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Unraveling Counseling Practices in HIV Prevention Targeted Intervention in India

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Unraveling Counseling Practices in HIV Prevention Targeted Intervention in India Unraveling Counseling Practices in HIV Prevention Targeted Intervention in India Apurvakumar Pandya ( [email protected] ) Indian Institute of Public Health Gandhinagar https://orcid.org/0000-0003-0178-3978 Shagufa Kapadia Maharaja Sayajirao University of Baroda Research Article Keywords: Counselors, counseling, HIV prevention, targeted intervention, culture, constructivist grounded theory, India Posted Date: July 13th, 2021 DOI: https://doi.org/10.21203/rs.3.rs-664012/v1 License: This work is licensed under a Creative Commons Attribution 4.0 International License. Read Full License Page 1/14 Abstract Counseling is an essential strategy for preventing sexually transmitted infections, including human immunodeciency virus (HIV). However, research on counseling practices in targeted HIV prevention interventions is limited. We conducted a grounded theory study to develop a theoretical model explaining HIV counseling practices within Targeted Interventions (TI) in Gujarat. Using constructivist grounded theory methodology, we conducted in-depth interviews of 14 counselors and observed counseling sessions of ve counselors. Data were analyzed using a constant-comparative method, performing four levels of coding: open, axial, focused, and theoretical. Our theoretical model illustrates key culture- specic features in HIV counseling and how counselors facilitate the counseling process in the local cultural context and programatic environment. Present study reveals the values and practices reective of the Indian culture that inform the counseling process and yield behavior change in clients. In the end, authors highlight challenges and recommendations for HIV counselors. Introduction Counseling plays an essential role in mitigating the spread and management of HIV/AIDS. The National AIDS Control Organization (NACO)’s National AIDS Control Programme (NACP) has counseling as one of the key strategies for preventing and controlling HIV in India. NACP has adapted counseling for prevention in HIV Testing Centres, known as Integrated Counselling and Testing Centres across district hospitals in India, and Targeted Interventions with most at-risk populations, care, and treatment services like Anti-retroviral Centres and Associations of People living with HIV across all states (NACO, 2019). The NACO supports approximately 1443 targeted interventions in India to prevent and control HIV with the most-at-risk population (MARP) such as Female Sex Workers (FSW), Men who have Sex with Men (MSM), Injecting Drug Users (IDUs), Truckers, and migrant workers (NACO, 2019). Essential services under TIs include reaching out to the most-at-risk populations, referral service to STI clinics, HIV test centres and anti-retroviral therapy (ART) centres, condom demonstration and distribution, counseling, distribution of materials related to information, education, and communication (IEC), and behavior change communication (BCC). Counseling in TI focuses on bringing change in risky behaviors MARP by adopting preventing alternatives. In India, these TIs are implemented through civil service organizations and community-based organizations. With more than two decades of experience of HIV prevention, critical insights into the need for behavior change have focused on strengthening counseling to reduce HIV prevalence among the MARP. The NACO has introduced an HIV counseling module for counselors working with TIs and integrated HIV testing and counseling centre (ICTC), anti-retroviral treatment centre (ART) in 2011. Saksham Program implemented by Tata Institute of Social Sciences (TISS) has developed resources for ICTC counselors and trained ICTC counselors in the country. At the same time, Saksham Program, in collaboration with UNODC, designed a counseling module for injecting drug users. Page 2/14 Studies have shown the importance of counseling as a preventive mechanism to reduce Sexually Transmitted Infections, including HIV (Kumar & Parashar, 2012; Miranda & Barroso, 2007). However, research on counseling practices in targeted interventions, both in Indian and international contexts, is scarce. In India, most researches are primarily conducted in hospital settings to understand counseling in the context of pre and post HIV test, treatment of STIs and adherence to ART (Agarwal et al., 2019; Duggal et al., 2018; Kanekar, 2011; Pendyala & Lewis, 2020). Research on the effectiveness of HIV counseling and behavioral interventions in the hospital setting (voluntary counseling and testing centers-VCTCs, prevention of parents to child transmission centers- PPTCTs, STI clinics, and ART centers) has been largely conducted in the Western and African countries (Grinstead & Van der Straten, 2000; Liechty, 2005; Solomon, 2002). Various behavior change models (such as Becker’s (1974) Health Belief Model, Fishbein and Ajzen’s (1975) Theory of Reasoned Action, AIDS Risk Reduction Model by Catania, Kegeles and Coates (1990), and Trans-Theoretical Model (Prochaska & DiClemente, 1982) and counseling approaches such as Rogers’s (1951) person-centered counseling, Hogmann’s (2011) cognitive behavior theory have been applied to HIV prevention. These models and theories have been replicated in developing countries without rigorous attention to cultural appropriateness in counseling (Kalichman, 2007; Solomon, 2002). In the absence of empirical research on HIV counseling practices in TI, examining HIV counselling practices is crucial in generating a theoretical framework of culturally grounded counseling and understanding counseling practices in the Indian cultural context. Methodology The present research adopted a qualitative design guided by Charmaz ’s (2006) constructivist grounded theory. A constructivist grounded theory is evolved from systematic data collection, researchers’ interactions with the eld, participants, and carefully applying data analysis techniques. Using theoretical sampling, 14 counselors were interviewed. The sample represented six geographical locations of the Gujarat State, namely, Vadodara, Anand, Mehsana, Surat, Bhavnagar, and Rajkot, four typologies of TIs such as Core TIs (exclusively working with MSM, FSW or IDU population) and Core Composite TI s (TIs that are working MSM and FSW TI) and diverse educational backgrounds (high-school educated, graduates, psychology post-graduates and post-graduates in other elds). Table 1 presents demographic details. The data collection process was facilitated by data collection protocols, which were pilot tested before its use. During the entire data collection process, eld observations were done and recorded as per the data collection protocol. Data collection involved an iterative process. Out of 14, 5 counselors representing four typologies of TI, ve geographical locations, and pragmatic counseling approach were purposively selected for participant observations of the counseling sessions. Data collection was continued until theoretical themes were saturated. Each interview and participant observation of the counseling session was analyzed before conducting another. As a result, the Page 3/14 researcher introduced new elements into the subsequent data collection phase, which were 'grounded' in the information collected before. Data (audio and text) were transcribed, translated, and coded as collected. Based on Charmaz’s (2006) coding framework, the data were coded, and categories were developed. The data were re-coded by two external coders, and codes were compared. Based on the comparison of external coders’ coding with the researcher’s coding, the coding scheme of the research was revised. Preliminary data analysis of each interview and participant observation was shared with each participant to get their feedback on codes and analysis. Their feedback was incorporated, and individual analysis was transported into cross-case analysis using the triangulation method. Using a constant comparison method, categories were compared to nd similarities and differences in meanings to develop conceptual and contextual categories. Based on these categories, theoretical frameworks were developed. Preliminary ndings of the study were again shared with participants to seek their feedback and ensure that the theoretical frameworks that emerged from the research are grounded in the information they have shared. Results And Discussion The research evolved a framework of HIV counseling in the Indian cultural context. Figure 1 illustrates HIV counseling in an Indian cultural context. Counseling and sexual behavior in the Indian cultural context Culture, in general, is understood as a set of shared values, mentalities, and beliefs that characterize national, ethnic, moral, and other group behaviors (Craig & Douglas 2006; Faure & Sjostedt, 1993; Shweder, 2003; Valsiner, 2009). Review of research on Indian culture suggests that Indians are fundamentally interconnected and interdependent (Chaudhary, 2004), collectivist and individualistic (Sinha, Sinha, Verma, & Sinha, 2001), yet ‘dividuals’ (Marriott, 1990) and pragmatic (Chong & Liu, 2002; Kakar & Kakar, 2007). One primary cultural feature is that Indians have learned to “co-exist,” which has resulted in a cultural context that invites relationships to be shaped despite disagreements and an atmosphere lled with contradictions (Arulmani, 2009; Chaudhary, 2011). The second cultural feature is that Indians are fundamentally interconnected and interdependent (Chaudhary, 2004). This is relevant to sexual behaviors of most at-risk populations. Same-sex sexual activities, sex work, multiple
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