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    Couples HIV Counseling and Testing

    Module Six: Providing Discordant Results


Module Perspective

    This module will review discordance essentials, including multiple factors that influence

    the transmission of HIV. Interactive exercises will help participants to understand the

    factors that contribute to the chance of being infected with HIV.

The trainer will review the CHCT Protocol for providing couples with a discordant result.

    Participants will also have an opportunity to evaluate and critique explanations

    commonly given to clients about discordance. The trainer will assist participants in

    understanding the importance of clearly communicating discordance to couples.

Participants will return from lunch to review components V-C through XI-C of the CHCT

    Protocol. Participants will highlight the differences between providing a discordant

    result and a concordant positive result in a small group exercise. This module will

    conclude after conducting the fourth and final role play covering the initial session of the

    protocol and the second session, Providing Discordant Results. The trainer will process

    the role play before adjourning for the day.

Objectives for Module Six:

    ? List at least five factors that can influence the transmission of HIV.

    ? Explain the importance of communicating discordance clearly and simply.

Advance Preparation

    ? Prepare Overheads 6-1 through 6-13

    6-1: Multiple Factors that Influence the Transmission of HIV

    6-2: HIV Transmission in the Family

    6-3: Essential Counselor Responsibilities

    6-4: Essential Counselor Responsibilities (Continued)

    6-5: Component V-C: Provide Discordant Results

    6-6: Component V-C: Provide Discordant Results (Continued)

    6-7: Communicating Discordance

    6-8: CHCT Results Session: Discordant

    6-9: Component IX-C: Discuss protecting the negative partner from HIV

    6-10: Major Issues for Concordant Positive Couples

    6-11: Major Issues for Concordant Positive Couples (Continued)

    6-12: Major Issues for Discordant Couples

    6:13: Major Issues for Discordant Couples (Continued)

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    Module Six: Providing Discordant Results

? Make copies of Handouts

Explaining Discordance (H6-1)

    Potential Differences between a Concordant Positive and a Discordant Couple Counseling

    Session (H6-2)

    Counselor scripts for the Second SessionComponents VI-C through X-C (Providing

    Discordant Results)

    Role Play Background (Female) (H6-3)

    Role Play Background (Male) (H6-4)

    Laminated CHCT Intervention Protocol

    Counselor Check Sheets (H6-5 through H6-8)

? Prepare the Bean Exercise (see page 4)

? Prepare Newsprint

Questions from an HIV-Positive Partner (page 11)

    Helping Couples Understand Discordance (page 16)

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    Module Six: Providing Discordant Results

    Day Four

    Module 6: Topics/Activities Schedule

Start time: 8:30am

     Activity Time

     Morning Review 20 Minutes

     Discordance Exercise 30 Minutes

     Factors that Influence Transmission of HIV 30 Minutes

     Morning Break 20 Minutes

     Discordance Essentials / Exercise 40 Minutes

     Second Session : Discordant 90 Minutes

     (Component V-C: Providing Results) and Discordance

     Continuum Exercise

     Lunch Break 60 Minutes

     Components VII-C through X-C: Discordant 60 Minutes


     Afternoon Break 20 Minutes

     Role Play Preparation 15 Minutes

     Role Play # 4 70 Minutes

     Processing of Role Play 30 Minutes

     Wrap-Up/Adjourn for the Day 5 Minutes

End time: 4:50pm

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     Welcome and Brief Review

    Welcome participants back. Conduct a culturally appropriate morning


    Facilitate a brief discussion of what has been covered so far.

    Welcome to the fourth day of our training.

    Today we will spend the day covering discordance. However,

    before we begin our discussion, what questions do you have

    about the topics we have covered so far?

    Answer or clarify questions as necessary.

    Preventing transmission within a discordant couple is one of the

    most critical reasons for offering couple HIV counseling and

    testing services. The best way for a couple to find out that they

    are discordant is for both partners to be tested together for HIV


    Therefore, we will spend the entire day today going into more

    detail about discordance and reviewing the CHCT procedure

    for counseling discordant couples.

    We will then cover important issues for discordant couples,

    such as coping and providing each other support; positive living,

    care, and treatment; risk reduction; family planning; disclosure;

    and getting support.

    There is a lot to cover, but before we get started we are going Discordance to conduct an exercise that will help you understand the risk of Exercise:

    HIV transmission. Multiple Factors

     That Influence the

    Transmission of Who can tell me what the chances are of the following:


    1. Getting malaria from a single mosquito bite?

    2. Having a girl baby versus a baby boy?

    3. Getting into a car accident?

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    Module Six: Providing Discordant Results

    Acknowledge responses and reinforce that all of these things happen by chance.

    Getting malaria from a single mosquito bite, getting into a car accident, and having a girl baby or a boy baby all involve probability and chance. As in all of these scenarios, elements of chance and probability play a role in HIV transmission. The reality is, people don‘t always get infected from every exposure

    to HIV. While it‘s possible for an HIV-negative individual to

    have unprotected sex with an HIV-positive individual one time and acquire HIV from that one exposure, it is also possible that the HIV-negative individual will not acquire HIV from this exposure. When one member of a couple is HIV-positive and the other member is HIV-negative, this couple is discordant. We are going to spend the morning discussing how and why this happens.

    We are going to start with a short exercise to demonstrate the role of chance and probability in the transmission of HIV.

Bean Exercise:

    The following Bean Exercise is designed to help the participants understand the dynamics of HIV transmission: HIV is not transmitted in every sexual encounter. Chance and probability play a role, as well as many other factors that will be discussed after the exercise. This exercise also shows that people frequently transmit and acquire HIV unknowingly.

    The trainer should prepare for this exercise by bringing in a bag of white and red beans. The white beans represent an HIV-negative status; the red beans represent an HIV-positive status.

Introduce the exercise as follows:

    This exercise is designed to help you see how discordant couples can remain discordant. If the couple does not abstain from sex or use condoms, the HIV-negative partner can be infected any time they have sex. However, it is also possible that the HIV-negative partner will not become infected. Sometimes it is a matter of chance. Sometimes other factors are involved, which we will discuss.

    For this exercise, you will pretend you are couples in which one partner is infected with HIV and the other is not. In other words, you are a discordant couple. I will be giving a handful of beans to each of the HIV-infected partners. The partner with the beans is HIV-positive and the partner without the beans is HIV-negative.

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    Module Six: Providing Discordant Results

1. Now let’s break into couples.

2. Break the participants into pairs. These will be the couples for this


3. Ask the participants to stand next to their partners and form a large

    circle. Ask one partner from each couple to hold out his or her


4. Walk around the circle and give the partner who is holding out his

    or her hands 10 beans. Seven of those beans should be white and

    three should be red. Ask the partner receiving the beans to not look

    at which kind of beans he or she has been given.

5. Ask the participants to turn to their partner.

6. Now ask the participants holding the beans to choose one bean

    from their hand WITHOUT looking at the beans.

7. Ask the participants to hand the chosen bean to their partner. The

    partners receiving the bean should look at the bean they received

    and note if they received a red bean.

8. The partners with the beans should choose another bean without

    looking and hand that bean to their partner. Again, the partner

    should look to see if he or she received a red bean.

9. Be sure to note that passing a red bean symbolizes transmitting

    HIVit does not represent getting rid of HIV.

10. Ask the participants who first held the beans to raise their hands.

    Inform them that they were each given a red bean, and therefore

    they are all HIV-positive.

11. Next ask the partners to raise their hands if they received a red

    bean during the first exchange. Tell them to keep their hands raised.

    How many partners received a red bean after one exchange?

12. Finally, ask partners to raise their hands if they received a red bean

    during the second exchange. How many received a red bean after

    two exchanges?

13. Have the participants look around the circle. How many people are

    now infected with HIV? How many partners were lucky enough to

    avoid HIV infection?

14. Debrief the exercise using the script provided.

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    During each exchange of beans, there was a possibility that the negative partner could acquire HIV.

    Although all of you engaged in the same behavior, not everyone became HIV-positive. Those of you who did not get any red beans were fortunate and avoided acquiring HIV infection, but only by chance.

    The partners who originally received a handful of beans and did not know whether they were HIV infected demonstrated how one member of a couple may transmit the infection to his or her partner or partners unknowingly.

    For our clients the same will be true; there will be multiple factors that influence whether or not they get infected with HIV.

    This exercise was conducted to help you see the dynamics of transmission and to help you understand that not every act of risk behavior will result in HIV infection. Behavior that most of us have engaged in at some point in our lives can result in becoming infected with HIV.

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    Factors that Influence Transmission of HIV

In the bean exercise, each HIV-positive partner had the same

    number of red beans and each couple participated in the same

    risk activityexchanging beans. Therefore, every partner in the exercise had the same probability of acquiring HIV, even

    though some were lucky and did not receive one. However, in

    real life once an individual has engaged in risk behaviors,

    several factors influence the likelihood of the transmission and

    acquisition of HIV. These factors make it more likely for a

    person to transmit HIV or for a person to acquire HIV. In

    couples, multiple factors influence whether they are discordant

    and how long they remain discordant.

Let‘s take a few minutes to look at the many factors that can

    influence the transmission of HIV and generally affect the

    health of the infected person.

Display Overhead 6-1. Read through the factors on the overhead.

    Multiple Factors that Influence

    the Transmission of HIVSexually Transmitted Infections

    Level of Virus

    Recent Infection with HIV

    Frequency of Sexual Exposures

    Injury of the Genital Tract

    Chance-ProbabilityOverhead 6-1

    Go over each factor:

Sexually transmitted infections (STIs)

    ? HIV-infected persons with STIs are more likely to transmit

    HIV than people without STIs

    ? Partners are more likely to acquire HIV if they have STIs

Level of virus

    The more HIV the HIV-positive person has in his or her body,

    the more likely it is that he or she will pass HIV to a sexual

    partner. When individuals develop AIDS, they are ill because they have very high levels of HIV in their body.

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Recent infection with HIV

    When someone is infected with HIV, he or she will initially have a higher amount of virus in his or her body. This increases the chance of passing HIV to others.

Frequency of sexual exposures

    Each time an uninfected person has sex with someone who has HIV, he or she is at risk of getting HIV. The more exposures he or she has, the more likely it is that he or she will become infected.

Injury of the genital tract

    Partners with cuts or abrasions of the membranes of the genital tract are more likely to acquire HIV than partners with intact membranes.


    To some extent, HIV transmission is unpredictable. This was illustrated by the bean exercise. Whether or not the virus is passed during a specific exposure relies partly on chance.

    Cover the overhead and ask participants to name as many factors as they can that facilitate HIV transmission.

    Remember that couples can remain discordant for a long period. We have seen how many factors can influence the transmission or acquisition of HIV.

    On the other hand, we have also seen that unless discordant couples receive counseling and testing and subsequently take steps to reduce the risk of transmission, many HIV-negative partners will become infected with HIV from their positive partners.

    In addition to the HIV status of the partners and their health, the health of their children is important also.

Please turn to page __ in your manuals.

Allow a moment for review.

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     Ask participants to turn to page ___ in their manuals and to

    review both photos of the farmer’s crop and try to explain why the farmer’s crop in the first year is significantly better than the

    farmer’s crop in the second year. Facilitate a brief discussion

    on the multiple factors that influenced a change in the farmer’s

    crop from one year to the next.

    Farmer’s Crop the First Year

    Farmer’s Crop the Second Year

Tell the participants that as in tilling, planting, cultivating, and

    harvesting crops, a multitude of factors determines the health of

    an HIV-infected person and whether individuals will transmit or

    acquire HIV.

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