Chapter 27. Principles of Risk Reduction Counseling

• • Effective counseling to prevent sexually transmitted diseases (STDs), including HIV, comprises the following elements:
• • Conducting a thorough risk assessment using exploring, open-ended questions.
• • Addressing barriers to risk reduction and supporting preventive actions already taken.
• • Addressing misconceptions.
• • Selecting with the patient a high-risk behavior he or she is most willing and able to change.
• • Developing a step-wise risk reduction plan.
• • Providing referrals if needed.

Education and counseling have historically played a role in STD prevention activities, usually as an adjunct to testing, treatment, and partner notification services. However, it was not until the advent of the HIV epidemic that behavioral interventions, including counseling, became the focus of systematic efficacy research. A detailed review of this research and its underlying theoretical considerations is outside the scope of this chapter. However, arguably the single most important study that put counseling to reduce sexual risk behaviors on the map as an effective and feasible intervention for use in a variety of settings was Project Respect. This randomized controlled trial demonstrated that a specific type of counseling (subsequently referred to as prevention counseling), comprising two 20-minute counseling sessions, was significantly more effective in preventing subsequent STDs when compared with standard prevention messages.

The findings of this study have important consequences for STD prevention, especially because the effects of prevention counseling were shown to be particularly favorable for populations at highest risk for STDs, including individuals younger than 20 years of age and those with a baseline STD. Thus, there is a strong rationale to include counseling to reduce sexual risk behaviors when providing care for persons at high risk for STDs—that is, as long as the counseling process adheres to a number of critical elements. Subsequent sections of this chapter describe these elements and suggest ways in which prevention counseling can be incorporated into a busy practice setting where time and resources are important limiting factors.

Guidelines for HIV prevention counseling have been put forth by the Centers for Disease Control and Prevention (CDC) since 1986. Prevention counseling as evaluated in Project Respect (sometimes also referred to as client-centered counseling) was first described in 1993 and updated most recently in 2001. An adapted summary of these guidelines appears in Table 27–1, and a more detailed description follows.