From the aDepartment of Psychiatry, Muhimbili University College of Health Sciences, Dar es Salaam, Tanzania and bthe Department of Social Medicine, Harvard Medical School, Boston, Massachusetts, USA.
Requests for reprints to: M. C. Smith Fawzi, Department of Social Medicine, 641 Huntington Avenue, Harvard Medical School, Boston MA, 02115, USA.
Received: 18 May 1999; accepted: 21 May 1999.
The article titled ‚A psychological epidemiology of people with HIV/AIDS in Kenya: An approach for improving counselor training‚ by Vollmer et al., in the current issue of this journal covers a very important topic for individuals seeking HIV/AIDS counseling in sub-Saharan Africa. The information collected provides data on the typology of psychological problems reported among individuals seeking HIV counseling, and empirically categorizes these into groups of problems that can be the focus of a training curriculum for para-professional HIV/AIDS counselors. Very often the counseling component of counseling and testing interventions is minimized and greater emphasis is given to the need for an HIV test and the provision of test results. It is therefore encouraging that this article addresses issues related to psychological needs that can then be used to develop targeted training for counselors. The psychological impact of HIV/AIDS and assessment of the impact of psychological interventions are often difficult to measure objectively. The longer-term psychological needs of persons with HIV/AIDS are often overshadowed by physical and social needs in a setting with limited resources and are often ignored. As noted by the authors, para-professional counselors will continue to attempt to meet the needs of persons seeking HIV/AIDS counseling in Africa for a long time given the nature of the AIDS epidemic and the paucity of health workers with skills in psychological therapies in the continent.
Issues related to formal training in counseling arise in a setting where such support has often been based within an informal traditional care system that is undergoing rapid change. The African continent is diverse in terms of its economics, cultural heritage and the level of education of its people. Medical pluralism exists with complex interactions between lay, traditional and emerging allopathic systems of care. The more prevalent and culturally relevant traditional systems of care provide psychological and informational support using a more directive approach than what is usually provided in Western-based counseling. Low education levels in populations in sub-Saharan Africa has encouraged a greater emphasis on the informational than psychological support aspects of health counseling in allopathic care settings. In addition, access to allopathic health services may often imply automatic consent to all medical examinations that are required; a norm that has been questioned with the advent of the HIV/AIDS epidemic, where a clear understanding of the disease is necessary to facilitate behavior change and reduction in transmission.
Development of counseling in relation to HIV/AIDS has occurred in hospital settings [1,2] and in communities  as a response to psychosocial needs generated by individuals with HIV/AIDS and their families. Approaches to counseling in hospital settings are often short-term, focused on crisis management, and offered predominantly by health workers. Another area of development of counseling has been in the setting of voluntary testing for HIV antibodies: this meets an ethical requirement as perceived by researchers and health care providers [4-8]. Short-term pre- and post-test counseling in these settings has developed into considering options available for longer-term emotional support. In community-based HIV/AIDS counseling and some voluntary testing and counseling settings, para-professional counselors often provide counseling. Increased availability of screening services for HIV in sub-Saharan Africa will result inevitably in an increased identification of asymptomatic sero-positive individuals for whom counseling needs may differ from those of persons with symptomatic HIV and AIDS.
For many patients in the African setting, allopathic medicine is often considered only for certain types of conditions due, in part, to the very different local conceptualizations of explanatory models for illness and health that are constructed by prevailing cultures. In Uganda, ‚The AIDS Support Organization‚ had a primary concern of bridging the gap between African approaches to illness and disease and allopathic medical systems, and was able to establish a comprehensive community-based approach towards the care of those affected by HIV and AIDS . Several authors have noted cultural issues that may impact on counseling in relation to HIV/AIDS, including the importance of the economic and emotional aspects of sexual relationships, the strong cultural links between women‚s status and childbearing, and fatalistic acceptance of misfortune [6,10]. Allwood et al.  emphasize the need in training of counselors for skills in assessing world views and education level in order to determine what language to use, at what level information should be given and what relevant idioms to use. Low education level has also been noted to correlate positively with low HIV/AIDS knowledge . Chaava  describes a counseling approach with a strong education component where complex issues were simplified to content that could be understood; this is an important factor in encouraging persons with HIV and communities to take a proactive approach in decreasing the spread of HIV/AIDS. Empirical data support the need for client-centered counseling in the African setting. Provision of factual information needs to be balanced with a person-centered approach, exploring the client‚s conception of the problem and helping the client identify persons in their network who can give further psychosocial support .
Disclosure of HIV sero-status is an initial and important step in dealing with the reactions to a stigmatizing disease. Sensitivity of counselors to the fears of blame and rejection amongst persons with HIV that are related to issues surrounding disclosure of HIV status in the African context is very important. The role of counseling in increasing rates of disclosure amongst persons who are sero-positive in sub-Saharan Africa is an area that has not yet been explored. Heyward et al.  note that although counseling and testing are associated with high rates of contraceptive and condom use in the short term, disclosure rates remain low. Ladner et al.  noted higher rates of partner disclosure (around 50%), and that fear of conflicts and expulsion from the marital home are major reasons for non-disclosure. Evidence indicates that a comprehensive community-based, and culturally sensitive approach towards care of persons with HIV can increase community acceptance of these individuals and improve disclosure, with a large proportion of persons with HIV being able to move beyond sero-positivity to planning for the future .
The value of involving families in the counseling process has been recognized in strengthening traditional systems/patterns of support and care and positively changing community normative attitudes and practices regarding sexual behavior and dealing with issues of stigma [2,4,5,15]. Family involvement as well as issues surrounding disclosure need to be balanced against issues of confidentiality and the fear of stigma amongst persons with HIV . The knowledge and skills required in counseling families will originate in a set of psychological problems different from those identified at a more individual level.
Baggaley et al.  note that many counselors are faced with personal tragedies related to HIV that may interfere with their ability to counsel others, due to unresolved personal issues. Very few are able to face the advice they are trained to give, such as discussing HIV transmission with a sexual partner or submitting to HIV screening. Allwood et al.  note that availability of an adequate support system for counselors is important in order to support counselors in coping with patients‚ suffering from a stigmatizing disease and managing a large workload. The ability to keep up-to-date with scientific developments and apply them to one‚s work environment is another important quality required of counselors. In addition to expressed individual psychological distress, the cultural context within which such distress occurs, and how this impacts on the knowledge and skills required by counselors needs to be considered for a comprehensive training program.
A focus on cultural factors, at both the individual and the community level, is essential if normative attitudes are to be influenced by counseling and undergo changes that minimize risks related to HIV/AIDS transmission. Culture-sensitive counseling approaches that provide a safe environment for disclosure and maximal use of the potential of confidants in coping and prevention activities need to be explored. Counseling models need to move beyond the individual to the family and wider community to ensure development of sustainable support for persons with HIV.
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