab, free legal aid is given to PLHIVs through the District Legal Authority and
the Human Right Law Network.
 In Tamil Nadu, Legal Aid Cells are set up in 16 ART centres to address various social,
legal and livelihood issues of the PLHIVs.
Safe Environment :
 Andhra Pradesh, Bihar, Delhi, Gujarat, Punjab and Rajasthan have provisions for
orphanages for CLHIV as well as short stay homes for Women Living with HIV.
 In Patna, Bihar, FXB India runs a short stay home for all PLHIVs.
 In Gujarat, the government has planned two homes for CLHIVs in Surat and
Gandhinagar respectively. The Gujarat government is extending a financial support
of Rs. 65 lakhs per annum for this initiative.
Grievance Redressal Mechanism :
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The states of Andhra Pradesh, Bihar, Delhi, Gujarat, Orissa, Punjab, Rajasthan, Uttar
Pradesh, Maharashtra Jharkhand and Kerala have Grievance Redressal mechanisms in
place.
Additional Schemes:
Some SACS have worked on making additional provisions for PLHIV on the basis of their
needs.
 In Rajasthan, the Palanhar Yojana is run by the Department of Social Justice and
Empowerment for CLHIVs. Rs. 500 per month is given to children upto age 5, Rs.
650 per month to school going children and an additional Rs. 2000 per year for
expenses such as uniform and study materials.
 In West Bengal, Ambuja Cement Foundation supports the education of children
affected by HIV.
 Jharkhand SACS has facilitated the formation of District Level Positive People’s
networks and the State Positive People’s network.
 Haryana SACS has facilitated the formation of seven District Level Positive People’s
networks.
 In Kerala, under the Ashraya scheme, poor families are adopted by PRIs to provide
housing, food, medical care etc as per the requirement of the beneficiary.
 In Karnataka there is a special government OVC scheme in three districts worth
Rs. 1 Crore
Manual on Advance Counselling for ICTC Counsellors
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 Government of Tamilnadu gives educational assistance to infected and affected
children through the OVC Trust.
 Gujarat has organized educational scholarships for affected and infected children of
HIV positive parents. Another support is in the form of special (and confidential)
leave for the
 children for ART and OI treatment. The government has earmarked Rs. 60 lakhs for
the parents who adopt CLHIVs.
 The Union Territory of Chandigarh is planning to establish a school-cum-vocational
training centre for CLHIVs with boarding facilities.
 In Chandigarh, a corpus fund has been initiated by the Union Territory of
Chandigarh with the help of donations from NGOs and philanthropic organizations.
This money is utilized to support investigations and treatment of poor PLHIVs.
Sewing and embroidery machines are provided to the DIC to develop the skills of
the PLHIVs and subsequently ensure a sustainable livelihood to them.
 In Haryana, special remuneration is given to Health Care Providers (ASHAs
[Accredited Social Health Activists]) for accompanying positive pregnant women for
institutional delivery. Orissa also gives this kind of assistance to pregnant WLHIVs.
 In Karnataka, under the Yashaswini scheme, incentives are given to the entire
medical team that attends to the delivery of positive pregnant women.
Reference:- Refresher Training Programme for ICTC counsellors ( Second
edition)Trainee’s Handouts, April 2011
Manual on Advance Counselling for ICTC Counsellors
Page 37
Strengthening Service Linkages
ICTC – ART Linkages
ICTCs are the first contact point of the client with the entire range of preventive, care and
support services provided under the National AIDS Control Programme. The ICTC must link
clients appropriately with the Care and Treatment services they need. However, there is a
substantial loss of clients between ICTCs and ART centres.
A study of clients followed from ICTCs to ART Centres has shown that 82.9% of clients had
received information about the availability of free ARV medications at government ART
centers and 77.5% had been given referral slips by the ICTC counsellor. This means some
clients are still not getting complete information.
The study showed that younger clients, single clients and clients working as unskilled
manual labour are less likely to register for ART. Further, ICTC clients who perceive
themselves as enjoying relatively good health or who fear disclosure of their HIV status are
also less likely to register at ART centres.
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Role of ICTC Counsellor in
ensuring linkage with ART:
Centre –
The ICTC counsellor should try to address these barriers during counselling and ensure
that PLHIVs reach the ART centres. One way to do this is to check in with the ART Centre at
monthly coordination meetings or over the telephone whether clients reached after a
referral has been made. You can also periodically look over the referral forms returned
from the ART centre. Matching the returned forms against the forms you wrote out will be
useful to know who reached and who did not. This is a simple way of checking. Another
way is line-listing.
ICTC counsellors may also use contact telephone numbers to contact clients who have not
reached even 6 weeks after the test. Of course, for this, counsellors should seek permission
to contact the client over the telephone and should be very discreet while making the
telephone call. Your goal as an ICTC counsellor is to ensure that each and every one of your
positive clients has reached and registered at the ART centre.
The ICTC counsellor must also give hope to the client by informing him/ her about ART, its
importance and its free availability at the ART centre. Inform the client what he/ she can
expect at the ART centre. This is called Anticipatory Guidance. Providing the client an
idea of what happens at the ART centre will make him/ her feel less anxious about what to
expect, and perhaps more tolerant of the wait-time required for the initial investigations.
Prepare your clients as to what to expect when they go to
the ART Centre. This is the skill of anticipatory guidance.
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Discuss with him/ her about the services available at ART centre. Inform them that at the
ART centre they will be registered into Pre-ART care by the ART counsellor. For the
registration they have to carry the ICTC test result, a documentary proof of address,
two passport-size photographs and the referral form. The ART counsellor will make the
patient ID card and will refer the client to the Medical Officer for the necessary
investigations (including the CD4 count).
The reports are usually available on the next day. Based on the reports the medical officer
will prescribe treatment. The client will also interact with the counsellor and the nurse at
the ART centre. After treatment has begun, he/she will have to follow up each month at the
ART centre to obtain the drugs as well as to have the routine monthly check.
Provide the referral form to the clients and give them accurate instructions to reach the
ART centre. It may be a good idea to display a small map on your ICTC wall.
Once the HIV-positive client is registered at the ART centre, all basic investigations are
carried out including the CD 4 count The ART centre counsellor will send the referral form
back to the ICTC by email (or by post if e-mail is not available) after filling in the necessary
details.
For registration at the ART centre, clients must carry
ICTC test result
Documentary proof of address
2 passport-size photographs
Referral form
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Reference:- Refresher Training Programme for ICTC counsellors ( Second
edition)Trainee’s Handouts, April 2011
Understanding Marginalization and Vulnerability in Relation to HIV
Stigma and Discrimination
Social responses of fear, denial, stigma and discrimination have accompanied the HIV epidemic
right from the time it was first discovered in India. The HIV epidemic is considered to be a three
fold, as in, an epidemic of HIV, AIDS and stigma and discrimination. Stigma and discrimination are
potentially the most difficult aspects of HIV/AIDS to address, but addressing them is key to
overcoming the spread of the disease.
Meaning of Stigma
StigmaMeaning
is associated
with disfiguring or incurable diseases, in particular, diseases that society
of Stigma
perceives to be caused by the violation of social norms, including norms about sexual behavior.
HIV/AIDS is a good example of this type of disease.
Parker (et. al., 2002) describe stigma as a tool of social control that is used to identify and use
“differences” between groups of people to create and legitimize social hierarchies and inequalities.
Stigma ‘significantly discredits’ an individual in the eyes of others and also has important
consequences for the way in which individuals come to see themselves.
Why is there Stigma in HIV and AIDS?
Meaning of Stigma
Factors which contribute to HIV/AIDS-related stigma:
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HIV/AIDS is a life-threatening disease.
HIV is associated with behaviours (such as sex between men, injecting drug-use, sex with women in
prostitution) that are already stigmatized in our society.
People living with HIV/AIDS are often thought of being responsible for becoming infected.
Religious or moral beliefs lead some people to believe that having HIV/AIDS is the result of moral
fault (such as promiscuity or 'deviant sex') that deserves to be punished.
Fear of contagion and death among people.
Incomplete/ incorrect information about HIV and AIDS.
In the past, diseases like leprosy, cholera and tuberculosis, the real or supposed contagiousness of
the disease led to the isolation and exclusion of infected people. In the early stages of the AIDS
epidemic, a series of powerful images (see box below), were used that reinforced and legitimized
stigmatization.
Perceptions and Images associated with HIV/ AIDS:
As punishment (e.g. for immoral behaviour)
As a crime (e.g. in relation to innocent and guilty victims)
As war (e.g. in relation to a virus which need to be fought)
As horror (e.g. in which infected people are demonized and feared)
As otherness (e.g. HIV cannot happen to me, but only to others who are set apart)
Together with the widespread belief that HIV/AIDS is shameful, the above images represent 'readymade' but inaccurate explanations that provide a powerful basis for both stigma and
discrimination. These stereotypes also enable some people to deny that they are likely to be
infected or affected.
Meaning of Discrimination
Meaning of Stigma
Discrimination occurs when a distinction is made against a person that results in his or her being
treated unfairly and unjustly on the basis of their belonging, or being perceived to belong, to a
particular group. Hospital or prison staff, for example, may deny health services to a person living
with HIV/AIDS. Or employers may terminate a worker’s employment on the grounds of his or her
actual or presumed HIV positive status. Families and communities may reject and ostracize those
living, or believed to be living, with HIV/AIDS. Such acts constitute discrimination based on
presumed or actual HIV-positive status and violate human rights.
Inter-linkages between Stigma, Discrimination and Denial
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Meaning
of Stigma
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Stigma and discrimination tend to be used interchangeably. While stigma refers to a feeling of
inferiority raising a question of acceptance of the PLHA by others, discrimination is the act of non
acceptance and exclusion. Stigma and discrimination are self-perpetuating. A stigmatized group
experiences suffers discrimination, while discrimination underlines and reinforces stigma.
Discrimination leads to denial and violation of human rights. For example - in fear of being
stigmatized and hence discriminated, a PLHA often conceals his/her status and is thus denied of the
needed services and care. Stigmatizing and discriminatory actions, therefore, violate the
fundamental human right to freedom from discrimination. Additionally, discrimination directed at
PLHA or those believed to be HIV-infected, leads to the violation of other human rights, such as the
rights to health, dignity, privacy, equality before the law, and freedom from inhuman, degrading
treatment or punishment. Ensuring the protection, respecting and fulfillment of human rights is one
important way of combating HIV/ AIDS-related stigma and discrimination (Refer to Module Two for
more information on Rights Based Approach in HIV/ AIDS).
Figure – 3.4 Cycle of Stigma, discrimination and Violation of Human rights (Maluwa and Aggleton, 2000)
Intersection of HIV related stigma and discrimination with pre-existing
S & D associated with sexuality, gender, caste and poverty
To understand the ways in which HIV/ AIDS-related stigma and discrimination appear and the
contexts in which they occur, one needs to understand how stigma and discrimination in HIV/ AIDS
interact with pre-existing S&D associated with sexuality, gender, caste, and poverty and preexisting
fears about contagion and disease.
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Sexuality and HIV/ AIDS Related S & D
Meaning ofS&D
Stigma
HIV/AIDS-related
are most closely related to sexual stigma. The HIV epidemic initially affected
populations whose sexual practices or identities are different from the “norm” (sex workers, men
who have sex with men). HIV/AIDS-related S&D has reinforced pre-existing sexual stigma
associated with STIs, homosexuality, promiscuity, and prostitution. The belief that sex workers and
homosexuals are to blame for the epidemic or that sex workers or homosexuals are the only group
at risk of HIV is still common. MSM’s and IDU’s often deal with the dual stigma in relation to their
HIV status and their sexual identity or their addiction respectively.
Gender and HIV/AIDS Related S & D
Meaning of Stigma
HIV/AIDS-related S&D are also linked to gender-related stigma. The impact of HIV/AIDS-related
S&D on women reinforces pre-existing economic, educational, cultural, and social disadvantages
and unequal access to education, information and services. In heterosexual transmission of HIV,
most often women (in monogamous relationships with their spouses) have been blamed for
bringing illness to the family and have been denied their rights to live in marital house and custody
of children. Men are likely to be 'excused' for their behaviour that resulted in their infection,
whereas women are not.
“ My mother-in-law tells everybody, 'Because of me, her son got this disease. Her son is simple, holy and pure
like a cow but I brought him this disease.”
- HIV-positive woman, aged 26, India
Caste, Class and HIV/ AIDS Related S & D
Meaning
of Stigmaof an HIV positive person from lower caste or low socio-economic status
The trials
and tribulations
are likely to be much greater than a person from an upper caste or better economically placed
person, especially with regard to access to health care, ARVs, and nutritious food. The HIV/AIDS
epidemic has developed during a period of rapid globalization and growing polarization between
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rich and poor. New forms of social exclusion associated with globalization have reinforced preexisting social inequalities and stigmatization of the poor, homeless, landless, and jobless.
It is highly likely that caste and class related S & D interact with HIV/AIDS-related S&D resulting in
marginalization of population groups based on caste/ class, increasing their vulnerability to
HIV/AIDS, which in turn exacerbates stigmatization and discrimination. (Refer Module 2, Unit 2.A
for more information poverty and vulnerability to HIV/ AIDS).
How are stigma and discrimination manifested?
HIV/AIDS-related S&D take different forms and are manifested at different levels -societal,
community and individual - and in different contexts. The following examples highlight where
HIV/AIDS-related S&D have been most frequently documented and where there is the greatest
potential for interventions to reduce or mitigate S&D.
Policy and Legal Contexts
Meaning of Stigma
HIV/AIDS-related S&D in society is commonly manifested in the form of laws, policies, and
administrative procedures, which are often justified as necessary to protect the “general
population”. Examples of stigmatizing and discriminatory measures include compulsory screening
and testing, compulsory notification of AIDS cases, restrictions of the right to anonymity,
prohibition of PLHA from certain occupations and limitations on international travel and migration.
Discriminatory practices include mandatory HIV testing for individuals seeking international work
permits or individuals seeking tourist visas required to declare their HIV sero-status.
Institutional Contexts
Meaning of Stigma
 Educational Settings: Children whose HIV status is known to the school are denied access to
education and are often ostracized on grounds that the positive child may infect others,
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he/she would have negative impact on other children etc. which are based on ignorance and
myths about the disease.
 Employment and the Workplace: Evidence of stigma and discrimination at the workplace
can be understood by looking at the findings of a study conducted by NCAER in
collaboration with UNDP and NACO, (Pradhan, Sundar and Singh, 2006) in six high
prevalence states in India. According to the interviews conducted with majority of the
PLHAs in the study, fear of losing their job, social discrimination and lowering of prestige
were cited as reasons for not disclosing their HIV status at their workplace. The small
percentage of the sample who shared their sero-status at the workplace, faced several
discriminatory practices like being forced to resign or take voluntary retirement, denying of
promotion and benefits
and refusal of loan
facilities.
“ Nobody will come near me, eat with me in the canteen, nobody will
want to work with me, I am an outcast here”
Discrimination at the workplace
-- HIV positive man, aged 27, India
has manifested through attitude of
co-workers as well that ranged
“ Though we do not have a policy so far, I can say that if at the time
from neglect, isolation, avoiding
of recruitment there is a person with HIV, I will not take him. I' ll
close proximity, abuse, teasing
certainly not buy a problem for the company. I see recruitment as a
and name calling. However, this
buying-selling relationship. If I don't find the product attractive, I'll
not buy it.”
survey also pointed out that most
of those who had revealed their
status were those who were
working in NGOs in the field of HIV and AIDS. They reported getting support from their employers
and benefits like leave with pay and adjustable timings.
 Health Care Systems: Health settings have emerged as the most frequently encountered
place of discrimination, followed by familial and community contexts (Pradhan, et. al, 2006).
A New Delhi based study aimed at understanding the causes and manifestations of stigma
and discrimination against PLHAs in hospitals (Mahendra et al., 2006) brought forth some
of the following key points:
 Common manifestations of stigma and discrimination in hospitals include:





Unwarranted referrals to other
facilities,
Condescending, judgmental, and
moralistic attitudes among staff
Segregation and labeling of patients,
Excessive use of barrier precautions
by staff,
HIV testing without consent,
“ Nobody will come near me, eat with me in the canteen,
nobody will want to work with me, I am an outcast here”
-- HIV positive man, aged 27, India
“ Though we do not have a policy so far, I can say that if at
the time of recruitment there is a person with HIV, I will
not take him. I' ll certainly not buy a problem for the
company. I see recruitment as a buying-selling relationship.
If I don't find the product attractive, I'll not buy it.”
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


Inadequate pre- and post-test counseling,
Withholding of HIV test results from the patient, and
Disclosure of test results to family and non-treating staff without consent.
 Both individual and institutional factors contribute to HIV/ AIDS-related stigma and
discrimination in health care settings - staff prejudice against HIV-positive patients and
patients considered to be at risk for HIV, staff misconceptions about HIV transmission and a
resultant fear of contact with blood-borne pathogens, lack of hospital policies protecting
people living with HIV/AIDS and ensuring staff safety, and inadequate training of staff on
infection control contribute to differential treatment of HIV-infected clients.
We are often refused treatment in hospitals. They tell us we have no empty bed. Another thing that they say is
we don't have facilities for treating HIV. They then refer us to other hospitals.
--PLHA
The doctor refused to examine me for almost two months. Even stopped doing my dressing. He just told me
to continue with my medicines. He also referred me to another hospital for an operation that he wouldn‟t do as
it would be very costly for me.
-- PLHA
 Religious Institutions: In some contexts, HIV/AIDS-related S&D has been reinforced by
religious leaders and organizations, wherein religious doctrines, moral and ethical positions
regarding sexual behavior, sexism and homophobia, and denial of the realities of HIV/AIDS
have helped create the perception that those infected have sinned and deserve their
“punishment,” increasing the stigma associated with HIV/AIDS.
 Family and Community Contexts:
According to the study report to understand
(Pradhan et. al., 2006), it was observed
that the family is the main source of care
and support for PLHAs. While families
provide care and support, they may also
perpetuate S and D against infected
individuals. Women are more likely to be
badly treated than men or children.
Daughters-in-law are treated much worse
than the sons and there is no place in the
the socio-economic impact of HIV and AIDS in India
“ My mother-in-law has kept everything separate for memy glass, my plate, they never discriminated like this with
their son. They used to eat together with him. For me, it's
don't do this or don't touch that and even if I use a bucket
to bathe, they yell - 'wash it, wash it'. They really harass me.
I wish nobody comes to be in my situation and I wish
nobody does this to anybody. But what can I do? My
parents and brother also do not want me back. ”
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family for them if the son dies (Bharat, 1999).
HIV/AIDS-related S&D in communities is commonly visible in the form of blame, scapegoating,
difficulty in procuring a place of stay, teasing and name calling. Communities often shun or gossip
about those perceived to have HIV or AIDS. In more extreme cases, it could take the form of
violence. HIV/AIDS-related S&D is known to extend to families, neighbors and friends of PLHA. This
‘secondary’ stigmatization and discrimination has played an important role in creating and
reinforcing social isolation of those affected by the epidemic, such as the children and partners of
PLHA.
PLHAs experience discrimination not only during their lifetime, but also at death. There have been
reported cases of discrimination at the time of cremating a PLHA, when family members have had
difficulty in obtaining transport to the cremation ground, experienced lack of co-operation from the
staff of cremation ground or the community has not allowed to perform the last rites (Pradhan et.
al., 2006).
 Individual contexts:
In individuals, the way in which HIV/AIDS-related S&D are manifested depends on family and social
support and the degree to which people are able to be open about such issues as their sexuality as
well as their sero-status. In contexts where HIV/AIDS is highly stigmatized, fear of HIV/AIDSrelated S&D may cause individuals to isolate themselves to the extent that they no longer feel part
of civil society and are unable to access the services and support they need . This has been called
internalized stigma. In extreme cases, this could lead to premature death through suicide.
Even where laws exist to protect PLHA rights and confidentiality, few individuals are willing to
litigate for fear of disclosure of their HIV status. Even when the family response is positive, fear of
stigmatization and discrimination by the community may mean that an individual’s sero-status is
not revealed outside the home.
Today people who are working on the issue of HIV/ AIDS (e.g., doctors, other health care providers,
NGO workers) are also stigmatized for being associated with a work which carries stigma to such a
great extent.
Discrimination can be seen in different forms that are enumerated below:
Direct discrimination is done openly against a particular group or individual towards whom the
discriminatory behavior is directed. (Eg: Not allowing a PLHA or HIV affected family to access
common drinking water facility, refusing to treat a PLHA in a health care setting, etc.)
Indirect discrimination happens when the situation is not so obviously discriminatory; however it
has a negative impact on the person or the group. (Eg. Avoiding hand shake, close proximity or
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interaction with PLHAs may not appear as overt forms of discrimination but a PLHA may feel
rejected by friends, colleagues and family on account of his/her positive status).
Reactive discrimination is more at an emotional level when a person based on his/her emotion/
feelings manifests a discriminatory behavior to an individual or group or situation or information
(Eg. People reacting with different discriminatory behaviours towards all sex workers, MSMs,
truckers (high risk groups) on an assumption that they are HIV positive).
Proactive discrimination takes place when the discrimination is well planned and deliberately
done to ostracize the targeted person or group. (Eg. Compulsory testing for HIV for traveling to the
middle east and denial of visa to persons turning positive to the tests, proposed mandatory premarital HIV testing by some of the States governments in India).
Passive discrimination occurs by omission or a failure to act, when the particular needs of
particular groups are not met, or they are inadequately represented. (Eg. Medical Officer not taking
action against health care staff who discriminates against PLHAs in health settings).
Vilification happens when discriminatory remarks/comments are made with the intention to hurt
a particular targeted person or group.
Box 3.11: Impact of Stigma, Discrimination and Denial
At an individual level stigmatization and discrimination lead to:
Non disclosure of his/her HIV status.
Denial of the positive status.
Delay or total neglect to health seeking.
Feelings of fear, anxiety, self harm behaviors, anger towards others etc.
Suicidal attempts are also common.
Poor quality of life.
At a family level the outcome can be in form of:
Non acceptance of the HIV positive family member in the family.
Denial to access to family resources including care and treatment, especially towards women.
Blaming and accusation.
Loss of status and power.
At a macro level (community/state) the outcomes of discrimination are:
Increase in the vulnerability of the disease.
Continued marginalization of some groups.
Social invisibility of the infection and magnification of the negative impact of the infection.
Denial of access to community and state resources.
Lack of political will and apathy.
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Marginalized Population: Outside the Pale
It is difficult for preventive and harm reduction strategies to reach marginalized populations - who
are often most at risk - because the law sees them as criminals. Atiya Bose and Kajal Bhardwaj of
the Lawyers Collective argue for a change in such laws regarding MSM, sex workers and injecting
drug users
There is ample epidemiological and demographic evidence from the trajectory of the HIV pandemic
to show that certain populations are more vulnerable to infection because of the particular social,
cultural, economic and legal circumstances to which they are subject. In India, it has been seen that
marginalized populations that live in an environment of inequity, criminalization, oppression and
violence have an increased vulnerability to HIV and AIDS, and have been disproportionately
affected by it. Some of these vulnerable groups are injecting drug users, sex workers, and men who
have sex with men. All three groups engage in behaviours that are known to be high-risk given that
the routes of transmission of the disease are through sexual intercourse, and via blood.
The vulnerability of these groups stems from the fact that behaviours associated with them are
considered criminal, are socially disapproved, and lead consequently to their needs and rights
being trampled or neglected and to their marginalization. Their access to healthcare and prevention
services is accordingly impeded. Ironically, the government runs several HIV programmes with
these groups which are often hampered, or in some cases completely disrupted, by law enforcers
acting in conformity with criminal laws.
Injecting Drug Users
Although injecting drug use occurs throughout the country, HIV prevalence among injecting drug
users (IDUs) in northeast India is among the highest in the world. Injecting drug use is a known
risk-factor in the transmission of HIV because of the dangers inherent in sharing needles that might
be infected. The use of drugs also significantly impairs a person’s judgment regarding risky
behaviour in general. Since drug use is a criminal offence, drug users are forced to live under the
radar, and on the periphery of society and out of reach of health care services and information. This
prevents drug users from accessing prevention, harm reduction and treatment information and
services.
‘Harm reduction’, is the umbrella term used to explain interventions that aim to reduce the negative
health consequences of a specific behaviour (i.e drug use) rather than eradicate the behaviour. The
two most widely practiced models of harm reduction in the context of drug use are needle syringe
and exchange programmes, or NSEPs (where clean needles are provided in exchange for used ones
in order to reduce the risk of transmission of HIV and other blood borne diseases) and drug
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substitution programmes (where drug users are weaned off illegal opiates by being put on a
regimen of buprenorphine in a supervised and regulated setting).
Both these interventions are controversial because they are seen as abetting the criminal offence of
drug use - giving a drug user a clean needle, which is drug apparatus, assists him in the crime of
injecting drugs. Studies show that these programmes are successful in controlling the spread of HIV
without increasing drug use while also bringing down crime. Although these programmes do exist
in some parts of India, they do so despite the law and are constantly in fear of being caught,
harassed and even shut down. The absence of laws protecting such crucial interventions leaves
them open to the caprice of law enforcement personnel in preventing or permitting them.
At the very least there has to be legal recognition of harm reduction programmes in a manner
whereby drug users accessing such programmes and individuals managing them are excluded from
the ambit of criminalization for possession, use, consumption and abetment and are protected from
harassment and other excesses by law enforcement.
Sex Workers
The HIV epidemic has increased the attention paid to sexual behaviours particularly the behaviours
of populations that have multiple sexual partners. In this context, sex workers have come to be seen
as a “high risk group”, being susceptible to sexually transmissible infections and HIV. Concerns
about the spread of HIV from high risk groups into the bridge (clients) and general populations
(regular sexual partners of clients including wives) led to the introduction of HIV prevention
interventions among sex workers.
Such intervention efforts brought to light some of the experiences of sex workers, including the
difficulty in insisting on condom use and safer practices. These experiences revealed that the ability
to practice safer sex in sex work settings depends on a range of factors including information and
access to preventive measures, the extent of control exerted by other agents including madams,
touts, pimps, brothel owners, clients, and the fear of external agents like the police. The socioeconomic and legal context to sex work is the larger backdrop in which the sex worker’s
vulnerability to HIV infection emerges and gets perpetuated.
To understand the nexus between sex work, HIV and criminal law, it is critical to examine the
extent to which the rights of sex workers are either protected or violated by the State and the
strategies that are adopted to change, reduce, or eliminate the selling of sexual services. Criminal
sanctions imposed upon sex work push them underground into hidden and dangerous settings
where they have minimal control over their health, safety and earnings. When sex workers are
forced to negotiate their livelihood in conditions of fear, insecurity and exploitation, health and HIV
concerns become low priorities. Criminalisation adds to the existing stigma and negative attitudes
attached to sex work thereby making it even harder for persons in sex work to access information,
health care and treatment, HIV and AIDS education and prophylaxis.
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The Immoral Trafficking Prevention Act, 1986 (ITPA), the main statute dealing with sex work in
India, does not criminalize prostitution or prostitutes per se, but mostly punishes acts by third
parties facilitating prostitution like brothel keeping, living off earnings and procuring. There are
exceptions, however, and practicing prostitution in the vicinity of public places and solicitation are
two activities for which sex workers are penalized. Over 90% of all “trafficking” convictions are
under provisions relating to these activities, and not for the more serious acts that the legislation is
intended to curtail. In other words, 90% of the time it is the sex worker who is arrested, harassed or
penalized for a “trafficking” crime.
Moreover, the criminalization of soliciting for sex greatly diminishes the sex worker’s ability to
negotiate the terms of services, including income and condom use and pushes sex workers
underground or into ghettoised locations where they are difficult to reach and more vulnerable to
abuse. Peer-based interventions have been hampered as women carrying condoms are
apprehended by the local police on charges of ‘promoting prostitution.’ Ironically, the same sex
workers who are engaged by one arm of the government to distribute condoms and carry out HIV
prevention efforts among sex workers are criminalized by another arm for doing the same.
ITPA also gives immense power to the police and to magistrates to conduct searches, remove, evict
and detain sex workers leading to the severest forms of human rights violations against individual
sex workers and the community as a whole. Further, it prescribes certain ‘rescue’ and ‘raid’
measures without consideration of the age and volition of the person being ‘rescued’. This have not
only led to a violation of rights of persons in sex work but has also proven to be counterproductive
for HIV interventions.
For example, in 2003, the police carried out a series of raids in Chakla Bazaar, the red-light district
of Surat in Gujrat. They entered private premises without search warrants, destroyed property,
arrested residents and forcibly evicted women from their place of work/residence rendering them
homeless. Many women were harassed and physically abused, and hundreds of sex workers were
prevented from earning a living. Approximately 1500 women were affected by the police actions.
The police invoked certain provisions of ITPA, to justify their actions. These included Section 7
(1)(b) wherein carrying out prostitution in a notified area is an offence (Chakla Bazaar had been
notified pursuant to a circular issued by the commissioner of police in 2000 - as allowed by the
ITPA section, because of proximity to educational and religious institutions - although it has a 400year-old history of being the area where sex workers live/work); Section 14, which makes offences
cognizable ie allows arrests without warrants; and Section 15, which allows for search without a
warrant.
In response to the police action, Sahyog Mahila Mandal, a sex workers collective from Chakla Bazaar
petitioned the Gujarat High Court, challenging the above provisions of ITPA on grounds that they
violated the fundamental rights guaranteed under Articles 14 (Equality before law), 19 (Right to
freedom of speech) and 21 (Right to life and personal liberty- and thereby livelihood). They also
challenged the notification of Chakla Bazaar making prostitution in those areas an offence. The
court’s judgment in Sahyog Mahila Mandal & another v. State of Gujarat & Ors [Special Civil
Application No 15195 of 2003 with Special Civil Application No 4594 of 2003] was as follows:
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The court rejected the sex workers’ contention that sex work ought to be recognized as a
legitimate means of livelihood and that they should be permitted to carry on their work
outside the notified area, holding instead that allowing prostitution would mean an open
invitation to trafficking in women.
The court further held that the restriction of personal liberty imposed by Section 7, ie, the
deprivation of liberty to carry on prostitution in public places, is in the interest of the
general public and is in keeping with procedures established by law as well as the
Convention for Suppression of Trafficking in Persons and of the Exploitation of Prostitution
of Others to which India is a signatory. It also held that the right to privacy is not absolute
and unlimited and must be balanced with the needs of the community and with other rights.
Intruding into the sphere of sex between two people that was “indiscriminate” and “for
reward” is not an invasion of privacy, because “by making her sexual services available for
hire to strangers in the market-place, the sex worker empties the sex act of much of its
private and intimate character.”
The court also said that ITPA was aimed at combating trafficking, and that rescuing and
rehabilitating trafficked women was a part of its objective. Therefore, the special powers
given to the police (search without a warrant) did not violate any fundamental rights.
The court directed the state government to form a State Level Rehabilitation Committee
(SLRC) and a Local Cell to look into the grievances of the affected women and girls who
deserve to be rescued and rehabilitated under the ITPA.
The impact of this judgment was that it drove sex workers underground, and even the governmentrun HIV prevention programme among sex workers witnessed a decline in delivery of condoms and
a concomitant rise in prevalence of sexually transmitted infections. Similarly, in 2004 in Baina in
Goa, efforts to introduce risk reduction practices among sex workers were interrupted after the red
light area was demolished. For several months, displaced sex workers were seen soliciting on the
streets for survival, at the cost of condoms and HIV protection.
At present, the government is considering amendments to ITPA which sex workers’ organizations
are arguing will lead to their further harassment and the disruption of HIV prevention programmes.
Men Who Have Sex with Men
In India, as in many other parts of the world, men who have sex with men (MSM) have a heightened
vulnerability to HIV. The vulnerability arises in part from the increased risk of HIV infection during
penetrative, particularly unprotected, anal sex, but an equal, if not greater cause for vulnerability is
the stigma attached to male-to-male sex that causes discrimination and criminalization, and
enforces a silence around such acts that raise significant barriers in imparting information about
health risks in an objective and scientific manner.
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In India, Section 377 of the Indian Penal Code (IPC) criminalises sodomy thereby criminalizing
consensual sex between men. The impact of Section 377 on MSM is severe. This law, combined with
local police acts and laws on public nuisance, obscenity, abetment and criminal conspiracy, is used
by law enforcement agencies and officials to exploit, threaten, harass, blackmail and perpetrate
other forms of violence against MSM.
Criminalization of MSM also perpetuates negative and discriminatory beliefs towards same-sex
relations and this misinformation is often used by the Indian medical community to conduct
‘aversion therapy’ on MSM (involving inhumane methods of electric shock ‘treatment’). MSM are
thus pushed to the fringes of society where spaces are unavailable to negotiate stable relationships,
safe sex and access to information and medical services that should be provided free of
discrimination and social censure. As a result MSM vulnerability to HIV is greatly increased. Also,
many MSM in India are married men, and so there is an increase in vulnerability to HIV infection for
their spouses and families too.
These laws have also been used to disrupt the work of NGOs working with MSM in the field of HIV
and AIDS. For instance, in July 2001 the premises of an NGO in Lucknow, that worked on sexual
health awareness programmes with the MSM population was raided. Its workers were arrested on
charges of abetting a crime under Section 377, and for violating obscenity laws for publishing safesex messages, distributing condoms to MSM and explaining the dangers of HIV/AIDS. It was only
after 47 days in jail that the workers were granted bail.
Decriminalizing adult consensual sexual activity between men and creating a positive legal and
social environment where their rights are guaranteed, and where they can access health
information without fear of reprisal is the most effective way to reduce the vulnerability of MSM to
the risk of HIV infection.
To this end, in 2001, Naz Foundation filed a public interest litigation before the Delhi High Court
challenging the constitutional validity of Section 377 and asking that the provision be read down to
exclude adult consensual sexual activity; as Section 377 is also the law that is used to address child
sexual abuse in India its complete repeal has not been prayed for.
The High Court passed an order dismissing the petition stating among other things that Naz
Foundation had no standing to file the case since they were not themselves being prosecuted under
Section 377, that a petition could not be filed to test the validity of any legislation, and also that it
would not consider an academic challenge to the constitutionality of a provision.
This ruling relied on outdated case law and ignored the fact that Naz had filed a public interest
litigation, in which a petitioner is not required to have ‘standing’ (or locus standi, in legal parlance).
Naz Foundation then approached the Supreme Court challenging the Delhi Court’s dismissal.
In Naz Foundation v. Govt. of N.C.T. of Delhi and Others, [SLP No. 7217-7218 of 2005], the Supreme
Court set aside the order of the Delhi High Court and remanded the case back to the High Court for a
decision. The Supreme Court observed that the matter did not deal with an academic question and
that it was a public interest issue that was being debated all over the world. The case is at present
before the Delhi High Court. NACO (National Aids Control Organization) in its reply to the court has
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acknowledged that Section 377 hampers its prevention programmes with MSM. Although it has
been well over a year since the case was remanded to the high court, there has been no further
action.
(Atiya Bose is media and communications officer and Kajal Bhardwaj is head of the technical and
policy unit at the Lawyers Collective HIV/AIDS Unit. The Lawyers Collective HIV/AIDS Unit was set up
in 1998 based on a realization that law, policy and judicial action that upheld the human rights
framework had a central role to play in effectively containing the HIV epidemic. The Unit comprises
lawyers, law students and activists working in offices in Mumbai, Delhi and Bangalore, and offers free
legal services to the persons living with, affected by or vulnerable to HIV and undertakes advocacy and
research initiatives related to law, rights and HIV.)
© Lawyers Collective HIV/AIDS Unit www.lawyerscollective.org. Infochange News & Features, February
2008
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Gender and HIV
Meaning of Gender and Sex
Gender and sex tend to be used interchangeably. Sex refers to the biological difference between
of Stigma
males Meaning
and females.
Sex can also be used to describe physical acts of sex that includes penetrative
penile-vaginal intercourse, oral sex, anal sex, masturbation and kissing, among others.
Gender refers to the economic, social and cultural attributes and opportunities associated with
being male/ masculine or female/ feminine in a particular social setting at a particular point in
time.
Meaning of Femininity and Masculinity
Femininity refers to the qualities or characteristics considered appropriate for women/girls. The
dominant ideologies of femininity expect women/girls to be subordinate, obedient and dependent;
passive in sexual relations; virgins, chaste and monogamous; and privilege motherhood as the
primary reason for having sex.
Masculinity refers to the qualities or characteristics considered appropriate for men/boys. The
dominant ideologies of masculinity expect men/boys to be independent, dominant, aggressors and
providers, strong and virile.
What is considered female or male virtues and qualities depends on the cultural context and time.
It can also differ depending on factors such as class, age, ethnicity and other social differences.
It is important to distinguish between what society has constructed for each gender and what is
biological. For example ideas that women/ girls are gentle, love to dress, have no sex drive etc. are
created by society versus women giving birth which is biological. Biological differences are
magnified to justify unequal treatment of men and women.
Manifestations of Gender Differences
Gender difference is found in the construction of roles – what women and men do; relations – how
Meaning
men and women
relateoftoStigma
each other and identity – how women and men perceive themselves.
Gender roles are not the inherited ones. Boys and girls are systematically taught to be different
from each other. Socialization towards gender roles begins early in the life. This includes learning to
be different in terms of appearance and dressing, behaviour, activities and pastimes, emotions that
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we show, responsibilities and intellectual pursuits. Gender roles are learnt and therefore, can be
unlearnt. They are not unchangeable.
Gender roles are taught and reinforced by various social institutions; the family, school, religious
institutions, workplace, society as represented by peers and neighbours. Women play a significant
role as men in socializing girls and boys into their gender roles. Society prescribes specific roles for
girls and boys, women and men, but values them differently. Girls and women are valued less than
boys and men. This unequal value is the source of discrimination and oppression for women and
accounts for the inferior status given to women in society.
Gender relations refer to the relation of power between men and women, women and women, and
men and men. They are revealed in a range of practices, ideas, and representations, including the
division of labor, roles and resources. Gender relations are influenced by interaction with other
structures of social hierarch such as class, caste and race.
Gender relations constitute relations of dominance and subordination with elements of cooperation, force and violence sustaining them. Therefore in a traditional joint family set up in India
there are clear roles where the father has more power over the sons, but the sons exercise more
power over the mother and other women in the family. The mother might be lower in the hierarchy
but can exercise more power over the daughters and daughter in laws.
Gender identities refers to how people perceive their own gender- whether they think of
themselves as a man, a woman, both or as a different gender. Many cultures and communities have
prescribed rules for appropriate gender identities based on biological sex of a person. It is
important to note that identities are not static. Individuals can change their gender identity
throughout their lives.
Gender and Vulnerability to HIV/AIDS
Several norms and attitudes related to gender roles
and relations have been critical in determining an
individual’s vulnerability to infection, his or her
ability to access care, support or treatment, and to
cope when infected or affected. These are
substantiated below:
Vulnerability
Refers to the likelihood of being exposed to HIV
infection because of a number of factors or
determinants in the external environment, which are
beyond the control of a person or particular social
group.
Physiological Vulnerability
Transmission during sexual intercourse is almost twice as likely to lead to female infection as to
male infection because women have a larger mucosal surface where micro-lesions can occur and
facilitate the transmission of HIV.
Meaning of Stigma
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Access to and Control Over Resources
Women and men have unequal access to and control
Meaning of Access and Control
over resources. For example: Gender norms in our
Meaning of Stigma
society restrict women’s mobility. The purdah
Access is the ability to use a resource.
practice (common in many Hindu and Muslim
Control is the ability to define and make
communities in India) where women are confined to
decisions about the use of a resource.
their homes, prevents them from travelling to access
health or other services. In other cases, women may
(WHO, 2001)
have access to health services, but no control over
what services are available and when. Men too face barriers in accessing services. Gender norms
assign reproductive responsibilities entirely on women and keep men out of parenting or nurturing
roles. For example: If men were regarded as partners in nurturing roles and encouraged to
accompany women to the ante natal clinics (ANC), then men too would benefit from the HIV/AIDS
information and services often provided in these clinics.
ACCESS TO AND CONTROL
OVER RESOURCES
Internal
Resources
Economic
and Social
Resources
Political
Resources
Information
/ Education
Time
POWER AND DECISION-MAKING
Fig 3.1: Access to Control Over Resources (WHO, 2001)
Gender norms cast women as being primarily responsible for reproductive and productive
activities within the home whereas men are viewed as primary producers outside the home. Due to
this, women have inequitable access or control over a range of different resources like economic
resources (work, food, money, transport, insurance, child care facilities etc.) political resources
(positions of leadership and access to decision-makers), social resources (community resources
and social networks), information/ education (formal and non-formal education), time and
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internal resources (self-esteem, ability to express one’s own interests). (See figure 3.1). This has
resulted in women having limited control over their own health, the timing, context and safety of
intercourse, and vulnerability to gender-based violence.
Gender Norms Related to Sexuality
Gender norms shape attitudes towards sex, sexuality, sexual risk-taking and fidelity. These have
played a critical role in the spread of the HIV epidemic since the primary mode of HIV transmission
in IndiaMeaning
is sexual. of
Common
Stigmagender norms in our country require women/ girls to remain ignorant,
passive, subordinate and faithful in sexual relations. The dominant ideal of masculine behavior and
sexuality promotes men and boys as assertive, independent and strong. High sexual drive and the
ability to father many children are considered among the core qualities of men.
These notions of gender and sexuality make it very difficult for women/ girls and men/ boys to
access reliable information about sexuality and reproductive health services, openly discuss sexual
matters, practice safe sex and promote more gender equitable relations.
Lack of Negotiation Power Regarding
Safer Sex Measures
It is widely accepted that the risk of HIV infection can be minimized if men and women take steps to
Meaning of Stigma
have safe and consensual sex. This insight has informed the national and global response to
HIV/AIDS in the terms of the ABC model. Wherein, “A” stands for Abstinence, “B” stands for be
faithful and “C” stands for correct and consistent condom use. The fourth alphabet ‘D’ that stands
for ‘Don’t Penetrate’ is a recent addition to HIV prevention methods. However, the decision
regarding safer sex measures to prevent STIs/ HIV, in particular condom use is not merely a matter
of individual choice, but depends on several socio-cultural norms that are explained in Figure 3.2
below.
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Pleasure: Belief
that condoms
decrease sexual
experience
Emotions: Desire to
have children or
willingness to
consider adoption
Social norms/values
on ‘appropriate’
male/ female
behaviour and
sexuality (external &
Iinternalised)
Safer sex behaviour
to reduce HIV risk
for oneself and/or
one’s sexual
partners depends
on several factors
Access of services and
resources to prevent
HIV infection (e.g. STI
treatment
Knowledge /
Information about
risk of HIV infection
and how to prevent
it
Skills to act on
knowledge about HIV
prevention and to
negotiate safe sex or
abstention
Power / Absence of
coercion and violence to
asset sexual health and
negotiate safe sex
Socio-cultural norms affecting safer sex behaviors
In the Indian context, women most often do not decide when to have sex. As a result, women are
not in a position to negotiate safe sex and ask men to use condom (See figure 3.3). Moreover,
women have been the receiving end of most of the popular birth control measures (oral pills,
copper T, female sterilization etc) under the different national family planning programmes. Male
condom as a birth control measure has not received adequate emphasis. Several misconceptions
abound condom use thereby making consistent condom use in preventing STIs/HIV, a huge
challenge for AIDS Prevention Programmes.
Additionally, lack of female controlled HIV prevention methods has furthered the vulnerability of
women to STIs/ HIV. Although the female condom is available in Indian markets at subsidized rates
through some social marketing companies, its reach right now is more urban and there is
insufficient evidence regarding its popularity and consistency.
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Can threaten physical or emotional
violence
Perceives wife as
his property
Is the
breadwinner and
decision-maker
expenses
Condoms are not
available
Thinks condoms
are wasteful or
diminish sexual
pleasure
Is physically
stronger and can
impose himself
MAN
Owns the house
Is expected to
produce many
children/wants
children
Believes husband
can demand sex
whenever he wants
Cannot
discuss sexual
matters with
husbands
Do not know about
HIV and how to
protect against
infection
Fears violence
Economic
dependence
WOMAN
Condoms are not
available
Earns some money,
but is expected to
hand this over to
her husband
Is expected to have
children/wants to
have children
Believes he is not at
risk because he has
regular girlfriends
(ignorance)
Embarrassment
in procuring
condoms in ANC
Feels that using
condoms equates
her with a sex
worker
Factors influencing the power to decide on condom use in a heterosexual or marital relationship
Gender Based Violence
Violence against women and girls arises from notions
of masculinity based on sexual and physical
Meaning of Stigma
domination of men/ boys over women/girls.
Domestic Violence: Fact Sheet


In the context of rape and sexual abuse, whether by
husbands or other men, women and girls are least
able to refuse sex or insist on protective measures
like condoms. Violent sexual acts are also most likely
to result in internal tearing, which significantly
enhances the risk of contracting HIV or other STIs.
Furthermore, fear of violence often prevents women
from discussing faithfulness or safe sex practices
with their partner.



Domestic violence is a major problem in India,
both in the states and union territories.
Domestic violence is the most common but least
reported crime in India.
Domestic violence is the number one cause of
women‟s injuries.
Domestic violence occurs among all racial,
ethnic, religious, and socio –economic groups.
Women are socialized to accept, tolerate,
rationalize domestic violence and remain silent
about such experiences.
According to the National Family Health Survey (NFHS-3), out of the 199,000 women interviewed
between the ages 15-49 years, 40% of ever-married women experienced spousal physical, sexual or
emotional violence with large variations among the states. Prevalence of such violence is higher in
rural areas than in urban rural areas. Married women with no education were much more likely (at
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46%) than other women to have suffered spousal violence. However, spousal violence extended to
women who have 12 or more years of higher education, with 12% reporting violence. Slapping is
the most common reported act of physical violence (34 percent). Being physically forced to have
sexual intercourse (10 percent) and being forced to perform sexual acts that she did not want to
form (5 percent) were the forms of sexual violence (IIPS and Macro International, 2007).
The trafficking of girls and women into prostitution is another form of violence against women
which places them at risk for HIV infection and unwanted pregnancy. In Mumbai and Pune 54 %
and 49% of sex workers have been found to be HIV infected respectively (NACO, 2005). Women in
prostitution are not protected by law, experience social stigma, and have almost no access to social
and medical services.
Women as Care Givers
Female responsibility for care giving reduces girls’ and women’s participation in productive and
economic activities (including education) as the disease progresses. This in turn constricts women’s
social and economic opportunities, further contributing to the cycle of poverty, lack of
Meaning of
Stigma
empowerment,
and
vulnerability to infection.
Legal Aspects
Laws and regulatory frameworks
discriminate against women and
reinforce women’s subordinate
Meaning
of spheres
Stigma as: property
status
in such
and inheritance rights; marriage;
employment; rape and sexual
harassment; and reproductive rights.
Women, Poverty and HIV/AIDS
Women make up almost two-thirds of the world‟s illiterate.
Women earn 30-40 percent less than men for the same work, and most
of those who are working, are employed outside the formal sector in
jobs characterized by income insecurity and poor working conditions.
70 percent of the world‟s poor are women. The number of women living
in poverty throughout the world has been growing disproportionately
compared with the number of impoverished men.
Women carry the burden of unpaid domestic and subsistence work.
Women have unequal access to education and skills training.
All of these factors leave women impoverished and unable to challenge
their poverty, and in turn, this worsens the impact of the AIDS epidemic
on women.
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Poverty and Migration
Poverty and the lack of economic opportunities often result in migration of both men and women in
search of income and employment, which disrupts stable social and familial relationships and
of and
Stigma
exposeMeaning
both men
women to increased risk of infection. Moreover, migrant populations are
often socially marginalized, with restricted access to economic assets, information and services.
Vulnerability Factors of Women/ Girls to HIV infection
Physiological vulnerability to STIs/ HIV
Social, Economic and Emotional dependence on men
Trafficking and Sex work
Early marriage
Lack of education
Lack of access to services
Male dominance in sexual relations
Violence against women
Burden of family planning
Lack of affordable, widely available female controlled HIV preventions methods
Poverty and Migration
Laws relating to property rights and inheritance
Women and the HIV/AIDS in India
In India, adult HIV prevalence among the general population is 0.36 percent. Women account for
around one million out of 2.5 million estimated number of people living with HIV/AIDS. Nationally,
the prevalence rate for adult females is 0.29 percent, while for males it is 0.43 percent. This means
that for every 100 people living with HIV and AIDS (PLHAs), 61 are men and 39 women (NACO,
2007). The HIV epidemic is moving beyond high risk groups towards women and young people.
New HIV infections are occurring in women who practice monogamy in a marital relationship
[Source: TISS, UNDP (undated). Mainstreaming HIV/AIDS in development work. A manual for
trainers]
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Sex, sexuality and HIV
Meaning of Sex
Sex refers to the physiological attributes that identify a person as male or female:




Type of genital organs (penis, testicles, vagina, uterus, breasts)
Type of predominant hormones circulating in the body (e.g., estrogen, testosterone)
Ability to produce sperm or ova (eggs)
Ability to give birth and breastfeed children
Sex can also be used to describe physical acts of sex that includes penetrative penile-vaginal
intercourse, oral sex, anal sex, masturbation and kissing among others.
Meaning of Sexuality
Sexuality is often used interchangeably with sex or sexual intercourse. However, a comprehensive
view of sexuality includes social roles, personality, gender and sexual identity, biology, sexual
behaviour, relationships, thoughts and feelings. The expressions of sexuality are influenced by
social, ethical, economic, spiritual, cultural and moral concerns.
Key Elements of Sexuality
All people are sexual, whether or not they engage in sexual acts or behaviour.
Being sexual includes thoughts, attitudes and feelings along with sexual acts and behaviours.
Sexuality expressed positively, through consensual, mutually respectful and protected relationships,
enhances well-being, health and the quality of life.
Sexuality expressed negatively, through violence, exploitation or abuse, diminishes people‟s dignity
and self-worth, and may cause long-term harm.
Society exerts strong controls on sexuality, especially women‟s sexuality, through social norms,
values and laws.
The understanding of sexuality has considered men‟s experiences and needs and has ignored,
negated and devalued those of women.
In other words, dimensions of sexuality include:
 Biological aspects (sex anatomy, physiology and biochemistry of the reproductive system);
 Mental and emotional aspects (sexual orientation, sexual identity, thoughts, feelings, pleasure,
fantasies, eroticism, desires and intimacy) and
 Behavioral aspects (sexual behaviours and relationships).
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Sexual Behaviours and Practices
Traditionally sex is viewed as between a woman and a man, penile-vaginal, within marriage and for
procreation. Any form of sexual expression beyond this purview is seen as a deviation and labeled
as “abnormal”. For example masturbation, anal sex or oral sex and same sex relationships are
perceived as “abnormal” or unnatural as it moves away from the normative understanding of
society that sex is primarily for the purpose of reproduction. Sex for pleasure is generally not
recognized or accepted.
There are different types of sexual behaviors like masturbation, peno-vaginal sex, oral sex, anal sex,
kissing and so on. Some of these are briefly explained as follows:
Abstinence: Sexual abstinence means refraining from any sexual stimulation. Abstinence
protects individuals from STIs/ HIV, but in general it is usually advocated for moralistic
rather than health reasons.
Petting: Any touch designed to stimulate the other person sexually is called petting.
Masturbation: Masturbation refers to self-stimulation usually by touching/rubbing one’s
genitals. It can also involve fantasy, pornography and/or sex toys. Both boys and girls
masturbate. It is a healthy practice and a natural way to explore one’s sexuality. It does not
decrease one’s virility or sexual performance in any way. It helps release sexual tension in
the absence of other outlets.
Mutual masturbation is where two people stimulate their own and each other's genitals
for sexual gratification. Mutual masturbation is promoted widely as safe sex behaviour
between to prevent the spread of STIs/ HIV.
Vaginal or Sexual Intercourse: Vaginal intercourse refers to that act of an erect penis
penetrating the vagina and ejaculation of the semen into it after reaching orgasm. Vaginal
intercourse without the use of condom makes HIV/ STI transmission a high risk. Although
there tend to be some taboos against vaginal intercourse during menstruation, many
individuals continue sexual behaviour during menstruation. Safer sex advice should point
out that menstrual blood if HIV infected is an unsafe body fluid.
Anal Sex: Anal sex refers to penetration of the penis in the sexual partner’s anus. Most
people view anal sex as masti (fun) and not ‘sexual intercourse’ since it is not penile- vaginal
and for the purpose of procreation. Anal sex has a higher chance of transmitting HIV
especially for the passive partner because chances of minor aberration and tearing are
higher. This makes condom use a must during anal sex.
Anal sex is most often associated with homosexuals and believed to be unhealthy, abnormal
or perverse by many sections of our society. However, anal sex is reported to be a common
sexual behaviour among heterosexuals as well. Many older women, before the advent of
modern contraception, relied on anal intercourse to avoid pregnancy.
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Orogenital Sexual Behaviours: Fellatio refers to a male/female partner using their
mouth/tongue to stimulate a man’s penis. Cunnilingus refers to mouth contact with the
female genitalia. Orogenital sexual behaviours may occur singly, alternately or concurrently
to lead to orgasm.
It should be noted that teeth can produce genital trauma and that human bites can easily
become infected. Advice about how "safe" orogenital contact is difficult. Ejaculation into the
mouth should be avoided. Condom use on the male partner increases safety.
People’s comfort levels and preferences for these diverse behaviours vary. Those engaging in
consensual sexual behavior have the right to do so without fear of being judged or punished for
their activities. Several values affect our comfort levels and attitudes towards sexual behaviours.
These may cause shame and guilt about our own sexual desire and its expression even, when it is
safe and consensual. However, coercive sexual behavior of any kind, whether between regular
partners such as married couples or non-regular partners, is unacceptable.
Sexual Identity
Sexual identity refers to the identity people adopt for themselves, based upon whether they are
attracted to people of the same gender, a different gender, or to more than one gender. It is
important to note that sexual behavior and identity are different. Sexual behavior refers to the
sexual activity individuals engage in and not how they identify themselves. For instance, engaging
in sexual activity with a person of the same gender does not necessarily indicate homosexuality –
there are men who have sex with men (behavior) but do not think of themselves as homosexual
(identity).
Sex (whether a person has male or female genitalia), gender identity (whether a person thinks of
oneself as a man, women, both or a different gender), and sexual identity (being heterosexual,
bisexual, homosexual etc.) refer to different aspects of a person. In many cultures and communities,
there are often prescribed rules for appropriate sexual and gender identities and sexual behavior.
Deviation from this norm can often result in discrimination, stigmatization, abuse and ridicule.
However, having the option to choose and express a gender and sexual identity rather than
conforming to external rules is necessary for our self respect and well being. Every individual has
multiple identities, which intersect in unique ways to make the person who s/he is. For example,
someone may identify as a woman, a mother, a lesbian, a daughter, and a nationalist. Identities are
fluid, changing and personal. Stereotypes focus on only a single identity of an individual and may be
used to judge the person unfairly.
The terms below refer to commonly used sexual and gender identities. These terms and identities
are constantly being discussed and examined and therefore their meanings and how they are used
as identities change over time. Some people may decide not to use any identification, or may choose
to move from one identity to another. It is important to understand and recognize that there is a
range of sexual and gender identities.
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Different Sexual and Gender Identities
* Gay: A man who is sexually attracted to other men and/or identifies as gay. This term can also be used to
describe any person (man or woman) who experiences sexual attraction to people of the same gender.
* Heterosexual: An individual who is sexually attracted to people of a gender other than their own and/or
who identifies as being heterosexual.
* Hijra: A term used in the Indian subcontinent, which includes those who aspire to and/or undergo
castration, as well as those who are intersexed (please see definition below). Although some hijras refer to
themselves in the feminine, others say they belong to a third gender and are neither men nor women.
* Homosexual: An individual who is sexually attracted to people of the same gender as their own, and/or
who identifies as being homosexual.
* Intersexed Person: An individual born with the physical characteristics of both males and females. These
individuals may or may not identify as men or women.
* Kothi: A feminised male identity, which is adopted by some people in the Indian subcontinent and is
marked by gender non-conformity. A kothi, though biologically male, adopts feminine modes of dressing,
speech and behavior and looks for a male partner who has a masculine mode of behavior, speech and attire.
* Lesbian: A woman who is sexually attracted to other women and/or identifies as a lesbian.
* Queer: A person who questions the heterosexual framework. This can include homosexuals, lesbians, gays,
intersexed and transgendered people. To some this term is offensive, while other groups and communities
have used it as a form of empowerment to assert that they are not heterosexual, are non-conformist. Against a
dominant heterosexual framework, and dissatisfied with the „labels‟ used on people who do not identify as
heterosexual.
* Transgendered Person: An individual who does not identify with the gender assigned to them. They may
or may not consider themselves a „third sex‟. Transgender people can be men who dress, act or behave like
women or women who dress, act or behave like men. They do not, however, necessarily identify as
homosexual.
* Transsexual Person: An individual who wants to change from the gender they have been assigned at birth
to another gender. They undergo surgery, hormonal medication, or other procedures to make these changes.
They may or may not identify as homosexual, bisexual or heterosexual. They may be female to male
transsexuals, male to female transsexuals or choose not to be identified as either.
* Transvestite: An individual who dresses in the clothing that is typically worn by people of another gender
for purposed of sexual arousal/gratification. Transvestites are often men who dress in the clothing typically worn by
women. They are also known as cross-dressers.
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Sexuality and Vulnerability to HIV/AIDS
In the Indian context, there is a culture of silence regarding sex and sexuality. Some research
studies and media reports indicate that premarital sexual behaviours among young people are on
the rise, resulting in unwanted pregnancies and STIs (Abraham, 2001). As per the NFHS – 3 data,
among women and men age 15-49 who had sex in the 12 months preceding the survey, 1 in every
1,000 women (0.1 percent) and 2 in every 100 men (2 percent) report having had two or more
sexual partners (IIPS and Macro International, 2007). Yet there is a general reluctance to discuss
sexuality, both in public and in private as it continues to be taboo topic.
Sexuality education for children and adolescents is often met with resistance and even discouraged
because of the fear that they will engage in sexual behaviours prematurely. There is abundant
evidence that lack of adequate sexuality education leads to teen pregnancies and STIs/ HIV. The
issue of HIV/ AIDS cannot be addressed if we shy away from discussions on sexuality.
Gender, Sexuality and Power
According to Weiss and Rao Gupta (1998), different P’s of sexuality include Practices, Partners,
Pleasure / Pressure / Pain, Procreation and Power. The power underlying any sexual interaction,
heterosexual or homosexual, determines how all the other Ps of sexuality are expressed and
experienced. Power determines whose pleasure is given priority and when, how, and with whom
sex takes place. Each component of sexuality is closely related to the other but the balance of power
in a sexual interaction determines its outcome.
Power is fundamental to gender and sexuality. Both gender and sexuality are constructed by
several social, economic and cultural forces that determine the distribution of power. For example,
the unequal power balance in gender relations favours men. This is reflected in sexual relations as
well because male pleasure is considered more important than female pleasure. Men have a greater
control than women over when, where, and how sex takes place.
Sexuality Norms and Women’s Vulnerability to HIV
Social and cultural norms require “good” women to be ignorant about sex and passive in sexual
relationships. This makes it difficult for women to be informed about risk reduction or, even when
informed, makes it difficult for them to be proactive in negotiating safer sex.
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The importance of virginity for unmarried girls that exists in our society, paradoxically, increases
young women’s risk of HIV/ STI infection because:
 It restricts their ability to ask for information about sex out of fear that they will be thought to
be sexually active.
 It puts young girls at risk of rape and sexual coercion because of the erroneous belief that sex
with a virgin can cleanse a man of infection.
 Of the erotic imagery, innocence and passivity associated with virginity.
 Some young women may practice alternative sexual behaviors, such as anal sex, in order to
preserve their virginity.
 Accessing treatment services for STIs/ HIV can be highly stigmatizing.
The primary role of women in childbearing and childrearing has conveniently pushed the burden of
family planning on women. Birth control options like oral pills, copper-T, female sterilization are
more popular as against barrier methods like the male condoms and non-penetrative forms of
sexual behaviour. This has proved to be a barrier while promoting and popularizing condoms for
HIV/ STI prevention.
Economic vulnerability of women makes it more likely that they will exchange sex for money or
favours, less likely that they will succeed in negotiating protection, and less likely that they will
leave a relationship that they perceive to be risky.
Sexual violence (coercion, abuse, rape or assault) contributes significantly to women’s vulnerability
to HIV. As per the NFHS – 3 data, more than a third (34 percent) of women age 15-49 have
experienced physical violence and 9 percent have experienced sexual violence. Thirty-seven
percent of ever-married women have experienced spousal physical or sexual violence. A large
majority of women who have experienced sexual violence, but not physical violence, have never
told anyone about the violence (85 percent), and only 8 percent have ever sought help. Abused
women most often seek help from their own families (IIPS and Macro International, 2007).
Sexuality Norms and Men’s Vulnerability to HIV
Unequal power balance in gender relations increases men’s vulnerability to HIV infection, despite
their greater power. Prevailing norms of masculinity expect men to be more knowledgeable and
experienced about sex. This puts men, particularly young men, at risk of infection because such
norms prevent them from seeking information or admitting their lack of knowledge about sex or
protection, and compels them to experiment with sex in unsafe ways, and at a young age, to prove
their manhood.
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Our society either condones or permits multi-partner sex in men for sexual release and justifies this
by regarding it as men’s nature or virility. This challenges the effectiveness of prevention messages
that call for fidelity/ faithfulness in partnerships or a reduction in the number of sexual partners.
Gender norms require men to be self-reliant, not to show their emotions, and not to seek assistance
in times of need or stress. This expectation of invulnerability encourages a denial of risk among
men that prevents them from engaging in protected sexual behaviour.
Notions of masculinity emphasize sexual domination over women as a defining characteristic of
maleness. This has significantly contributed to homophobia and the stigmatization of men who
have sex with men (MSM). Fear of stigma and non-acceptance has compelled MSMs to keep their
sexual behavior secret and deny their sexual risk, thereby increasing their own risk as well as the
risk of their partners, female or male.
[Source: TISS, UNDP (undated). Mainstreaming HIV/AIDS in development work. A manual for
trainers]
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Understanding Marginalization
Marginalization refers to the reduce power and importance of certain people in society. For eg
religious minorities, women etc.
The social process of becoming/being made marginal (especially as a group within the larger
society) is a means to keep someone away from power, because of the choices they make in
their identities, practices or appearance.
People in the mainstream hold over generalized views
about people from marginalized groups based on
limited information.
Mainstream
view of the
marginalized 
Seen as „bad‟, as deserving their problems
(e.g., “they get HIV only because they
indulge in bad behaviour”). Always
suspected for anything that goes wrong
(e.g., they are criminals). Always being
blamed for almost everything. Seen as
„them‟ (vs. „us‟), as „outsiders‟.
Feeling like an „outsider‟, feeling like a
„second-class‟ citizen, feeling helpless,
beliefs like „we can never catch up‟ or
„...be good enough‟; feeling frustrated;
believing that „we are blamed whether we
do anything wrong or not‟ and so on. Low
self-esteem, can lead to self-damaging
behaviours like engaging in unsafe sex.
Lack of opportunities and resources can
sometimes lead to engaging in socially
unacceptable behaviours / occupations.
Marginalized groups’ awareness of how they are seen affects how
we feel as members of marginalized groups.
Mainstream’s perceptions of marginalized groups perpetuates marginalization
The diagram can be used to make the point that when mainstream populations perceive marginalized
populations in a prejudiced and stereotyped manner, it causes further damage.
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Each of the words written inside the circle refers to a mainstream group, and the word(s)
written next to it outside the circle is a marginalized group. The further away from a circle
a word is, the more marginalized it is (e.g., MSM people are more marginalized than gays,
and divorced more marginalized than widowed).
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Structural Factors and Vulnerability
The term driver relates to the structural and social factors, such as poverty, gender
inequality and human rights violations that increase people’s vulnerability to HIV
infection. These factors operate at different societal levels and different distances to
influence individual risk and to shape social vulnerability to infection.
Structural factors can be understood as the factors external to individual. These
factors arise out of political, employment or economic conditions such as poverty
and migration.
Recently the term driver is also used to describe those risk factors which are so
widespread as to account for the increase and maintenance of an HIV epidemic at
the population level.
It is important to understand that it is not just individual behavior or choices that
put people at risk to HIV infection. Choice is never absolute.
There is ample epidemiological and demographic evidence from the trajectory of the
HIV pandemic to show that certain populations are more vulnerable to infection
because of the particular social, cultural, economic and legal circumstances to which
they are subject.
In India, it has been seen that marginalised populations that live in an environment
of inequity, criminalization, oppression and violence have an increased vulnerability
to HIV and AIDS, and have been disproportionately affected by it.
Some of these vulnerable groups are injecting drug users, sex workers, and men
who have sex with men.
Failure to understand and accept the structural factors and vulnerability
perpetuates stigma and discrimination.
Marginalisation and stigma are seen as the greatest hurdles to effective measures of
prevention and treatment. Stigma and discrimination often results in exclusion of
those most in need of care, information and services.
For example - in fear of being stigmatized and hence discriminated, a PLHA often
conceals his/her status and is thus denied of the needed services and care. This
results into a hidden epidemic and hinders the achievement of the care and support
goals of the national programme .
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Mental Health Aspects Of HIV/AIDS
MENTAL HEALTH ASPECTS OF HIV/AIDS
LEARNING OBJECTIVES
 To introduce the meaning of mental health and mental illness
 To orient the participants to the broad categories of mental disorders
 To help participants understand the relevance of mental disorders in the context of HIV
 To help participants plan a referral to a mental health professional
 To facilitate participants’ competence in counselling for some common mental health
problems in the context of HIV
According to statistics from the World Health Organization (WHO), at least 25% of the
population will experience mental illness at some point in their lives. It is highly likely
that someone you know very closely has a mental illness. Learning about mental health
and mental illness is worth your effort as it can help in your life and work.
The prevalence of HIV is higher (about 1.7%) among people with severe mental illness
(Carey, Ravi, Chandra, Desai & Neal, 2007) as compared to the general population
(0.23% to 0.33%; IIPS and Macro International, 2007)
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Objective 1
Introduction to the meaning of mental health and mental illness
Working in the field of HIV makes all of us part of the public health field, relating our work to
different aspects of health. Mental health is a crucial aspect of health in the context of HIV for
several reasons as we shall see later (Objective 3). As per WHO also, mental health is an integral
part of health; indeed, there is no health without mental health. WHO constitution’s well-known
definition of health states that: "Health is a state of complete physical, mental and social well-being
and
not
merely
the
absence
of
disease
or
infirmity"
(http://www.who.int/topics/mental_health/en/index.html). Similar is the case with the traditional
Indian system of medicine, Ayurveda, which defines health as per Sushruta Samhita as: “Health is a
state wherein the … mind is in a state of total satisfaction” (sama dosha sama agnishcha samadhatu
mala kriyaaha| Prasanna atma mana indriyaha swastha iti abhidheeyate ||).
Accepting and understanding mental health as a crucial aspect of health brings us to the next level
of questions; that is what do we mean by mental health, mental illness or disorders. Mental health
is defined by WHO as not just the absence of mental disorder. It is defined as a state of well-being
in which an individual realises his or her own potential, can cope with the normal stresses of
life, can work productively and fruitfully, and is able to make a contribution to her or his
community (http://www.who.int/features/qa/62/en/index.html).
Mental health, as defined by the Surgeon General’s Report on Mental Health, “refers to the
successful performance of mental function, resulting in productive activities, fulfilling
relationships with other people, and the ability to adapt to change and cope with adversity.” On
the other end of the continuum is mental illness, a term that “refers to all mental disorders. Mental
disorders are health conditions that are characterized by alterations in thinking, mood, or
behaviour (or some combination thereof) associated with distress and/or impaired
functioning” (http://www.psychosocial.com/policy/satcher.html).
To summarise: Mental health successful performance of mental function, resulting in
productive activities, fulfilling relationships with other people, and the ability to adapt to change
and cope with adversity
Mental disorders are health conditions that are characterized by alterations in thinking, mood,
or behaviour (or some combination thereof) associated with distress and/or impaired
functioning.
This notion of a continuum sees mental health on one end as ‘successful mental functioning’
compared to mental illness on the other end as ‘impaired mental functioning.’ Thus, in simple
words, probably none of us is completely mentally healthy or mentally unhealthy. This is similar to
physical health such that all of us may be only relatively healthy or unhealthy, in different aspects of
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physical functioning. Just as it may be extremely rare for someone to be ‘perfectly’ physically
healthy, or ‘completely’ unhealthy; it is very rare that someone has perfect mental health or that
someone is perfectly mentally unhealthy.
As Figure 1 shows, a person with successful mental functioning engages in higher productive
activities, has more fulfilling relationships with other people, and has a higher ability to adapt to
change and cope with adversity. For example in terms of a person’s sleep or appetite, is likely to be
‘within normal limits’ while examples of abnormalities can be many. The same pattern holds true
for all other aspects of functioning also, like memory, concentration, mood, and so on.
Like physical health, it is easy to overlook mental health when things are fine. For example, just as
we would to ignore the presence of our knee or back unless we feel pain in these; similarly we are
likely to take our sleep for granted unless we have nightmares or are unable to fall asleep.
Figure 1: The continuum of mental health and illness
Mental Health
Mental Illness
Successful mental functioning
Impaired mental functioning
Higher
 Productive activities 
Lower
Higher
 Fulfilling relationships with other people 
Lower
Higher  Ability to adapt to change and cope with adversity 
Lower
Examples:
Sound sleep of 6-8
hours on all nights
Sleep
Too little / too much sleep
Nightmares / night terrors
Difficulty falling or staying asleep
Desire to eat food every few
hours in a day on all days
Appetite
Too little / too much desire to eat
No desire to eat at all
Desire to vomit out after eating
Desire to eat dirt
Excessive cravings
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Keeps oneself busy in
a productive activity
Is able to concentrate on work
Enjoy all the activities at work
Constantly improves at work
Work
Unable to find any meaningful work
Unable to complete any work
Unable to sustain a job
Unable to balance work and life
Disinterested in any work
Unable to learn and improve at work
Excessive absenteeism
Mental health is not easy to define even though many components of mental health may be
identifiable. Mental illness is an umbrella term for all diagnosable mental disorders. A mental
illness is a medical condition that disturbs a person's thinking, mood, behavior, ability to relate to
others and daily functioning. Mental illnesses are medical conditions that often result in a reduced
capacity for coping with the ordinary demands of life. For example, Alzheimer's dementia is a
mental disorder with problems largely in thinking (especially memory). Depression is an example
of a mental disorder with changes mainly in mood. Attention-deficit/hyperactivity disorder is an
example of a mental disorder marked by problems largely in behaviour (overactivity) and/or
thinking (difficulty in concentration). Alterations in thinking, mood, or behaviour lead to a host of
problems – patient distress, impaired functioning, or heightened risk of death, pain, disability, or
loss of freedom (American Psychiatric Association, 1994; DSM IV).
When is it ‘normal’ to have symptoms of mental illness?
Sometimes it is ‘normal’ to have some symptoms of mental illness. Examples of this are like
being unable to sleep, or concentrate on anything, or even hearing the person’s voice in their
absence when someone is in love. Similarly, such symptoms can also be seen when a person
has just had a severe loss, like a heartbreak, or the death of a loved one, or finding out that
they or a loved one has HIV, the person is likely to be experiencing ‘grief’ or going through a
period of ‘bereavement’. It is very usual and understandable to ‘see’ or ‘hear’ the deceased
person, or lose sleep and appetite, or be lost in one’s thoughts or crying very often. The
symptoms can very often be similar to depression, but the person is usually not given a
diagnosis of depression, but is given some supportive counselling, and may sometimes be
given some mild medicines to help them calm and sleep better. In case the person is suicidal,
it is important to refer the person to a psychiatrist immediately.
In our daily language we sometimes say things like “I am depressed”, “he has a dog phobia”, or
“she is obsessive”, while it may be more accurate to say “I am sad”, “he is scared of dogs”, or “she
is very particular”. Let us try to learn the difference between these terms and use them more
accurately.
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Some facts to remember about mental illnesses:
 Mental illness can affect a person of any age, race, religion, region, gender or income.
 Mental illnesses can be caused by a person’s biology, drugs or alcohol, traumatic events,
or through a number of other ways. Mostly more than one cause is involved, and many
times the real cause(s) is unclear.
 Mental illnesses can range from mild to severe (like mild depression and severe
depression.
 Mental illnesses can be short lasting (like adjustment disorder or acute stress disorder)
to long lasting (like schizophrenia or dysthymia).
 Mild and severe, as well as short lasting and long lasting mental illnesses can be very
disabling as they can affect the person’s functioning in multiple ways, e.g., by increasing
chances of suicidality and high risk sexual behaviour.
 Like most physical illnesses Mental illnesses can be treated, and some can even be
‘cured’.
 Most people with a mental illness experience relief from their symptoms by taking
proper treatment.
 Everyone with HIV does NOT get depression or anxiety, though some people may.
Sometimes the term “mental health problems” is used for problems that are not enough in intensity
or duration to meet the criteria for any mental disorder, but are still a deviation from mental health.
Almost all of us experience mental health problems in which the distress we feel is similar to some
of the signs and symptoms of mental disorders. This does not mean that we have that mental
disorder. This, however, also does not mean that we or someone we know cannot get a mental
disorder. This also means that because anyone can get a mental disorder or a mental health
problem, we need to NOT stigmatise people with mental disorders and avoid using terms like ‘mad’,
‘mental’, ‘paagal’, ‘lunatic’ and ‘derailed’, for example. Instead, timely and appropriate treatment
needs to be made available to anyone facing mental health issues.
It is as harmful to stigmatise mental illness, as it is to stigmatise HIV.
Terms like ‘mental illness’, ‘psychiatric illness’, ‘mental disorders’, and ‘mental health
problems’ have been used here interchangeably.
Common Warning Signs for Mental Illness
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Each mental illness has certain specific symptoms, as we shall see in the next section. However, a
counsellor needs to know some general warning signs that can alert them that a client might need
professional help. Some of these signs include










Inability to manage daily activities and cope with problems
Strange ideas (e.g., “Mahatma Gandhi talks to me”)
Excessive worries
Long periods of sadness and indifference (as in the song “na koi umang hai, na koi tarang
hai...”
Significant changes in eating or sleeping patterns (eating and / or sleeping too much or too
little for a number of days)
Thinking or talking about suicide or harming oneself
Extreme mood swings — feeling extremely happy or extremely sad
Abuse of alcohol or drugs
Excessive anger, hostility, or violent behaviour
Marked change in personality
A person who shows any of these signs may have a mental illness and should be referred to a
qualified mental health professional. The above are however, possible general signs of mental
illness, so now we look at the different categories of specific mental disorders.
Objective 2:
To help the counsellors understand the broad categories of mental disorders
Adult mental disorders can be classified into the following categories:
Importance of
counselling and other
psycho-social
treatments
1. Organic mental disorders
2. Substance (alcohols and drug) use disorders
3. Psychotic disorders (Non-affective, e.g., Schizophrenia
and delusional disorders)
4. Mood [affective] disorders
5. Neurotic disorders
6. Behavioural syndromes
7. Personality Disorders
8. Mental Retardation
9. Developmental Disorders
Importance of
medicines and other
biological treatments
Figure 2: Broad categories of Mental Disorders (WHO, 1992)
Figure 2 shows the different categories of mental disorders as per International Classification of
Disorders (ICD-10; WHO, 1992). In the order given in the figure, those disorders that are higher up
are normally treated with medication and other biological treatments, whereas those lower in the
list normally respond well to counselling and other psychosocial interventions. However, it is
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mostly a combination of counselling, psychotherapy and medication that is helpful in almost all the
disorders, while their relative importance depends upon many factors like the severity of the
illness, and its effect upon the daily functioning.
Mental illnesses are diagnosed by mental health professionals only after taking a detailed
history. No mental illness can be diagnosed based on just 1-2 signs or symptoms. Each sign or
symptom can point towards a number of disorders. For example, “talking to oneself” can be seen
in psychosis (e.g., schizophrenia), or under the influence of a substance (drug), but it can also be
seen in any other disorder, or even among normal people who are shy to talk to the others or
who live alone. Similarly, “not eating” can be seen in organic disorders, psychotic disorders,
depression, eating disorder, or anxiety disorders, to name just a few. A mental health
professional asks in detail about the reasons, patterns, duration, and so on of each sign or
symptom to arrive at a diagnosis.
As such, it is somewhat similar to the fact that “fever” in itself does not give information about
any particular disorder; instead it is indicative that something is not okay, and only further tests
clarify the picture.
The following brief description of some of the categories of mental illnesses is not sufficient
to let a counsellor diagnose an illness, but they are meant to orient a counsellor to mental
illnesses.
1. Organic mental disorders:
This group of disorders has demonstrable injury or disease in the brain, leading to mental
dysfunction. Examples of organic mental disorders are dementia and delirium.
Dementia patients may complain of forgetfulness or feeling depressed, but may be unaware of
memory loss. Patients and family may sometimes deny severity of memory loss. Dementia is
frequent in old age. Memory loss and confusion may cause behaviour problems (e. g., agitation,
suspiciousness and emotional outbursts). Memory loss usually proceeds slowly. Some amount of
cognitive decline (e.g., poor memory) is seen in around one-fourth of the people living with HIV,
while dementia can also be seen in the advanced HIV infection. However, the prevalence of
dementia has reduced significantly after the introduction of the ART.
When the patient has dementia, a referral needs to be made to a psychiatrist. A counsellor can
help in the following ways when there is some amount of memory loss, not amounting to dementia.
 Inform the patients and relatives that ART can help in reducing problems with memory.
 Family members and others close to the PLHIV can be important sources of support by
reminding about or giving the medication.
 A familiar environment makes it easier to remember things.
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



Different ways of reminding oneself / family member about medicines can be devised,
e.g., marking on a calendar, using alarm clocks and so on.
Family members need to remain calm when the patient becomes forgetful, confused or
agitated, the counsellor can advise the family members to gently guide a patient in such
a state, and avoid confronting them.
Patients with advanced dementia may need placement in a special facility to ensure
their safety.
Offering activities that keep their minds alert such as assisting simple chores like folding
clothes, wiping dishes dry, solving simple picture puzzles and the like. These activities
are to be decided in consultation with the mental health professional treating the
patient.
An example of dementia is what some of us may have seen Amitabh Bachchan‟s character
suffering from (Alzheimer‟s Dementia) in the movie „Black‟.
The patient has memory loss? It may not necessarily
be dementia.
Memory loss can also be seen in:
Depression
Anaemia
B12 Deficiency
Folate Deficiency
Syphilis
HIV Infection
Delirium, another organic disorder, is characterised by confusion and disorientation in the patient.
It is commonly seen in people with HIV infection, especially in advanced stages of the illness. The
causes of delirium include – brain infections, severe systemic infection, alcohol or drug withdrawal,
electrolyte disturbances because of diarrhoea or decreased nutritional intake. It is generally acute
in onset and improves rapidly if the underlying medical cause is treated. Delirium can be life
threatening and thus requires urgent medical attention.
2. Substance (alcohols and drug) use disorders
This group of disorders contains a variety of disorders caused due to the use of one or more
psychoactive substances or drugs which may or may not have been medically prescribed. The
disorders can differ in severity and form.
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Table 1: Common Types of Substances
Tobacco
(smoking Beedi, cigarette, gutkha, khaini, zarda etc (all forms contain
and smokeless)
the addictive chemical nicotine)
Alcohol
Beer, wine, spirits (rum, whisky, vodka, brandy), illicit
alcohol, home brewed alcohol
Opioids
Brown sugar, heroin, codeine containing cough syrup,
narcotic pain killers i.e. dextropropoxyphene (chasing,
injecting, swallowing)
Cannabis
Ganja (marijuana, joint), bhang, hashish, charas
Sedatives
Sleeping tablets (benzodiazepines)
Inhalants or solvents
Petrol, glue, typewriter erasing fluid
Other substances
Cocaine, LSD, amphetamine
The following five steps can help identify substance use disorders:





Ask about substance use
Assess pattern of use and problems
Advice stopping or reducing use
Assist with specific interventions
Arrange follow-up support and appropriate referrals
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A counsellor must ASK each HIV positive client about the use of
substances.
Some simple ways to ask may be:
What do you do when you are very upset?
What do you do to relax?
Do you ever take alcohol or any drug?
What do you take? How often? How much?
If a client drinks, the following questions can help to see if the drinking has reached a
problem level for them. (C-A-G-E)
C – Have you tried but failed to Cut down your drinking?
A -- You are Annoyed by criticism from others about drinking?
G -- You feel Guilty about the consequences of drinking (such as loss of job or
relationship)?
 E – Have you needed an Eye-opener drink or a drink steady your nerves or treat a
hangover?



If the answer is "yes" to two or more of these questions, there could be a problem with
alcohol.
Identifying Substance Abuse
Early recognition of substance abuse increases the chances for successful treatment. Normally a
person’s friends and family are the first to recognise the signs of substance abuse. The following
indications can point to substance abuse or dependence. Some of these can be observed by a
counsellor and some would be reported by the client or a family member or friend if they are asked:
Declining marks or work performance
Aggressiveness and irritability
Forgetfulness
Frequently disappearing money or valuables
Increased use of room fresheners, incense and mouth fresheners
Stopping activities of interest, e.g., sports, homework, or socialising in order to get drunk or
high
 Feeling hopeless, sad, or even suicidal
 Sounding selfish and not caring about others






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















Signs of things like cigarette butts, packets of different kinds of powders and rolling paper
Trembling hands
Being drunk or high on drugs on a regular basis
Telling lies, especially about the amount of alcohol or drugs being used
Planning drinking in advance, hiding alcohol, drinking or using other drugs alone
Needing more alcohol or drug to get the same high
Believing that in order to have fun you need to drink or use other drugs
Frequent hangovers
Pressuring others to drink or use other drugs
Taking risks, including sexual risks
Having “blackouts” – having no memory of what he or she did the night before
Constantly talking about drinking or using other drugs
Getting into legal trouble
Frequently borrowing money
Drinking and driving
Suspension from school or work for an alcohol or drug-related incident
Keep in mind that problematic use of alcohol or other substances can be of different levels of
severity. Thus, alcohol or substance abuse is different from dependence.
 With abuse, a person uses alcohol in excess but may not have regular cravings, a need to use
daily, and/or withdrawal symptoms during sudden stoppage. The person may often have
heavy alcohol binge episodes separated by periods of not drinking.
 If a person is dependent on alcohol, he or she needs to drink regularly or even daily and drink
more and more to get the same effects. The person also experiences withdrawal symptoms if
he or she stops drinking and wants to quit drinking alcohol but can't.
If the client has alcohol abuse or dependence it is important to refer to a psychiatrist or a
deaddiction centre.
The section on substance use disorders is also given as a handout for easy reference.
 Be non-judgemental and respectful while talking about alcohol and other substances.
 DO NOT tell a client who is dependent upon alcohol or any other substance things like
“stop drinking”, “you can do it if you decide to” or “where there is a will, there is a way”.
It would be like asking someone with a fractured leg to try and start running! It is beyond
their control and requires treatment.
 Treatment of dependence is done under medical supervision through detoxification,
which often requires hospitalisation.
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3. Psychotic disorders:
In simple terms, a person with psychotic disorder loses contact with reality, and thus, is almost in
another world. A patient with psychosis tends to suffer from vivid hallucinations, i.e., they see or
hear things that do not exist. This is different from what most of us experience, because we do not
“believe” that what we saw or heard is really there, whereas a patient with psychosis really believes
it does. Psychosis can be very dangerous because the patient’s behaviour can be strongly influenced
by their beliefs. Treatment of psychosis is usually done with antipsychotic medicines, educating the
family about the illness, and support to the patient and family.
This group of disorders include severe mental illnesses such as schizophrenia and delusional
disorders.
Psychosis is characterised by symptoms like:








Hearing of voices not heard by others- hallucinations
Talking to self, irrelevant talk, gesturing to self (due to hallucinations)
Odd and strange beliefs not shared by others (delusions)
Suspiciousness, fearfulness, unprovoked anger
Social withdrawal
Poor self care, disorganisation and disinhibition
Loss of touch with reality
Lack of insight, i.e., not knowing that they are going through a mental disturbance.
A person with a psychotic disorder is more vulnerable to HIV due to higher chances of their
engaging in substance / alcohol abuse, risky sexual behaviour, vulnerability to sexual abuse, and
difficulty taking decisions in their best interest. Psychotic disorders (psychosis) are less common as
compared to anxiety and depression, and may occur in about 4-10 % of PLHIV (Ellen, Judd, Mijch &
Cockram, 1999; Sewell, 1996).
A person with symptoms of a psychotic disorder must be referred to a psychiatrist for
treatment.
An example of psychotic disorder is what Konkona Sen‟s character had in the movie 15
Park Avenue.
What not to do with a psychotic client:
DO NOT ask the client with psychosis to stop thinking / hearing what they do.
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DO NOT assume that the client with psychosis is being lazy if they are not doing house
work or taking care of personal hygiene.
DO NOT assume that supportive counselling alone can remove the client’s psychotic
symptoms.
DO NOT assume that a patient with psychosis can improve if they try harder. It would be
like assuming that a patient with a fractured leg can start running immediately if they try
harder.
4. Mood [affective] disorders
a. Major Depression
Major depression or simply depression or depressive disorder, is the commonest mental illness
associated with HIV infection, such that a PLHIV has up to 50% of getting major depression (OweLarsson, Säll, Salamon & Allgulander, 2009).
The symptoms of major depression as outlined below must be present continually for at least a two
week period.









Sadness of mood
Lack of interest in previously pleasurable activities
Difficulty in attention and concentration
Feelings of worthlessness & hopelessness
Excessive feelings of guilt
Suicidal ideas or attempts
Disturbed sleep
Loss of appetite and weight loss
Loss of interest in sex
However, not all PLHIV develop depression. The chances of getting depression are higher for PLHIV
in the presence of the following factors.
Risk Factors for Depression in HIV (Chandra, Vas & Dahale, 2013)
 Greater disability/disfigurement
 Social isolation
 Recent losses
 Uncontrolled pain
 Past history of depression
 Advanced disease
 Substance use
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If a patient has a sad mood, it may or may not be depression.
The different reasons for the PLHIV’s sad mood may be:
(Colibazzi, Hsu, & Gilmer, 2006)
 Major depression
 Bipolar disorder
 Adjustment disorder
 Bereavement (while grieving over a major loss)
 Secondary depressive syndromes:
o Primary HIV encephalopathy
o Other infections in the brain (e.g., meningitis)
o Side effect of certain medications
o Substance abuse
b. Mania
Bipolar disorder is a mood disorder, along with depression. A person is considered to have bipolar
disorder if they have had mania in the past. Mania is a distinct period during which a patient may be
excessively cheerful, overactive, have very high plans, increased sexual desire and decreased need
for sleep. The patient may also have irritability or disinhibition and may wander away. Mania can
thus be considered as the opposite of depression. It can be difficult to distinguish mania from
schizophrenia because mania can also be present, like schizophrenia, with delusions, hallucinations,
and highly disorganized behaviour.
Mania is commonly associated with HIV infection and may be secondary to medications or due to
the direct effect of HIV infection on the brain (Nakimuli-Mpungu, Musisi, Mpungu & Katabira, 2006).
5. Neurotic, Stress-related and Somatoform Disorders (Anxiety Disorders)
This category includes the most common mental disorders. People with anxiety disorders face
huge amounts of fear, chronic worrying, and irrational behaviour due to their fears and anxiety.
Some amount of stress, worry, tension and anxiety are part of most people’s lives. However, just
experiencing some amount of anxiety or stress does not mean that one has an anxiety disorder. Like
all other feelings – happiness, sadness or anger, some amount of anxiety is natural and normal for
everyone to feel. In fact, anxiety is a helpful warning signal in a dangerous or difficult situation, and
gets us into action to do something quickly – like fear of fire helps us take steps to prevent fire, and
get alerted if we see smoke or something burning, and rush to douse the fire. If we had no fears or
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anxiety, we would have no way to think of possible difficulties in advance and preparing for them.
Anxiety becomes a disorder when the symptoms last very long and interfere with our daily
lives.
People who suffer from chronic anxiety often report many of the following symptoms:











Fear or confusion
Constant worry
Muscle tension
Physical weakness
Poor memory
Sweaty palms
Inability to relax
Shortness of breath
Palpitations
Upset stomach
Poor concentration
Anxiety disorders are common with HIV infection and nearly one-third of PLHIV may have
features suggestive of an anxiety disorder at some time during the infection (Chandra, Ravi, Desai,
& Subbakrishna, 1998).
All
anxiety
symptoms
do
(http://www.hivguidelines.org):
not
necessarily
point
to
anxiety
disorder
Anxiety-like symptoms may also be present in other mental disorders like:




Depression
Psychosis
Adjustment disorder with anxious mood
Personality Disorders
Underlying medical conditions may also cause anxiety-like symptoms, like:
 CNS pathologies: HIV-related infections, neoplasms, dementia, or delirium
 Systemic or metabolic illness: hypoxia, sepsis, electrolyte imbalance
 Endocrinopathies: thyroid disease, hypoglycemia, pheochromocytoma, Cushing‟s
syndrome
 Respiratory conditions: pneumonia
 Cardiovascular conditions: arrhythmias, pulmonary embolus
 Substance intoxication/withdrawal: from alcohol, nicotine, caffeine, cocaine, and
amphetamines
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Manual on Advance Counselling for ICTC Counsellors
Panic attacks or
panic disorder
Yes
Discrete episodes of
intense anxiety/fear
with chest pain,
pounding heart,
shortness of breath?
Phobia
s
Yes
Fear/avoidance of
certain situations,
places or objects?
Generalized
anxiety
disorder
Yes
Worrying about a
variety of things for
months or years?
No
Obsessive
compulsive
disorder
Yes
Intensive,
disturbing
thoughts or
compulsive
rituals?
Because of medical, substances or
medication reasons?
Yes
Anxious?
Symptoms ≥ 1
month
PTSD
Acute
stress
disorder
Adjustmen
t disorder
with
anxious
mood
Yes
History of a
stressful situation
causing
nervousness or
upset?
Event
<1
month
ago
Yes
History of a
traumatic event
continuing to
cause great
distress?
Yes
Anxiety likely due to a
general medical
condition, substance,
or medication
Figure 3: Algorithm for Distinguishing Anxiety Disorders (www.hivguidelines.org)
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Types of Anxiety Disorders
A. Panic disorder
B. Specific Phobias
C. Generalised Anxiety Disorder (GAD)
D. Obsessive Compulsive Disorder (OCD)
E. Reaction to severe stress, and adjustment disorders
a. Acute Stress Disorder
b. Post Traumatic Stress Disorder (PTSD)
c. Adjustment disorders
Clinical features of each of the above are as follows:
A. Panic disorder
 A panic attack is a clear cut (discrete) episode of very severe anxiety or fear
 At the time of the attack the person feels chest pain, breathlessness, choking,
palpitations, excessive sweating (diaphoresis), dizziness, and intense fear of dying or of
going mad
 A panic attack is sudden and unpredictable
A panic attack usually lasts only for about 10 to 15 minutes, but sometimes can continue for over an
hour. Panic disorder is diagnosed when a person has recurrent attacks of panic, which are
unpredictable and not restricted to any particular situation or set of circumstances. Panic disorder
is much more intense than GAD, and can cause great distress among patients. Untreated panic
disorder can lead to more severe mental disorders like agoraphobia, which is the fear of leaving
home.
B. Specific Phobias
A specific phobia is an unreasonable fear caused by the presence of a specific object or situation (or
even a thought of it) that usually poses little or no actual threat. Because of this distress, phobia can
significantly interfere with the person’s ability to function normally. People with a specific phobia
usually recognise that the fear is unreasonable, but are unable to overcome it.
Symptoms of specific phobias may include:


Excessive or irrational fear of a specific object or situation.
Avoiding the feared object or situation or tolerating it with great difficulty and suffering.
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Physical symptoms of anxiety or a panic attack, such as a pounding heart, nausea or
diarrhoea, sweating, trembling or shaking, numbness or tingling, problems with breathing
(shortness of breath), feeling dizzy or lightheaded, feeling like you are choking.
 Anticipatory anxiety, which involves becoming nervous ahead of time about being in certain
situations or coming into contact with the object of your phobia. (For example, a person
with a fear of dogs may become anxious about going for a walk because he or she may see a
dog along the way.)

A child with a specific phobia may express the anxiety by crying, throwing a tantrum, or clinging to
a parent.
Different types of specific phobia may be:
Animal phobias: Examples include the fear of dogs, snakes, insects, or mice.
Situational phobias: These involve a fear of specific situations, like flying, travelling by a public
transport, going over bridges or in tunnels, or being in closed places like lifts.
Natural environment phobias: Examples include the fear of heights, storms, or water.
A specific phobia that many counsellors encounter
among clients is AIDS phobia. This is excessive and
irrational fear of developing AIDS and dying of it even
when in very early stages of infection.
C. Generalised Anxiety Disorder
Patients who suffer from General Anxiety Disorder (GAD) have a constant worry despite the
realisation that it is irrational.
GAD can manifest as:
Constant worry –e.g., about illness, future and death
Insomnia – trouble falling asleep or staying asleep
Gastrointestinal problems
Lack of concentration
Irritability and muscle tension, especially in the neck and stomach – leading to headaches
and other aches and pains
 Inability to relax
 Anxious Foreboding (a feeling that something very bad is about to happen which one does
not know about)





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 Sweating
 Palpitations
 Dizziness
When we learn about various disorders, there is a tendency to start diagnosing oneself
and / or others with one or more disorders. This has been termed as „Medical Student
Syndrome‟. Has this been happening with you as you are learning about these
disorders here?
D. Obsessive-Compulsive Disorder (OCD)
Someone who suffers from OCD feels trapped in a pattern of repetitive thoughts and behaviors
that are senseless and distressing. The person tries hard to stop these thoughts and behaviours, but
finds it extremely difficult to do so.
The thoughts can be like a fear that one may harm oneself or a loved one, an excessive concern
with becoming infected or contaminated, or an extremely high need to do things correctly or
perfectly. Again and again, the person experiences a disturbing thought, such as, “My hands may be
contaminated—I must wash them”; “I may have left the house unlocked”; or “I am going to harm my
child.” These thoughts, that are intrusive, unpleasant, and cause a high degree of anxiety are called
obsessions. Sometimes the obsessions can also concern illness, like “I have HIV”.
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In response to their obsessions, most people with OCD resort to repetitive behaviours, which are
called compulsions. The most common compulsions are washing and checking. Examples of other
compulsive behaviors are counting (often while performing another compulsive action such as
hand washing), repeating, hoarding, returning home several times to check the lock, or asking the
same question(s) or getting HIV test repeatedly. Mental behaviours, such as mentally repeating
phrases, list making, or checking are also common. The intention behind compulsions is generally
to ward off harm to the person with OCD or others. Performing these behaviours thus gives the
person with OCD some relief from anxiety, but it is only temporary.
OCD can range in severity from mild to severe. If severe OCD is left untreated, it can significantly
damage a person’s capacity to function at work, school, or even at home.
OCD is treated with medicines or behaviour therapy or both. A common sense approach of
reassuring or supporting the client, or answering their repeated questions or getting irritated with
or scolding the client DOES NOT HELP. If a counsellor suspects OCD in a client, it is very important
to refer the client to a psychiatrist.
E. Reaction to severe stress, and adjustment disorders
a. Acute Stress Disorder
Acute stress disorder is a transient disorder diagnosed in a person without any other mental
disorder, after they have experienced or witnessed a traumatic event that involved serious injury or
death (or a threat of it) of oneself or others, and if the person’s response involved intense fear,
helplessness, or horror. Acute stress disorder usually subsides within hours or days, and maximum
within 4 weeks.
Either during or after experiencing the traumatic event, the individual has significant symptoms
like:
A sense of numbing or detachment
Reduced awareness of their surroundings (being in a daze)
Inability to recall an important aspect of the trauma (amnesia)
Recurrent and intrusive flashbacks or distressing recollections of the event, including
images, thoughts, or perceptions
Repeated distressing dreams of the event
Intense psychological distress and reactivity at exposure to internal or external cues
that symbolize or resemble an aspect of the traumatic event
Sleep difficulties
Irritability or outbursts of anger
Difficulty concentrating
Hypervigilance and exaggerated startle response
Treatment of Acute Stress Disorder Supportive psychotherapy and counseling are usually the
most effective in treating acute stress disorder. Sometimes medications (mostly sleeping aids) are
enough to get the person back to normal functioning.
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DO NOT tell the client to try and forget the event or accept it. They would already be trying to do
that more than enough.
b. Post-Traumatic Stress Disorder (PTSD)
PTSD, like Acute Stress Disorder, arises after exposure to a stressful event or situation of an
exceptionally threatening or catastrophic nature, which is likely to cause pervasive distress in
almost anyone. PTSD is a delayed response to such an exposure.
Typical features include:













Episodes of repeated reliving of the trauma in intrusive memories ("flashbacks"),
Dreams or nightmares,
A sense of “numbness” and emotional blunting,
Detachment from other people,
Unresponsiveness to surroundings,
Anhedonia (no pleasure in any activities), and
Avoidance of activities and situations that remind of the trauma.
A state of autonomic hyperarousal with hypervigilance,
An enhanced startle reaction,
Sleep difficulties (insomnia).
Anxiety
Depression
Suicidal ideation.
The onset of these symptoms is a few weeks to months after the trauma.
c. Adjustment disorders
Adjustment disorder is a short-lasting condition that is caused when a person is unable to cope with
(or adjust to) a particular source of stress. The source of stress can be, for example, ending of a
relationship or marriage, losing or changing job, death of a loved one, developing a serious illness or
getting to know one has HIV (oneself or a loved one), being a victim of a crime, meeting with an
accident, undergoing a major life change (such as getting married, having a baby, or retiring from a
job), living through a disaster, such as an earthquake, fire, flood, or tsunami.
A person with adjustment disorder develops emotional and/or behavioural symptoms as a reaction
to the stressful event. In an adjustment disorder, the reaction to the stressor is greater than what
would be typical or expected for the situation or event. The person may feel anxious or depressed,
may be unable to sleep, work, or study or even have suicidal thoughts. The person can feel
overwhelmed with the normal daily routines, or may make careless decisions. Symptoms of
adjustment disorder generally begin within three months of the event and rarely last for more than
six months after the event or situation.
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Treatment of adjustment disorder is often helpful and needed only briefly; while in rare cases it
may last long. Treatment mostly comprises of counselling or psychotherapy, though occasionally
medicines may also help.
6. Behavioural syndromes associated with physiological disturbances and physical
factors
A. Eating disorders
An eating disorder is an illness that causes serious disturbances to the person’s diet, such as
eating extremely small amounts of food or severely overeating.
a. Anorexia nervosa
An eating disorder where the person has significant weight loss, deliberately induced and
sustained by the patient. It occurs most commonly in adolescent girls and young women,
but adolescent boys and young men may also be affected, because the person is scared of
becoming fat. The symptoms include restricted dietary choice, excessive exercise, induced
vomiting, and the like.
b. Bulimia nervosa
Bulimia nervosa is a syndrome characterized by repeated bouts of overeating and an
excessive preoccupation with the control of body weight, leading to a pattern of overeating
followed by vomiting or use of purgatives. This disorder shares many psychological features
with anorexia nervosa, including an overconcern with body shape and weight.
B. Nonorganic sleep disorders
Sleep disturbance can many times be one of the symptoms of another disorder, either
mental or physical. Some of the common sleep disorders are as follows:
a. Nonorganic insomnia
b. Nonorganic hypersomnia
c. Nightmares
A handout given along can prove useful in helping with some of the common sleep disturbances.
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C. Sexual dysfunction, not caused by organic disorder or disease
Sexual dysfunction covers the various ways in which an individual is unable to participate in
a sexual relationship as he or she would wish. Sexual response is a psychosomatic process
and both psychological and somatic processes are usually involved in the causation of
sexual dysfunction. Some of the common sexual dysfunctions include:
a. Lack of sexual desire
b. Sexual aversion and lack of sexual enjoyment
c. Orgasmic dysfunction
d. Premature ejaculation
e. Nonorganic vaginismus
f.
Excessive sexual drive
Most of these can be treated with the help of a qualified clinical psychologist or a
psychiatrist.
7. Disorders of adult personality and behaviour
Personality disorders, as they are commonly called, include a variety of conditions and behaviour
patterns. These patterns are clinically significant and tend to be inflexible and persistent across a
broad range of personal and social situations situations. Among individuals who have a personality
disorder, these patterns appear to be the characteristic expression of the lifestyle and mode of
relating to oneself and others. They represent extreme or significant deviations from the way in
which the average individual in a given culture perceives, thinks, feels and, particularly, relates to
others. These negative thinking and behavioral patterns usually lead to relationship problems with
almost everyone as no one around them understands their thought process. Family and friends of
people with personality disorder describe them as very tiring, very difficult or even impossible to
deal with. As such, they can be the harshest people around.
Personality disorders are quite common. They are sometimes classified into three clusters.
A. The odd and eccentric cluster includes paranoid, schizoid, and schizotypal.
B. Dramatic and erratic cluster includes the histrionic, narcissistic, antisocial, and borderline
personality disorders.
C. Anxious and fearful cluster includes the avoidant, dependent, anankastic personality disorders.
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It is important to distinguish between those with personality disorders and those with neurotic
disorders (e.g., anxiety disorders). A person with a neurotic disorder sees their behaviour as
unacceptable both to oneself and to the society. They are aware that problems exist and try hard
to change themselves, and feel very frustrated because they cannot. In contrast, those with
personality disorders do not see any problem with themselves and therefore do not feel any
need for help. It is often their family members who seek help for depression or anxiety disorders
because they are unable to cope with the person with personality disorder.
8. Mental Retardation
Mental retardation or intellectual disability is a condition where people have considerable
difficulties in learning and understanding due to an incomplete development of intelligence. There
can be permanent impairment in the skills of a person with mental retardation in areas such as
cognition, language, motor and social abilities, which often causes significant difficulties in school,
work and regular life of the person. The causes of mental retardation are often either genetic, or
environmental factors during pregnancy. Most of the times the parents are able to recognise mental
retardation in a child within a few months of years after birth, because there is often a clear delay in
most of the milestones like sitting, walking, talking and so on.
People with mental retardation are not ill, and do not need medicines for treatment unless they
have an illness. People with mild intellectual disability might need some additional education, but
can often live independently with little support. People with more severe mental retardation often
need lifelong educational and social support. Any services for people with intellectual disability
must be oriented to increase their abilities and their inclusion into normal life of society
While doing HIV prevention work or while providing help with positive living for people with
mental retardation, information needs to be easy to understand. Also the information needs to be
given to another caregiver in addition to the person with mental retardation.
9. Developmental Disorders
Developmental disorders or “pervasive developmental disorders,” (PDDs), refer to a group of
conditions that involve delays in the development of many basic skills. Most notable among them
are the ability to socialize with others, to communicate, and to use imagination. Children with these
conditions often are confused in their thinking and generally have problems understanding the
world around them. In the current context, it is sufficient to know that autism is the most well
known type of PDD.
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Table 2 Examples of Symptoms of Some of the Mental Illnesses
Mental Illness
Psychotic Disorders
Schizophrenia
Mood Disorders
Depression
Mania (Bipolar Disorder)
Anxiety Disorders
Generalized anxiety disorder, panic
disorder, obsessive-compulsive, disorder,
post-traumatic stress disorder
Adjustment disorders
Personality disorders
Sleep disorders
Sexual functioning disorders
Examples of Symptoms
Auditory hallucinations, delusions, thought
disorders
Sadness across situations, lack of interest in
previously pleasurable activities, constant
fatigue, suicidal ideation, hopelessness,
changes in appetite and sleep
Increased energy, decreased need for sleep,
too many thoughts, grandiosity, increased
religiosity, excessive dressing up and talking
Nervousness, heightened arousal, panic
attacks, intrusive anxiety-provoking thoughts,
obsessions/rituals, flash backs
Depression and/or anxiety of less severity and
directly related to an identifiable stressor
Persistent, maladaptive life behaviors that
interfere with interpersonal relationships
Difficulty initiating and/or maintaining sleep
Reduced or no sexual desire, difficulty having
an orgasm, difficulty obtaining or maintaining
an erection
Table 3 - Common Psychiatric disorders seen in PHLIVs (Chandra, Desai & Ranjan, 2005;
Khouzam, Donnelly & Ibrahim, 1998; Owe-Larsson, Säll, Salamon & Allgulander, 2009)
Disorder
Subtypes
Mood disorders
Depression, Bipolar disorder
Anxiety disorders
AIDS phobia, Health anxiety, Panic attacks, Post
Traumatic Stress Disorder, Adjustment disorder
Alcohol dependence, IV Drug use, Cannabis use,
Nicotine Dependence
Hypoactive, Hyperactive
Substance use
disorders
Delirium
Cognitive
disturbances
Sleep disorders
AIDS Dementia, minor cognitive disturbance,
cognitive disorders due to opportunistic infections
such as meningitis
Insomnia, hypersomnia
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Psychosis
Schizophrenia-like, Acute Psychosis, ART related
Personality
changes
Personality changes refer to signs of organic changes
in personality including irritability, lack of
motivation, and poor personal care
Objective 3:
To help participants understand the relevance of mental disorders in the context of HIV
Figure4 : HIV and mental health problems can both affect each other
I. Mental illness
 Increased chances of sexual abuse
 Increased chances of substance abuse, high risk behaviour
 Increased chances of HIV infection
II. HIV
 Increased mental stress
Mental health problems due to ART, and HIV infecting the brain
III. Mental illness + HIV
Increased high-risk behaviour
Dual stigma
Poor adherence to ART
Impaired lifestyle and poor nutrition
Increased caregiver burden
A. Following are some of the ways in which HIV can lead to a mental health problem or
psychiatric disorder
 Stress caused due to HIV infection: Living with HIV can be very stressful and thus, depression
and anxiety, and sometimes psychosis may occur as a result of this stress.
 Spread of viral infection: HIV infection can affect the brain. In rare cases, acute psychosis,
minor cognitive problems and even dementia can be seen due to the HIV infection in the brain.
 Alcohol and drug use – Use of alcohol and drugs can indirectly both lead to HIV infection as
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well as be a result of HIV especially if the person also has certain psychiatric problems
(Chandra, Desai & Ranjan, 2005).
Effect of ARTs: Some anti-retroviral drugs, especially Efavirenz, can lead to psychological side
effects as Table ## shows. Medicines used in managing other opportunistic infections (e.g., some
anti TB drugs) can also cause psychosis or depression.
Table 4 - Psychotropic effects of antiretrovirals (Taylor, Paton & Kerwin, 2007)
Implicated agent
Abacavir
Efavirenz
Indinavir
Nevirapine
Didanosine
Efavirenz
Zidovudine
Abacavir
Efavirenz
Nevirapine
Abacavir
Nevirapine
Efavirenz
Abacavir
Efavirenz
Mental health problems
Depression
Mania
Psychosis
Vivid dreams
Suicidal ideation
B. Mental health problems among PLHIV affect overall care and treatment in several ways.
Some examples of this are:
Reduced help-seeking and poor adherence to treatment
A mental health problem can reduce a person’s motivation to seek help. In addition, it can also
affect a person’s ability to judge what is good for them; to decide if they have a physical or mental
illness; and if they need professional help. For example, patients with depression feeling helpless
and hopeless, and are less likely to go to an ART centre, because they may feel that there is no point.
For similar reasons, even if they start treatment, they may not adhere to it. The presence of mental
illness among HIV infected can reduce the likelihood of treatment uptake and adherence. If the
person gets evaluated and treated for the psychiatric condition, it can help in initiating and
adhering to ART treatment also.
Increase in high risk behaviour
PLHIV are more likely to engage in high risk behaviors such as risky sex and use of alcohol and
drugs if they have severe mental illness such as psychosis, because it can impair decision making.
As is well known, engaging in risky behaviours can increase the risk of acquiring sexually
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transmitted infections, transmission of HIV to a negative partner, and faster HIV disease
progression due to re-infection. Research from India shows that PLHIV with psychiatric disorders
and persons with mental illness are both groups with whom it is difficult to use routine HIV
prevention programmes and suitable modification need to be made for this population (Chandra et
al, 2003).
Impaired lifestyle and poor nutrition
To keep the viral load under control, people living with HIV need to adopt a healthy lifestyle habits
by taking a nutritious diet, exercising regularly and avoiding alcohol and drugs. However, the
presence of mental illness in this group can make it difficult for the patients’ ability to follow a
healthy lifestyle. Due to various factors, nutritional status among persons with mental illness is
often poor, which may contribute to disease progression among PLHIV. Overall, the quality of life of
persons with HIV infection can get affected with the presence of a mental illness (Chandra, Desai &
Ranjan, 2005; Collins, Holman, Freeman & Patel, 2006).
Increased Caregiver Burden
Having both HIV infection and a mental health problem is known to increase the burden on a
caregiver (Collins, Holman, Freeman & Patel, 2006). Because there is stigma associated with both
mental illness and HIV, the double stigma that a person with mental illness and HIV faces can also
add to this burden, besides increasing the costs of treatment for both conditions. In addition,
caregiver burden can further be increased due to non adherence to treatment, suicidality,
aggression and poor personal care (Chandra, Desai & Ranjan, 2005; Senn & Carey, 2009).
Objective 4:
To help participants plan a referral to a mental health professional
Who is a mental health Professional?
A mental health professional is a trained psychiatrist, clinical psychologist (CP) or a psychiatric
social worker (PSW). A psychiatrist is qualified to prescribe medications. Thus, in case the
counsellor feels the PLHIV needs immediate medical attention in the form of medication or
hospitalization for mental health issues, a referral needs to be made to a psychiatrist. A CP and a
PSW play a role in the longer term and in-depth treatment of the individual and / or family. Mental
health professionals are trained in diagnosing, assessing, and treating mental illnesses.
Those who have undergone a training course in mental health counselling are also able to provide
counselling (mostly supportive counselling) to a client and or family dealing with mental health
issues. Some counsellors are trained in dealing with specific mental health issues, like addiction,
domestic violence, suicidality, or child abuse, for example. Not all mental health professionals are
necessarily equipped to deal with all kinds of mental health issues. Thus, it is advisable for an ICTC
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counsellor to be aware of the different kinds of counselling services available in one’s area so that
appropriate referrals can be made to the clients.
When to refer to a mental health professional?
A referral to a mental health professional is required in the following situations –
 If the patient has signs of suicidal intent or a sense of hopelessness
 If there seems to be a risk of harm to others
 If the patient’s mental disorder is making them unable to leave their home, fulfill the
routine daily activities, or take care of their children
 If the patient has a significant loss of sleep and/ or appetite
 If the patient’s hopelessness or sadness is interfering with adherence
 If counselling has been tried and has not worked
 If the patient requests to be seen by a mental health professional.
 If the patient or a family member reports that the patient is taking alcohol or a drug or if
the use has increased or is affecting their life
 The patient appears very withdrawn and uncooperative or appears to be lost or not be
listening to anything
 When the counsellor or a doctor requires the expertise of a mental health professional
to confirm a diagnosis or start special treatment
How to make a referral to a mental health professional?
When referring a patient to a mental health professional, write a note with the following
information (as much as you have) in brief and clear terms:









Patient’s name, PID Number, date of birth, address and telephone number
Presenting complaint – the reason why the patient came to you
Reason for referral – the reason why you are sending the patient to them
Past psychiatric history – in case the patient and / or family member has mentioned
anything to you
Current medication, details of any medication tried in the past few weeks. This includes ART
and any other medication the patient may be on.
Background – socio-economic status, education, occupation, marital status, where the
patient lives and with whom
Drugs and/or alcohol use or abuse in the present or past
If there is any suicidality, it has to be clearly mentioned in the note and the counsellor needs
to alert a family member / caregiver. The counsellor may also have to go along with the
patient to the mental health professional.
Counsellor’s name, designation, office address and contact number.
Need to make one’s own referral directory
A counsellor needs to have a list of the following services available in one’s area. For each service,
keeping some crucial details readily available can come in handy to make a quick referral. The
following table can be filled and modified as per the need by every counsellor.
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Table 5: Mental Health Referral Directory
Name
Psychiatrists
Address
and
contact
number
Days and Service(s) Charges
Timings
provided
Any
other
remarks
1.
2.
Clinical
Psychologist*
1.
2.
Psychiatric
Social
Worker*
1.
2.
De-addiction
center
1.
2.
Suicide
prevention
hotline
/
helpline
1.
2.
Mental
Health
Counsellor
1.
2.
This section is also given as a handout for easy reference.
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Objective 5:
To facilitate participants’ competence in counselling for some common mental health
problems in the context of HIV
Some issues commonly faced by our clients (or even by us sometimes) can be handled with
simple information and skills. The handouts given along are aimed to equip and empower a
counsellor to deal with the following issues:






Anger management
Dealing with anxiety
Dealing with suicidality
Dealing with difficulty sleeping
Dealing with sexual orientation related distress
Dealing with substance use disorders
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Helping a client with sleep difficulty
A good night’s sleep is as essential for our good health as diet and exercise. It helps in keeping us
alert and energetic, and for building our body’s defenses against infection, chronic illness, and even
heart disease.
People differ in their need for sleep. Some need as little as 4 hours, while some need as much as 10
hours of sleep, but most people need about 8 hours of sleep per night to feel rested, alert and active
the next day.
The need for sleep also changes with our age and health status. When we are sad or worried about
something, it can affect our sleep by making it take too long to fall asleep, making us wake up too
early in the morning, or making us wake up in the middle of our sleep.
In a person with HIV infection, there can be several reasons for a disturbed sleep, e.g., emotional
reaction to being HIV positive; physical symptoms like dyspnoea, apnoea or pain; depression;
anxiety disorders or substance use to name a few.
To assess if someone is sleeping well, it is good to ask an open ended question, like: “how is your
sleep?” After asking this question, the counsellor needs to be prepared for a variety of answers
about the amount and quality of sleep. If the person says they find it difficult to fall asleep or stay
asleep, the following can be helpful.
Do’s
 Relax before going to bed: Begin relaxing or winding down at least half an hour before
bedtime. Read something light, turn down the lights, listen to soothing music, have a warm
water bath, listen to a relaxation tape or CD.
 Relax in bed: Lie down in bed in any position, and simply breathe normally (There is no need
to ‘concentrate’ or focus on your breath). Each time you breathe out; imagine your body sinking
into the bed. Keep doing this, as it helps relax the body and mind.
 Exercise: Exercise tires the body and we are likely to sleep better when tired.
 Eat well: If your dinner was long before you go to bed, try having a healthy and plain bedtime
snack, about half an hour before bed, e.g., a glass of milk, a banana, a piece of toast.
 Make your sleeping environment comfortable. Keep the room cool and dark.
 Make a To Do List: Keep a notepad and pencil handy and if you think of something important
in bed, write it down and let the thought go. This will help you avoid lying awake worrying
about it.
 Go to bed only when you are sleepy.
 If you are in bed and haven’t fallen asleep within 15-20 minutes, get up and do something
else. Go to another room and do some quiet activity like reading or listening to music. Go back
to bed only when you become sleepy. Do the same thing if you wake up at night: if you do not
fall asleep after 15-20 minutes, get up and only go back to bed when you are feeling sleepy.
 If you wake up early and cannot sleep, get up and begin your day.
 Get up at the same time on all days of the week. If you get up at the same time even you have
slept late or not at all. Avoid sleeping during the day, this will initially be difficult to do, but will
slowly set the biological clock right and help you sleep on time at night.
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 Try going to bed around the same time every night. This again helps keeping the biological
clock functioning well.
 Reduce thinking and worrying in bed. For this, put aside some time during the day purposely
for thinking and worrying. This should be done anywhere else except the bed, and should end at
least 2 hours before you go to bed.
 When in bed, choose to focus on pleasant thoughts, things that you enjoyed during the day
or this week, think about the things you feel gratitude for in your life or something fun that you
are looking forward to.
Don’ts
 It is not helpful to “try” to fall asleep, sleep happens to us when we relax. “Trying to sleep”
makes us tense.
 Do not do any rigorous physical exercise late in the evening, as it can make us too alert to
sleep.
 Do not lie awake in bed unless you want to just relax.
 Do not worry about sleep. Focusing on sleep can make it more difficult to sleep. In fact
deciding to not sleep, and instead just relaxing often makes people fall asleep. Do not look at
the clock and worry that you have still not fallen asleep.
 Avoid daytime naps, they make us feel less tired at night and disturb our sleep. If you
absolutely have to sleep during the day, sleep for not more than 45 minutes, and wake up at
least 8 hours before you want to sleep at night.
 Do not eat a large meal close to bedtime.
 Avoid caffeine, alcohol and nicotine especially in the late afternoon and evening. Caffeine
(tea, coffee, chocolate and cokes) is a stimulant. If you take a lot of caffeine, try to cut back or
replace this with other drinks like green tea. Alcohol helps people fall asleep but results in side
effects like shallow and disturbed sleep, abnormal dreams and early morning awakening.
 Do not read, watch TV, eat or worry in bed. Associate your bed only with sleep, and use your
bed only for sleep and sex.
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Anger Management
Anger is an emotion. All emotions, be it happiness, sadness, or anger, are natural for us to feel.
Aggression is a behaviour, which is manifested as shouting, throwing things, and hurting oneself or
others. Often times, such aggressive behaviour is mistakenly called anger. While there is an overlap,
usually it is the behaviour of aggression that causes more damage outside to our relationships and
things, while the anger that stays within us is likely to cause more damage to us. Our behaviour is
much more under our control than our emotions are. If we can calm our anger down quickly, it is
less likely to result in aggressive behaviour.
Here are some ways to calm one’s anger down quickly:
 Cool down. Drink water, maybe two glasses. Take a shower. Wash your face. Do anything to
bring your temperature down a little bit.
 Breathe. Take 10 deep breaths. Start with exhaling (breathing out) – exhale as slowly as
you can, it will be difficult initially; but will slowly get better. Keep breathing as calmly and
slowly as possible (without making it too loud).
 Move away. If you feel that your anger is getting out of control, move away from the person
/ situation associated with anger.
 Count backwards. From 20 to 1. To make it even more effective, you can count backwards
in 3’s from 40 to 0 (40, 37, 34, 31...) or in 7’s from 100 to 0 (100, 93, 86, 79...). The idea is to
busy your mind doing something.
 Clean something. Sometimes the excessive energy that we have can be used (and diverted)
to doing some rigorous cleaning or organising that you have been postponing for long.
Some anger is more long-lived. This can manifest as resentment or holding a grudge. It is like
having a long term simmering anger. While the above would be similar to having a 104 C
temperature, this is like having a constant 99C temperature. This kind of a situation is often seen
among partners in unhappy marriages. The following are some suggestions that can help. Very
often the grudge is because we find something unfair – like a betrayal by a prtner
How to give up the grudge
List the injustices in your life. Divide the list into things you can change and things you
cannot change (yet). This can help you make a plan of action.
 Serenity Prayer: The well known prayer says: “God, give me the courage to change the
things I can, give me the serenity to accept the things I can’t, and wisdom to know the
difference.” Accept that everyone has some things in their lives that they have no control
over. And that it helps us more than anyone else to accept this.
 It is not black or white. Think, “Does this one injustice have to affect all areas of my
relationship / life all the time?” “Is there anything fair?” “Is there any way in which I have an
advantage over the others?” If thought in a calm state, the answers usually are more
moderated and not all black or all white.
 Choose and decide: “Can I still make my life meaningful in spite of this unfairness and
disadvantage?” When we are very angry, it would be difficult to say yes, thinking of

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examples from other people’s lives might help if thought on one’s own. A counsellor needs
to however, not push too much for this.
 Question your anger. If you find yourself thinking too much about an injustice, stop and
ask, “Will my being upset change the situation?"
 Modify your language of self-talk. Instead of saying, "This is unfair," say, "I am feeling
annoyed." The situation is what it is, it is how affected we are that the issue is. This verbal
shift sometimes helps keep perspective.
Think of your responses. Imagine different difficult situations that affect you or bring your anger
up. Think of how you want to act in those circumstances, in spite of the unfairness. And then do it,
slowly and steadily.
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Dealing with anxiety
Constant worry puts a strain not only on our mental health, but also on
our physical health. We all have plenty of things to worry about – from
personal relationships, social status, job security or health to larger
issues like fears about natural disasters or riots.
Is all anxiety bad?
No. Some amount of fear and anxiety are good, as they save our lives and also swing us into action
at crucial times. Fear of fire, heights, the dark, strangers, loud sounds, and so on, serve the
important purpose of protecting our precious lives. A feeling of fear or anxiety automatically
prepares our body for a ‘fight-or-flight’ reaction, so that we either attack or run away from the
danger to protect our lives.
But too much anxiety can take a toll on our sleep, affect our memory and concentration, lead to
aches and pains in different parts of the body, tax our immune system, and can even increase our
risk of dying from disease. Many people who suffer because of anxiety, do so because they start
becoming anxious about their anxiety; they begin to worry about worry, e.g., “what if I start
shivering again because of fear?”, or “what if I cannot make eye-contact again when I am talking to
my friends?” This kind of a situation multiplies the anxiety manifold.
The following questions may help a counsellor find out if anxiety is present in a client:






Do you worry a lot?
Do you feel anxious?
Are you scared or fearful or afraid?
Do you feel tense or irritable?
Are you restless?
Do you find it difficult to sleep?
If the answers to the above questions indicate the presence of anxiety in a client, the counsellor can
further assess the extent of anxiety by asking about its degree, duration and effects. The client is
likely to have an anxiety disorder occurs when the symptoms:
Interfere with a client’s daily functioning (e.g., the person is unable to work, leave home, or
take treatment due to anxiety)
 Interfere with personal relationships
 Cause marked subjective distress

Basic supportive and behavioural interventions are sufficient to alleviate anxiety in certain
patients.
Whether we have occasional bouts of anxiety or a diagnosable anxiety disorder, the good news is
that we can take small, effective and simple steps to manage and minimize our anxiety. Here are
some steps that can help all of us.
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Ways to deal with anxiety
1. Breathe
Deep breathing triggers our relaxation response, which is the opposite of our fight-or-flight
response. A simple exercise can be done for this. First exhale s l o w l y… as slowly and as
completely as possible (It would be difficult initially, but do it just as much as possible). And then
inhale slowly. Again exhale slowly and as completely as possible. And then again inhale slowly.
Keep repeating this exercise for at least 5 minutes. This needs to be practiced daily in a calm time,
and slowly it can become possible to do even in a stressful situation.
2. Evaluating the chances of the threatening event actually happening
Anxiety makes us believe that the “what ifs” we fear will definitely come true. Yet in reality, most of
the time what we worry about never happens. Using the method of writing down our worries, and
recording how many came true, we can notice how rational or irrational our fears are.
3. Decatastrophising
Anxiety can lead to ‘catastrophising,’ which refers to imagining the worst case scenario possible
even for minor events, or making mountains out of molehills. Anxiety also makes us ‘minimise’ our
ability to deal with different problems. We need to know that even if a bad event happens, it may
still not be the end of the world, and we may still be able to handle it using our coping skills and
problem-solving abilities or by asking others to help. It can help us to think in a relaxed state, either
on our own or with the help of a friend of a counsellor, what worst can happen, and if that does
happens then what can be done.
4. Set aside a planned “worry time”
Instead of worrying the entire day, we need to decide upon a 30-minute period of fixed time where
we can think about our problems. When this is suggested to an anxious person, initially it makes
them more anxious, but most people can usually see the benefit of this over time. A research group
has suggested a four-step program that can help highly stressed people take control of their
anxieties. Step one: Identify the object of worry. Step two: Come up with a time and place to think
about said worry. Step three: If you catch yourself worrying at a time other than your designated
worry time, you must make a point to think of something else. Step four: Use your "worry time"
productively by thinking of solutions to the worries.
Scheduling a time to worry helps us worry less over the long run.
5. Exercise
A number of studies show that people who exercise have lower anxiety levels than people who lead
a sedentary life. We can choose from a variety of exercises – walk, jog, swim, dance, do aerobics, or
pilates, or hit the gym or even skip a rope, for example. Exercise releases certain chemicals in the
brain that make us happier and reduce anxiety.
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6. Sleep well
Lack of sleep can trigger anxiety. If you’re having trouble sleeping, tonight, engage in a relaxing
activity before bedtime, such as taking a warm bath, listening to soothing music or taking several
deep breaths. If you have had a “worry time”, exercise, and followed a healthy and balanced diet, it
can help sleep more easily.
7. Avoid caffeine
Caffeine (coffee, tea, chocolate and colas) increases anxiety. Instead, milk, green tea or just plain
water can be relatively calming options.
8. Avoid alcohol and drugs
People sometimes resort to drugs and alcohol thinking that they help reduce anxiety. This is true
but ONLY in the short term; they often do just the opposite in the long term.
9. Laugh
Laughter releases tension and relaxes us naturally. If we are feeling anxious, we do not have to wait
for the anxiety to go for us to laugh, in fact anxiety would naturally reduce if we laugh
wholeheartedly.
10. Do Something calming
Meditation helps calm us down. It can sound like a difficult thing to exercise, but it is really not. It
does not require some deep concentration or drastic changes in lifestyle. You can start with sitting
down for even 3-5 minutes with your eyes closed and relaxing. It does not matter if your mind
wanders when you do this. It is enough if you start with just becoming ‘aware’ of all the sounds
around you, of the sensations (pain, tenseness, coolness etc) in different parts of your body, and
observe your thoughts wandering wherever they do. It is okay even if you are not fully aware of all
this, it slowly becomes easier. The time can then slowly be increased to about 20 minutes a day.
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Dealing with sexual orientation related distress
“I do not want to be homosexual; can you please help me change?” When a well-wishing counsellor
hears this kind of a request, they truly wish they could help reduce the client’s distress. Agreeing to
help change the client’s sexual orientation comes at least partly from the counsellor’s belief that
heterosexuality is the only “normal” or “healthy” sexual orientation.
A good counsellor needs to know the following very clearly:
 All sexual orientations are normal and healthy, be it heterosexuality, homosexuality,
bisexuality and any other orientation.
 Heterosexuality is only more common, just as right-handedness is, but that does not make
left handedness or all sexual orientations except heterosexuality abnormal or even less
normal. Thus, common ≠ normal.
 There is no clear reason why someone is heterosexual, bisexual, homosexual or
transgender, or any gender or sexuality for that matter. Thus, one need not waste time
thinking what made a person who they are.
 All the sexual orientations and genders have existed in all the countries and cultures, and
alternative sexualities and transgender are NOT western, modern city concepts. Ancient
temples, epics and scriptures of India give ample evidence for this.
 According to the international psychiatric classification systems, no sexual orientation is
abnormal.
 It is unethical to treat normality.
 Strong research evidence shows that attempts to change a person’s sexual orientation or
gender preference meet with no success. Some methods that were used in the past to
change a person’s orientation are now banned.
 If we try to help change a client’s sexual orientation, even if the client had asked for it, our
intention may be to help, but the impact it has is of making the person believe that they are
indeed abnormal. Our belief behind agreeing to help them change may be, e.g., “he is feeling
frustrated that his family does not accept his orientation, and that he is feeling guilty for
causing his mother so much distress, or that he is getting betrayed repeatedly because he
has no long-term partner... and that if he does become heterosexual, a lot of his problems
will be removed.” By helping him to change his orientation, we are agreeing with his belief
that the basic problem is with sexual orientation. It is the impact of what we say or do that
really matters, and not what our intention was, nor how accepting or understanding in
general we are of different sexual orientations and genders.
What to do
 Listen. And listen. Listening to what the person is saying (in words and nonverbally) is
what is most important to help us understand what the person is actually feeling. E.g., if a
person says “I come from a small village, and even though people are talking about it in
cities now, no one accepts this in my village, I feel so ashamed for who I am and what I do
with the other men”, what the person is probably also saying is that they actually have no
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



real problem with their sexual orientation, but that they are very distressed by the society’s
disapproval of it.
Empathise. Try to put yourself in the person’s place. Imagine that you are what you are and
for some reason society just does not accept you as that. It is not about what you DO but
what you ARE that the society expects you to change. Also imagine yourself as
Validate and normalise the person’s feelings. Say things like “that might feel very lonely,”
“I hope you know that there is nothing wrong with you, you are feeling so suffocated
because the society is pressurising you to be what you are not,” or “I might have also felt
like this if I was in your place.”
Be genuine. When we say things like those mentioned above, they have a much better
impact than if we say them as just words.
Do what you would do if someone asked you to help them commit suicide. If a client
said that they are sure the only option left for them is to end their life, would you help them
find ways of killing themselves? Definitely not. Instead, you would try to understand the
cause of their distress, help them gradually reduce their problems and increase their
strengths.
In case the person does NOT express that they are unhappy with their gender or sexual
orientation
 Deal with the issue that concerns the client. If the client’s gender or sexual orientation is
not their concern, but they are distressed, focus on the issue that is distressing them, and
DO NOT assume that their distress is because of their gender or orientation.
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Dealing with suicidal clients
Dealing with suicidal clients is one of the most difficult issues a counsellor faces. A counsellor needs
to be aware of suicidality because it is not just about people who end their lives with suicide.
Different phases of suicidality are:
 Death wish: When a person wishes to be not alive anymore or wishes that death happens to
them, without actively thinking of doing something to harm or kill oneself.
 Suicidal ideation: When a person has any thoughts of harming oneself or ending one’s life.
 Suicide attempt: When a person does any action with an intention to kill oneself.
 Completed suicide: When a person has dies after doing something with an intention to kill
oneself.
Suicidality is rather common amongst HIV-positive individuals. People from the following
populations within positive people can have a particularly higher risk of suicidal thoughts.




Positive people who are gay, bisexual or transgender
Those who regularly smoke cannabis
Those who have depressive symptoms
Those who were single and not in a relationship
Among all positive people, risk of suicide can be especially high in some periods. They are:





Soon after getting a positive test report
Soon after a loss, especially the death of an infected partner
Advancing HIV disease
Severe physical symptoms
A common and very harmful
During an episode of depression
myth is that if you discuss suicide
Examples of questions to ask:
with someone, you are giving
them this idea. A counsellor must
ask a client about suicide if they
feel that the person might be
suicidal.
 Do you feel that there is hope; that things will improve? Or do you feel hopeless? On a scale of 010, if ‘10’ is most hopeful, and ‘0’ is most hopeless, how do you feel nowadays?
 In the last 2 weeks or so, have you wished that death comes your way (Or... your life would end;
Or… you were no more?
 In the last 1 week or so (time frame can be changed while asking), have you thought of doing
something to end your life?
 Could you tell me specifically what kinds of thoughts have been coming to your mind regarding
ending your life yourself?
 When you get these thoughts, how long do they generally last?
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 How often do you get these thoughts?
 Have you been thinking of a method that you might use to end your life? Have you been
planning how you might do this? (If yes) What kind of methods you have been thinking about?
 What do you do when you get these thoughts?
 Have you ever done anything to harm yourself? (If yes, ask what and when; and how they were
saved).
 Have you ever told anyone that you have been feeling suicidal?
In case a client is suicidal, the counsellor must immediately refer the client to a mental
health professional.
Common Misconceptions about Suicide
(Source: SAVE – Suicide Awareness Voices of Education)
FALSE:
People
who
talk
about
suicide
won't
really
do
it.
Almost everyone who commits or attempts suicide has given some clue or warning. Do not ignore
suicide threats. Statements like "you'll be sorry when I'm dead," "I can't see any way out," — no
matter how casually or jokingly said may indicate serious suicidal feelings.
FALSE:
Anyone
who
tries
to
kill
him/herself
must
be
crazy.
Most suicidal people are not psychotic or insane. They must be upset, grief-stricken, depressed or
despairing, but extreme distress and emotional pain are not necessarily signs of mental illness.
FALSE: If a person is determined to kill him/herself, nothing is going to stop them.
Even the most severely depressed person has mixed feelings about death, wavering until the very
last moment between wanting to live and wanting to die. Most suicidal people do not want death;
they want the pain to stop. The impulse to end it all, however overpowering, does not last forever.
FALSE: People who commit suicide are people who were unwilling to seek help.
Studies of suicide victims have shown that more than half had sought medical help in the six
months prior to their deaths.
FALSE:
Talking
about
suicide
may
give
someone
the
idea.
You don't give a suicidal person morbid ideas by talking about suicide. The opposite is true —
bringing up the subject of suicide and discussing it openly is one of the most helpful things you can
do.
A counsellor must remember to NOT say the following things to a suicidal client.




“Don’t be so selfish. Think how your family will feel.”
“Many people in this world have bigger problems.”
“You have no idea what all I have been dealing with, but I do not think of suicide.”
“Be brave, do not be a coward.”
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






“I do not believe that you will actually do it.”
“Leave these thoughts and do something with your life.”
“Suicide is a sin – you will go to hell if you do this.”
“I cannot help you any more if you think / talk of suicide.”
“You are choosing to think like this, and you can choose to change your thoughts.”
“Stop trying to get attention.”
“Okay, so do it then!”
What you CAN say or do instead. Speak genuinely, reassuringly and in short sentences.
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“I know this is a really tough time for you. But you are not alone, I am there.”
“It may seem difficult to believe right now, but the way you are feeling will change with
time.”
“I care about you and want to help, though I may not be able to understand exactly how you
feel.”
“When you want to give up, tell yourself you will hold off for just one more day, hour,
minute—whatever you can manage.”
Offer to be available on the phone anytime of the day or night.
Give the number of a suicide hotline.
Make a contract of no self-harm. Say, “Promise to me that you will not do anything to
harm yourself.” Ask the person to say the whole thing rather than just saying ‘yes’, or ‘okay’.
Ideally, you can write this down on 2 sheets of paper, ask the person to sign it, and give
them a copy of it with your / hotline’s number that they can contact if they are feeling
extremely suicidal.
Make a referral to a mental health professional.
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When and how to make a referral to a mental health
professional?
Who is a mental health Professional:
A mental health professional is a trained psychiatrist, clinical psychologist (CP) or a psychiatric
social worker (PSW). A psychiatrist is qualified to prescribe medications. Thus, in case the
counsellor feels the PLHIV needs immediate medical attention in the form of medication or
hospitalization for mental health issues, a referral needs to be made to a psychiatrist. A CP and a
PSW play a role in the longer term and in-depth treatment of the individual and / or family.
When to refer to a mental health professional:
A referral to a mental health professional is required in the following situations –
 If the patient has signs of suicidal intent or a sense of hopelessness
 If there seems to be a risk of harm to others
 If the patient’s mental disorder is making them unable to leave their home, fulfill the
routine daily activities, or take care of their children
 If the patient has a significant loss of sleep and/ or appetite
 If the patient’s hopelessness or sadness is interfering with adherence
 If counselling has been tried and has not worked
 If the patient requests to be seen by a mental health professional.
 If the patient or a family member reports that the patient is taking alcohol or a drug or if
the use has increased or is affecting their life
 The patient appears very withdrawn and uncooperative or appears to be lost or not be
listening to anything
 When the counsellor or a doctor requires the expertise of a mental health professional
to confirm a diagnosis or start special treatment
How to make a referral to a mental health professional:
When referring a patient to a mental health professional, write a note with the following
information (as much as you have) in brief and clear terms:
Patient's name, PID Number, date of birth, address and telephone number
Presenting complaint – the reason why the patient came to you
Reason for referral – the reason why you are sending the patient to them
Past psychiatric history – in case the patient and / or family member has mentioned
anything to you
 Current medication, details of any medication tried in the past few weeks. This includes ART
and any other medication the patient may be on.
 Background – socio-economic status, education, occupation, marital status, where the
patient lives and with whom
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Manual on Advance Counselling for ICTC Counsellors
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Drugs and/or alcohol use or abuse in the present or past
If there is any suicidality, it has to be clearly mentioned in the note and the counsellor
needs to alert a family member / caregiver. The counsellor may also have to go along with
the patient to the mental health professional.
 Counsellor’s name, designation, office address and contact number.
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Need to make your own referral directory
A counsellor needs to have a list of the following services available in one’s area. For each service,
keeping some crucial details readily available can come in handy to make a quick referral:
Name
Psychiatrists
Address
and
contact
number
Days and Service(s)
Timings
provided
Charges
Any
other
remarks
3.
4.
Clinical
Psychologist*
3.
4.
Psychiatric
Social
Worker*
3.
4.
De-addiction
center
3.
4.
Suicide
prevention
hotline
/
helpline
3.
4.
Mental
Health
Counsellor
3.
4.
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