Stressors and Coping Strategies for HIV-Test Counselors Giving Rapid HIV-Test Results: An Exploratory Qualitative Study

Abstract

Stress has been extensively researched in the HIV services field. Yet, research regarding stress related to HIV-test counseling has solely focused on stressors related to giving results, even though stress on the HIV test counselor can occur at many points within a counseling session. This exploratory, qualitative study examines the stressors faced and coping mechanisms utilized by HIV-test counselors at AIDS service organizations (ASOs) during rapid HIV-test counseling sessions. Forty-two HIV test counselors were interviewed regarding HIV-test counseling sessions in which they provided preliminary-positive/reactive, negative/nonreactive, and invalid results. Regardless of the test result, HIV test counselors faced stressors, including giving HIV test results; dealing with emotions; difficult clients; self-doubt; and systemic stressors. Most stress was managed through social support, preparatory coping strategies, respite, and putting things into perspective. Despite the exploratory nature of the study, the findings suggest that strengthening support bases and improving current training standards will increase the well-being of HIV test counselors.

Introduction

I ndividuals in the HIV-services field endure high levels of stress.^1

–4 Employees of AIDS service organizations (ASOs) face a dual threat of stressors⁵: social work-related stressors (e.g., heavy workload, poor pay, unpleasant working environment, and bureaucratic restrictions)⁶ and AIDS stigma-related stressors (including fear of contagion).^4,7
–9 Stressors related to working in the HIV-services field have changed during the epidemic.¹⁰ In the 1980s, burnout occurred as staff witnessed their clients dying¹¹; improved medication improved the health of HIV-positive individuals but created larger patient loads.

Although the stressors related to HIV services have been extensively researched, there is a lack of research related to HIV testing. Myers et al.¹² found that giving a positive result was traumatic and stressful for HIV test counselors. Recommended guidelines exist to help medical practitioners prepare for and communicate bad news,^13

–16 yet many individuals have still expressed stress.^13,17

Stressors may also arise at many points within an HIV test counseling session (e.g., a first-time tester who knows little about HIV, a client who is crying because of fear of a positive test result). In addition, at many ASOs, an HIV test counselor is usually a volunteer or staff person who holds other responsibilities. These individuals, although trained to HIV test counsel, may not have the advantage of a related educational background or hold a higher degree in clinical psychology/therapy as those in previous samples exploring burnout. For example, Myers et al.¹² included 9 physicians in their sample of 25 HIV-test counselors. In Shinn et al.,¹⁸ 50% of the sample had master's degrees and 40% had doctorates. Studies with individuals of higher education levels may not result in support recommendations relevant to individuals of differing education levels. The HIV test counselor/client dyad may differ from the typical doctor/patient dyad. Doctors usually have multiple contacts with a client, and upon giving bad news, can continue to provide support for the rest of their working relationship.^16,19 HIV test counselors may have only one to two sessions with a client and then refer clients to other resources.

This study is exploratory in nature and examines the stressors experienced and coping strategies utilized by HIV test counselors during an HIV test counseling session, including when giving the three possible types of rapid HIV test results: (1) preliminary-positive/reactive; (2) negative/nonreactive; and (3) invalid. Understanding the experiences of HIV-test counselors will assist ASOs in improving staff well-being.

Methods

Participant eligibility and recruitment

Eligible participants were past and current HIV test counselors with a minimum 6 months of HIV test counseling experience who currently work/volunteer as HIV test counselors or previously worked/volunteered as HIV test counselors for at least 6 months between 2006 and 2009. Participants were recruited from five urban Midwest ASOs that offer HIV test counseling. Three sites were community-based organizations, two of which catered to minority communities. One site was located in a university setting. One site was a department of public health.

Participants were recruited via e-mail and at HIV-related community meetings. A total of 43 eligible HIV test counselors expressed interest in participating. Research staff interviewed participants face-to-face at a location convenient for the participant. One participant was interviewed by phone. One HIV test counselor opted out of the study prior to the interview, leaving 42 participants. The length of the audio-recorded interviews ranged from 23 to 82 min (mean, 44 min).

Data collection

The principal investigator (PI) served as the interviewer. After a consent process, participants were asked to talk about their general experiences as HIV test counselors and their methods of delivering HIV test results. Questions were modified from the Myers et al.¹² interview protocol to also apply to negative/nonreactive and invalid results. Next, participants were asked to recall two HIV-test counseling sessions of their choice: one with a preliminary-positive/reactive result and the other with a negative/nonreactive result. Questions pertaining to each HIV-test counseling session originated from Dervin's Sense-Making Methodology.²⁰ Questions focused on questions/confusions, ideas/thoughts, feelings/emotions, past experiences, sense of self, and helps and hindrances that participants encountered during HIV-test counseling: (1) the precounseling session, including the client's risk assessment and personalized risk reduction plan; (2) postcounseling (learning and sharing results with the client); and (3) the time period after the client left the HIV test counseling session. These questions sought to elicit feedback from participants that directly captured specific factors that they found contributed to HIV test counseling-related stress and coping.

Interviews were audio-recorded and transcribed with participant consent. Eight participants asked for their interviews to not be audio-recorded; instead, extensive field notes were taken. In order to protect confidentiality, participants' names and identifying information were excluded from written transcripts and edited out of all materials.

Data analysis

Research staff utilized an interpretive qualitative coding method based on and modified from grounded theory.²¹ The team discussed perceived themes from the interviews that would inform the coding scheme. Analysis proceeded with a line-by-line analysis of six randomly chosen transcripts. Discussion among the research staff continued as transcript analysis and coding ensued, with counts for each stressor and coping theme tabulated.

Results

Table 1 displays participants' demographic characteristics. In total, 62 HIV-test counseling sessions were recalled (26 with preliminary positive/reactive results, and 36 with negative/nonreactive results). A number of participants chose not to share specific HIV-test counseling sessions primarily because they either could not think of one specific situation that was most stressful, or preferred to keep specifics of HIV-test counseling sessions confidential in general. Table 2 displays the demographic characteristics of the clients. The diversity of the clients was similar to that of the HIV test counselors, although the majority of HIV test counselors were female (61.9%) and the majority of clients were male (75.8%).

Table 1.

Demographic Characteristics of HIV Test Counselors

Demographic	Category	n	%
Gender	Male	16	38.1%
	Female	26	61.9%
Race	White/Caucasian	22	52.4%
	Black/African American	10	23.8%
	Hispanic/Latino	3	7.1%
	Asian/Pacific Islander	3	7.1%
	Middle Eastern	4	9.5%
Age	20–24	12	28.6%
	25–29	11	26.2%
	30–39	10	23.8%
	40–49	6	14.3%
	≥50	3	7.1%
Education	High School Diploma	4	9.5%
	Some college	12	28.6%
	Bachelor's degree	20	47.6%
	Master's degree	5	11.9%
	Doctorate degree	1	2.4%
Current HIV test counselor?	Yes	33	78.6%
	No	9	21.4%
Type of staff	Paid staff	20	47.6%
	Volunteer	22	52.4%
Duration as HIV-test counselor	6 months–1 year	7	16.7%
	1–2 years	13	31.0%
	2–5 years	11	26.2%
	5–10 years	5	11.9%
	10–20 years	2	4.8%
	>20 years	1	2.4%
	Missing	3	7.1%
# Preliminary-positive/reactive HIV test results given	0	13	31.0%
	1–9	17	40.5%
	10–19	6	14.3%
	≥20	4	9.5%
	Missing	2	4.8%
# Invalid HIV test results given	0 1	35 5	83.3% 11.9%
	2	1	2.4%
	Missing	1	2.4%

Table 2.

Demographic Characteristics of Clients in Scenarios Recalled by HIV Test Counselors

		Preliminary-positive/reactive (n=26)		Negative/nonreactive (n=36)		Total (n=62)
Demographic	Category	n	%	n	%	n	%
Gender	Male	21	80.8%	26	72.2%	47	75.8%
	Female	5	19.2%	10	27.8%	15	24.2%
Race	White/Caucasian	15	57.7%	21	58.3%	36	58.1%
	Black/African American	9	34.6%	10	27.8%	19	30.6%
	Hispanic/Latino	2	7.7%	3	8.3%	5	8.1%
	Asian/Pacific Islander	0	0.0%	1	2.8%	1	1.6%
	Middle Eastern	0	0.0%	1	2.8%	1	1.6%
Age	≤19	2	7.7%	8	22.2%	10	16.1%
	20–24	5	19.2%	9	25.0%	14	22.6%
	25–29	4	15.4%	8	22.2%	12	19.4%
	30–39	7	26.9%	7	19.4%	14	22.6%
	40–49	5	19.2%	3	8.3%	8	12.9%
	≥50	3	11.5%	1	2.8%	4	6.5%

The primary research question sought to understand the stressors and coping strategies of HIV-test counselors per HIV-test result type (Tables 3 and 4). Little variability was found based upon HIV test result. Stressors and coping strategies, as well as any variability by HIV test result, will be discussed in the proceeding section. When the voice of the participant (P) describes and highlights themes, he/she will only be identified by participant number and gender (M, F) to maintain anonymity (e.g., P04, F).

Table 3.

HIV Test Result-Specific Stressors Encountered by HIV Test Counselors

		Type of HIV test result ^a			HIV test counseling time period ^b
Theme	Subtheme	PP	N	I	PTC	GTR
Giving HIV test results	Giving HIV test results	X	X			X
	Helping clients interpret results	X	X	X		X
Dealing with emotions	Dealing with own emotions	X	X		X	X
	Dealing with client emotions	X	X	X	X	X
Difficult clients^c	Clients' lack of interest in precounseling education				X
	High-risk clients unwilling to change risk behaviors				X
Self-doubt^c					X
Systemic stressors^c	Lack of privacy in certain HIV test outreach settings				X	X
	Lack of perceived professional support^d
	Lack of comprehensive education				X

PP, Preliminary-positive/reactive; N, negative/nonreactive; I, invalid/Indeterminate.

PTC, Pretest counseling; GTR, giving HIV test result.

Theme does not specifically relate to specific HIV test results.

Subtheme does not relate to specific HIV test counseling time periods.

Table 4.

Coping Strategies Utilized by HIV-Test Counselors, Plus Structural Recommendations

		Folkman and Lazarus (1980) coping strategy
Topic	Theme	Problem-focused	Emotion-focused
Coping strategies	Social support		X
	Preparatory coping strategies	X	X
	Respite		X
	Putting things into perspective		X
Structural recommendations	Emphasize open communication among HIV test counselors	X
	Regularly scheduled debriefing sessions with which HIV test counselors can speak formally with coworkers/supervisors	X
	Establish guidelines and reference guides that assist supervisors in directing HIV test counselors through HIV test counseling	X
	Continue training that highlights and clarifies HIV test counselor's role in network of HIV prevention and care	X

Stressors

The interviews with HIV-test counselors revealed a variety of stressors that participants experienced associated with the HIV-test counseling experience. The major themes identified were stressors associated with giving HIV-test results, dealing with emotions, difficult clients, self-doubt, and systemic stressors.

Giving HIV test results.

All participants identified aspects of giving results as stressful (n=42). Often, participants recounted giving results that had not been anticipated (n=12). An HIV test counselor (P10) described an incident in which a client that she was expecting to receive a negative result received a preliminary-positive result, thereby affecting the way she prepared subsequent clients: “I make sure that I make the person really prepared if it [comes] back positive.” A male HIV test counselor (P35) also reported that he “was not expecting an HIV positive result” when testing a 15-year-old boy. The HIV test counselor expressed feelings of frustration and sadness due to the client's lack of knowledge regarding HIV. Participants also expressed that they felt unsure how to impact a client's risky sexual behavior when they were expecting a preliminary-positive result and received a negative result: “I was 100% positive that he was gonna test positive. I had no doubt in my mind.” (P21, M).

Helping clients interpret results, whether preliminary-positive, negative, or invalid, was also experienced as a stressor for some participants (n=11). When an HIV test counselor gave a preliminary-positive result and received what she felt was a strange reaction, she assumed that the client did not understand: “It shocked me that she didn't react at all. It made me think that she didn't understand. The fact that she just looked at me blankly and said ‘okay’ made me think that she really didn't get it.” (P01, F). One participant described how some people that test negative remain concerned: “A lot of times, those people don't trust the test. So they ask you question after question about the test. What's the accuracy of the test?” (P20, M). Many participants reported needing to explain the window period to clients receiving a negative result (n=8). One participant described that it was difficult to tell clients their negative results while reinforcing the need to come back to get tested again: “I try to educate them about the limitations of the testing…Depending on when their last exposure was that they need to come in and see us again. So I harp on them on that.” (P07, F). Though there were few participants that had given invalid results (n=7), it was common for them to feel stressed when delivering these results. One participant described, “This was the hardest set of results to give. I would always try to go back to ‘we just have to do the test again…I'm so sorry for the inconvenience.” (P12, M)

Dealing with emotions.

One of the most salient themes across all the interviews, and regardless of the result given, involved the HIV-test counselor dealing with their own emotions and the emotionality of the client (n=40). When participants described having the most trouble processing their own emotions, it was often related to a particular client with whom they identified (n=18). One participant described how one client who tested negative, but positive for another STI, reminded her of her own son. She described being frustrated at his lack of knowledge and was moved to go home and talk to her own children about risky sexual behavior: “My mother instinct kicked in and I wanted to lecture versus counsel. I had to put the brakes on.” (P29, F). Another participant described the flood of emotions he experienced when testing a close friend who received a preliminary-positive result: “It was hard to control. It was pain. It was confusion. It was anger…it was the ‘why’ question. Um, it was…not understanding…All that stuff kinda combined.” (P13, M). It was not uncommon for HIV test counselors who had similar experiences to describe being emotionally and physiologically exhausted afterward.

HIV-test counselors repeatedly expressed feelings of needing to “be strong” and not letting their emotions get the best of them, because “test counseling is about managing your discomfort.” (P14, F). One participant (P29, F) described how her emotions sometimes became problematic for her: “How helpful was I to him if he saw me tearing up. I couldn't help it. [I needed to] not be that emotionally involved. [I needed] to be more objective and stronger.” Another recalled, “I shoulda held it together more than I did.” (P31, F). One counselor described, “I really feel like the worst thing you could do is walk into a client's counseling session and start crying or showing something. That's horrible.” (P03, F).

Dealing with the client's emotionality was also difficult for some participants. One HIV test counselor described a male client with three partners, a wife, and children: “He was so remorseful. He broke down, cried. He was a basket case. He was scared for his wife and kids. I felt remorseful, but at the same time I was like, you jerk! But I just gotta stay composed.” (P23, F). Another HIV test counselor recalled feeling that she had said something wrong when a client broke down and started crying: “I didn't know that person was harboring those emotions and it kinda knocks you off a bit.” (P39, F). In some cases when clients receive negative results, they were extremely anxious and then so relieved that they cried: “The client broke down big time. He was just so relieved. If I were a friend, I would have wanted to hug or pat [him] on the back.” (P25, M). HIV test counselors also noted that clients receiving invalid results expressed panic: “[She] freaked out…[she] thought [she] had [HIV].” (P9, F).

Difficult clients.

Participants expressed that dealing with difficult clients, such as those who did not express interest in the test counseling session, that conveyed a lack of knowledge regarding risky sexual behavior or repeatedly tested and displayed non-adherence behaviors, was often frustrating and affected how they thought about themselves as an HIV test counselor (n=29). HIV-test counselors face clients who are only interested in the result and not the pre-counseling session (n=11). One participant cleverly described how she felt confused and even helpless on how to support a client because of the client's lack of affect: “I mean there was just like (flat line noise). I mean, ‘can you give me any emotion here’ (makes knocking noises on table)? I mean, I think he was scared, even though he didn't say so.” (P04, F). Feeling pressure to educate people who have no understanding of HIV and the implications of risky sexual behavior can feel daunting: “Well it's not pretty, but to be perfectly honest, I was frustrated because she didn't know anything. And I know I had a huge responsibility to educate her on a lot of things before she got out of there.” (P01, F).

Trying to reach certain clients and encourage them to modify their risky behaviors was a point of frustration for some HIV test counselors (n=14). For example, one of the counselors described being frustrated and even angry with a client she knew personally, who engaged in risky behaviors repeatedly: “I wished I could have him get it and take on being safer. I wanted to scream at him.” (P04, F). Another participant powerfully described her experience dealing with clients who do not adhere to a risk reduction plan:

Sometimes I tell people, “You're [HIV-]negative now and if you don't change your ways,” especially if they made a piss poor risk reduction plan, “then it's not gonna be that way next time.” Sometimes it hurts me, because I feel like it's a matter of time for some people who don't quite get it. (P36, F)

Another described how a client's denial and resistance in accepting that he was engaging in high-risk behaviors made it difficult to reach him: “How do I get him to understand…that what he was doing is really, truly, risky?” (P09, F). Another participant described a session with a client that made her feel uncomfortable and unsure about herself: “She didn't want to answer any of the questions…She was very condescending towards me…and uncooperative…so I offered her the chance to leave, but she didn't want to leave either…I was frustrated and irritated.” (P11, F).

Self-doubt.

The preceding quote illuminates a rather abstract theme related to the HIV test counselor questioning their self or their capability as an HIV-test counselor (n=19). This theme was found across interviews in various explicit and implicit forms usually after the HIV test counselor experienced a test session where they became emotional, felt like they could not reach the client regarding their risky behavior, or felt that they did not do a good job with a certain client. For example: “I was definitely questioning some of my own self worth, and I was questioning whether or not I've been the best test counselor for this individual…My self-worth plummeted right after.” (P12, M). Another participant stated, “I doubted how I did and I also thought, maybe I shouldn't be doing this.” (P02, F). One participant described that she was very hard on herself after a difficult session and recalled thinking, “I suck.” (P14, F).

Systemic stressors.

In addition to the previous themes identified as stressors, participants also described circumstances not related specifically to the individual HIV-test counselor or client that sometimes resulted in heightened anxiety for them (n=10). For instance, in some testing situations (e.g., an off-site event) there was little privacy or ability to process difficult sessions with colleagues. One participant said, “I wanted to go over it with somebody, but the situation didn't really allow for that. It wasn't a private situation. We were all in one very big open room and the test counseling was in a separate room.” (P19, F). Another participant described testing at an outreach event and feeling rushed, “I had to do like three more tests immediately after so I didn't have a lot of time to process it.” (P33, F). Similarly, a participant expressed exasperatedly, “Oh, another client!” (P06, F) when doing outreach testing.

In addition, a lack of perceived professional support, such as an available therapist and/or appropriate, comprehensive training, was identified as a source of stress (n=5). One participant complained, “I was always told about sessions with the therapist that [the local ASO] would bring in. I went to one, but a lot of times it felt like other people monopolized the group time.” (P25, M). Two participants described that they did not feel prepared to deal with clients who had unique situations, such as IV drug users or victims of sexual assault (P33, F; P13, M). These participants' experiences highlight the need for organizations to assist in providing HIV-test counselors with resources to aid in coping with multiple stressors.

Coping strategies

The interviews with HIV test counselors revealed a variety of coping strategies participants used to deal with the stressors associated with the HIV test counseling experience. The major themes identified were: social support; preparatory coping strategies; respite; and putting things into perspective.

Social support.

Participants listed coworkers, close friends, and family members as their primary sources of social support to cope with the stresses of being an HIV-test counselor. All participants enthusiastically identified using coworkers as a positive social support for a variety of purposes (e.g., to process sessions, answer questions, vent). Having a supportive supervisor or testing coordinator was often identified as a positive (n=14): “[the HIV-testing coordinator] actually came in with me to help me out because I never had [a preliminary-positive result] before.” (P21, M). Another participant described that it was helpful “knowing that there's the support from other counselors, [the HIV-testing coordinator] and the administration.” (P33, F). Similarly, another participant expressed, “I feel great support here, when I had to give a positive, especially my first one. Everyone was so good about it.” (P03, F).

Many HIV-test counselors processed difficult sessions with colleagues:

I just think it's always helpful to have somebody else nearby…just knowing that there is somebody that I can check with and make sure there's nothing else I should be doing or getting some advice or whatever. (P28, F)

Another HIV-test counselor described, “It was good to just be able to bounce feelings and stuff immediately afterwards.” (P16, M). One participant expressively described how collegial support enabled her to cope after a difficult session: “I was much more calm because in the interim I talked with other counselors and started venting so it was easier to deal with.” (P11, F).

While communicating with family and friends was identified as a positive coping strategy for some HIV-test counselors (n=12), others described how they were not a useful source of support (n=8). One participant described that he had received some insensitive remarks from his friends and family regarding dealing with job related stress: “Unless people have done it, they can't understand it. So it wasn't very effective to share it with people outside unless it was somebody who had gone through it themselves.” (P12, M). Another participant described not wanting to burden his family and friends with his feelings related to the job:

I try to not involve them because…it's like trying to leave that safe place, because [this work] can be stressful. If you carry that to your family and friends, then you're putting that [stress] in every day of your life. (P34, M).

Preparatory coping strategies.

HIV test counselors often prepared themselves in various ways in order to feel equipped to deal with anticipated stress (n=32). That is, they used strategies such as relying on the test counseling protocol, their knowledge of HIV and risk reduction techniques, anticipating a preliminary-positive result, and their experience as a preparatory coping strategy. Many participants described following the protocol when giving a result (n=18): “I just go to the policies and procedures of how we're supposed to give a result from standard policy.” (P14, F). Most HIV-test counselors believed that the protocol helped them by giving them structure, or a “road map” (P27, F), to follow, and serving as a guide if they were stuck. Another participant described “having the education on the disease” (P20, M) while others described that experience helped them feel more prepared for what the testing experience might bring (n=17): “Experience helps. The more tests you give, the more comfortable you're gonna be.” (P16, M). Similarly, a male participant conveyed how being more comfortable does not mean that one becomes incapable of feeling empathy for the client: “Lack of experience leads to one feeling unsure. The more you test, the more comfortable you become with testing, and not that I become desensitized to what the person may be feeling.” (P35, M).

Another preparatory strategy used by some HIV-test counselors involved thinking that each session could result in a preliminary-positive result (n=14). This was used in order to avoid the potential shock of the client testing preliminary-positive when the counselor had expected them to test negative: “Like it could be positive. I make sure to be prepared for either way. (P10, F). Another participant described, “Just thinking that this could be a positive. And sort of preparing myself for what am I going to say, I guess.” (P28, F).

Respite.

Another common coping strategy used by participants was taking some type of a recess from the emotional stress of the work (n=20). For example, participants described needing to take a break after difficult sessions to process with colleagues or to go somewhere to clear their mind. Sometimes participants experienced such a degree of stress that they had to leave for the day or take subsequent days off from work:

I had a migraine for days. It would not go away. I didn't want to deal with it. I didn't want to talk about it. I didn't want to acknowledge it…I stopped testing because I couldn't do it anymore. I took a mental health day Friday. (P13, M).

Another participant described, “I went outside to smoke a cigarette and cried, which I wouldn't qualify as a bad thing. And then I went back inside and started testing again.” (P3, F).

Participants also reported using other ways of detaching from their work in order to process difficult experiences from testing: “I remember I went and just like vented in my journal (laughs)…I'm more of an internal processor so the journal works a lot better [than talking to coworkers].” (P27, F). Another described, “I get my mind off it by running around, playing basketball, working out, playing games with my friends, watching TV with my friends. Just doing something active or social that takes my mind off of it.” (P39, M).

Putting things into perspective.

Participants described coping strategies that involved self-talk regarding maintaining the professional boundaries associated with the role of HIV-test counseling that are often hard to uphold when becoming emotionally invested in particular clients (n=27). One participant described how she has learned not to take the job home with her: “I've learned to accept what I need to accept and let go of what I don't need to hold on to…Don't take the job [home].” (P14, F).

Another HIV test counselor in the study articulated:

You know, I just have to let it go…it's definitely not about me. It's not about what I do or didn't do. And it's not about, did I convince him or did I not convince him?…I did my job and he'll take whatever actions he takes. (P4, F).

Understanding that the HIV test counseling role is a limited one seems to be an important message to understand in order to aid in coping. One participant summarized this idea very well:

There's only so much you can do for a person. And you've done the first steps. Your job was to let them know that they were positive and what they need to do next. You're not a doctor. You're not a case manager. You're not a mental health counselor. You gotta put that in perspective. (P15, M).

Discussion

Our results build upon past findings (e.g., Myers et al.¹²) that giving HIV test results impacts HIV test counselors and that they do have strategies for managing the stressors that accompany this work. This study is the first to examine the impact of giving a variety of test results and to identify factors that contribute to stress throughout the entire HIV test counseling session. However, given its exploratory nature, this study's conclusions should not be perceived as definitive. Nevertheless, the contributions of this study could be important in developing strategies to help HIV test counselors cope with stressors related to HIV test counseling.

It was expected that stressors would vary on the basis of the HIV-test result given (i.e., preliminary-positive/reactive, negative/nonreactive, invalid); however, we found many stressors that HIV test counselors experience are not limited to specific test results. Stressors, such as incorrectly anticipating HIV test results, helping clients interpret HIV-test results, and dealing with one's own emotions were common. Other stressors, such as difficult clients and self-doubt, could occur before HIV test results were given. ASOs need to understand that at any point within an HIV test session, regardless of the HIV test result, HIV test counselors may face stressors. However, it should be noted that with 31% of participants having not given a preliminary-positive/reactive result, it is possible that such a conclusion cannot be extrapolated.

The HIV test counselors in this study described a variety of coping strategies that were helpful: social support; preparatory coping strategies; respite; and putting things into perspective. In comparison to existing literature, Myers et al.¹² found coping strategies to include: seeking social support from colleagues and peers; setting emotional boundaries to maintain professionalism and composure; the use of alcohol/snack food; and black humor to alleviate the tension of giving a positive-test result. Thus, both similarities and differences in coping strategies were found across these two samples. Participants in this study emphasized social support and also used preparatory coping strategies and practiced keeping things in perspective which served to help maintain professionalism and composure. No participants mentioned the use of alcohol/snack food; but, participants' engagement in respite activities, such as hobbies and other self-care seemed to serve the similar purpose of helping them detach from the testing session(s). The use of black humor was not identified as a coping strategy, perhaps due to the sample of participants being reluctant to share this with the interviewer or sample differences; given that Myers and colleagues'¹² sample included a large number of physicians who may have different coping strategies and resources for coping than the current sample.

The coping strategies identified by participants were found to fall into two categories, seen in previous research.^22,23 Emotion-focused strategies, such as social support, respite, and putting things into perspective controlled the emotional responses related to HIV test counseling. Problem-focused strategies, such as relying upon protocol, managed and/or altered the circumstances related to HIV test counseling. Our sample of HIV test counselors seemed to rely more heavily on emotion-focused strategies. Problem-focused strategies were lacking. Due to the lack of problem-focused strategies, we recommend a number of additional structural strategies to minimize stress, maximize coping, and reduce the possibility of burnout (Table 4).

Past studies have emphasized the imperative need for social and structural support in the HIV services field.¹² The HIV test counselors relied on coworkers to provide social support that helped to minimize stress. They also noted structural support from ASOs, such as having open communication with supervisors. HIV test counselors need opportunities to formally speak with co-workers and supervisors as a form of decompressing. For example, regularly-scheduled debriefing sessions would allow HIV test counselors to discuss their successes, concerns, and needs. Debriefing sessions have been found effective in preventing compassion fatigue in health care,^24,25 crisis-support,²⁶ and research settings.²⁷ Reducing work-related emotional exhaustion and providing positive feedback can help to reduce potential burnout.²⁸

Structural support also needs to focus upon the lack of preparedness that many HIV test counselors express. Myers et al.¹² note that health care providers should be prepared for a range of interactions when communicating with clients rather than following a standardized protocol. However, HIV test counselors in our sample confided that a sense of structure helped them to manage their stress and many expressed that the knowledge of a certain structure integrated into HIV testing protocol was beneficial. The support of supervisors to walk them through the guidelines was identified as useful. A number of HIV test counselors also noted that using paperwork to collect client information enabled them to stay focused on client needs. A number of HIV test counselors voiced their nervousness when they experienced new situations, such as HIV test counseling scenarios not adequately covered in previous training. In particular, despite training and shadowing opportunities, HIV test counselors expressed concern regarding their confidence in providing their first preliminary-positive test result to a client alone. Organizations offering HIV testing should facilitate open communication between HIV test counselors and supervisors so that HIV test counselors never feel unsupported during any part of the HIV test counseling process. In addition, we recommend having established guidelines that supervisors can utilize to help HIV test counselors during an HIV test counseling session. For example, a reference guide could include step-by-step instructions regarding handling specific situations (e.g., giving an invalid test result, referring clients that are victims of sexual assault to appropriate resources). Increasing an HIV test counselors' feeling of competence in their work can help to reduce potential burnout.²⁸

The amount of personal investment that many HIV test counselors put into their work is significant. Many noted their attachment to clients through their hopes that clients would follow through with referrals, seek treatment and support, etc. Such feelings seemed to lead some HIV test counselors to doubt their ability to do enough for the client, or even if they were apt to HIV test counsel. Those HIV test counselors that managed their self-doubt did so by acknowledging that: (1) they were one part of a much bigger system; (2) they helped the client to the best of their capabilities; and (3) the session was a learning experience that would enable them to better serve future clients. We recommend that future training and debriefing sessions emphasize these three valuable points as a method of reassuring HIV test counselors of their capabilities. Increasing an HIV test counselor's feeling of successful achievement in one's work can help to reduce potential burnout.²⁸

Although the findings yield interesting results, the study has several limitations. Our methodology utilized questions to specifically explore HIV -test counselors' stressors and coping strategies. The participants were asked to focus on individual test counseling situations rather than quantify the stressors that they routinely experienced, and the coping strategies that worked the best in most situations. Nevertheless, our methodology sought a full understanding of situations that participants found to be most stressful in order to find the coping strategies that would be most helpful. Although our recommendations aim to help minimize stressors and in turn, minimize the possibility of HIV test counseling-related burnout, burnout was not directly captured. Also, the sample may not represent the experience of HIV test counselors situated in different settings and the data is dependent on participant recall during the interview process. Future research can seek to explore both the breadth and depth of stressors and coping mechanisms related to rapid HIV test counseling.

Characteristics of HIV test counselors may also influence how they manage stress. For example, neuroticism has been linked to burnout in the HIV services field.²⁹ Future research should incorporate HIV test counselor characteristics to better understand how HIV test counseling affects individual differences in stress and coping. In addition, research utilizing numeric scales will help to quantify and determine the most influential stress and coping strategies. Although little variability was found in stressors and coping strategies by HIV test result, future research may benefit ASOs with low positivity rates (i.e., number of preliminary-positive results/number of HIV tests) by specifically examining negative results. Future research should also target HIV test counselors who have given invalid test results.

Interventions to prevent burnout in the HIV services field are lacking.^5,30 With heavier caseloads of HIV-positive people and the CDC's call for more HIV-testing targeted toward high-risk individuals,³¹ the potential for burnout has increased. Translational research that is focused on increasing social and structural support show promise in reducing and preventing burnout in HIV test counselors.

Footnotes

Acknowledgments

The authors would like to thank Tania Slack and Peggy Anderson of the Columbus AIDS Task Force, Linda Laroche of Columbus Public Health, and Iris Velasco of the Columbus Urban League for their time and thoughtfulness in discussing issues that helped develop the content of this article. The authors would also like to thank Emily Corturillo and Kayden Healy for their assistance in data analysis. Last, the authors would like to thank the HIV test counselors who agreed to participate in this study and share their experiences.

Author Disclosure Statement

No competing financial interests exist.

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