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HIV: Therapeutic Strategies for Guilt, Uncertainty, and Taking Control
HIV: Therapeutic Strategies for Guilt, Uncertainty, and Taking Control

Manual of Articles Sections 7 - 14
Section 7
Treating Multiple Bereavement in HIV Positive Gay Men

Question 7 | Test | Table of Contents | HIV/AIDS CEU Courses
Counselor CEUs, Psychologist CEs, Social Worker CEUs, MFT CEUs

Few attempts have been made to address how to assist clients who are grieving multiple AIDS-related deaths. However, a recent book by Nord (1997) has provided thoughtful guidelines for counselingGrief Sadness HIV Therapeutic Strategies counselor CEU individuals who have experienced multiple losses to AIDS. According to Nord (1997), grief responses vary widely, and how one copes with multiple loss will depend on a number of factors including one's level of social support, availability and use of resources, what one deems as supportive and unsupportive, and how one relates to others (Nord, 1997). In addition, it is important that individuals who have experienced multiple losses realize that the disaster is something that will not go away. If later losses are being submerged due to the grieving for an earlier important loss, gentle encouragement by the counselor to recognize and resolve additional losses might be necessary. It may even be useful to grieve the fact that there is so much to grieve.

Of the factors that affect coping with AIDS and AIDS-related loss, social support is an integral variable (Cherney & Verhey, 1996; Nord, 1997). Those who tend to isolate themselves from others will have a much more difficult time adjusting to the loss. Thus, individuals who are grieving multiple losses should be encouraged to seek support. There are many potential sources of support, including counseling and social support networks in the gay community. Clients may be unaware of these resources, and it is the counselor's role to be comfortable with the community resources and knowledgeable about how to access them. Counselors' levels of comfort raises another important issue. Counselors who work with gay clients experiencing AIDS-related losses must examine their own belief systems about gay men and HIV and ascertain whether they are working on the basis of misinformation; stereotypes about the sexuality of gay men, especially minority gay men (Nettles & Scott-Jones, 1989); or religious or moral beliefs (Holt, Houg, & Romano, 1999; House & Walker, 1993) that would be counterproductive to their work with clients (Croteau, Nero, & Prosser, 1993). Counselors must also prepare themselves to address themes of death and dying, topics that are often difficult for many counselors (Britton, Cimini, & Rak, 1999; Gutierrez & Perlstein, 1992).

Clients may also have to address their own internalized homoprejudice, homophobia, and beliefs about HIV and AIDS. HIV-related illnesses continue to bear a social stigma (Herek & Glunt, 1988; Holt et al., 1999) and clients, even those who have lost loved ones to the disease, may blame their friends for not being "careful enough" and then feel guilt over their anger. Clients who are HIV- may experience guilt over their own continued health (McKusick, 1988). It is important that counselors facilitate the client's acknowledgment of these emotions and assist the client in recognizing them as reasonable reactions to the situation so clients' emotional reactions do not undermine their own health-related behaviors. HIV+ gay men might also need to explore feelings of guilt or shame over earlier behaviors and the societally prevalent belief that they are responsible for the disease (Barrett, 1989). If clients are mourning former lovers, they may be suffering guilt over the possibility that they infected their lovers (Dworkin & Pincu, 1993) and will need to resolve this issue as well as concerns over their own health status. Gay relationships are often not recognized and validated in the same manner as heterosexual relationships. Therefore, the loss of a partner is often not marked by the same societal rituals designed to aid the resolution of grief (i.e., memorial services, time off from work, support from family and friends) experienced by a heterosexual individual whose spouse dies. The survivor will require support and validation of his loss (Schoen & Schindelman, 1989).

Families of origin can also be a supportive system (Winiarski, 1991) but may not always be a viable source of support, particularly for those whose families have rejected them (Nord, 1996). Again, counselors may be of assistance in providing family counseling to help rejoin families or to facilitate grieving the loss of family support if that has not previously been resolved (Holt et al., 1999; Nord, 1996; Strommen, 1990).

Although seeking individual counseling may be beneficial in providing support and validation of the survivor's feelings, Nord (1996,1997) suggested that because AIDS and AIDS-related loss is a community problem, adaptation to multiple loss can only occur if there is a community effort. Thus, counselors might take an advocacy role in facilitating the development of social support networks that can help the survivors realize that they are not alone. In addition, promoting involvement in community activities such as making a Names Project AIDS Memorial Quilt la quilt composed of panels, each commemorating someone who died from AIDS) and promoting participation in community gatherings that commemorate collective losses is important (Nord, 1996). Ironically, those who do become involved with social support networks are also putting themselves at risk for exposure to additional losses (Nord, 1997). However, the benefits of becoming connected to others in the community help to buffer the impact of loss and lead to better adaptation than would isolation in order to avoid loss.

Another way survivors can help themselves adapt to loss is to help others (Nord, 1997). There are many AIDS-related volunteer opportunities that will assist survivors in further developing their social support network. These activities may also result in a decrease in feelings of depression and learned helplessness and an increase in sense of empowerment and self-esteem. Furthermore, volunteer work might help ameliorate survivor guilt. Certainly, these activities will not be appropriate for all clients or at all stages of grief. When clients are experiencing intense grief emotions, they will be unlikely to be beneficial as supportive volunteers. However, in later stages of the grieving process, the sense of giving back to the community and taking a proactive stance against the disease that has caused so much pain can be a powerful healing experience. Thus, counselors can inform appropriate clients about community activities.

The process of grief resolution often includes helping individuals deal with the emotions they have about the losses (Holt et al., 1999; Nord, 1997). It is common for individuals to experience rage about the loss of so many close friends, and this rage may manifest itself in inappropriate behaviors. Although anger may be a positive response, it is important to help individuals learn to express anger in appropriate ways. It is also important to assist survivors in recognizing and dealing with emotions other than anger. Anger is often an easier emotion to recognize and express and may be used to avoid other emotions such as fear, sadness, grief, helplessness, and loss of control (Britton et al. 1999; Nord, 1997). Survivors need to recognize and express these emotions in a safe and validating environment. Counselors can be helpful in assisting survivors to deal with the emotional consequences of multiple losses through imagery, journaling, art, movement therapy, and various other expressive techniques.

Because the loss of loved ones can result in feelings of depression, worthlessness, and withdrawal (Jansen, 1985), counselors must be alert for symptoms of self-destructive behaviors and attitudes and assist clients in changing these behaviors and attitudes (Nord, 1997). Among the behaviors exhibited by individuals who experience multiple loss are alcohol/drug use, suicidal behavior, aggressive behavior, and risky sexual practices. Self-destructive attitudes might include bitterness, rage, self-hatred, or hatred directed at others. Alcohol and other drug use and engaging in risky sexual behaviors increases the client's own chances of being infected or reinfected. These behaviors and their implications must be discussed with clients because they, too, can be a way of expressing hopelessness and suicidal intent. Counselors can assist survivors in understanding the reasons for and negative consequences of their self-destructive behaviors and attitudes and assist clients in overcoming them through cognitive behavioral approaches (Nord, 1997). Of course, counselors should assess for suicidal ideation as appropriate and take necessary steps to ensure the safety of their clients.

Finally, clients must be assisted in accepting the experience of multiple loss as irrevocable. Although it is common to attempt to avoid feelings of being overwhelmed by denying the experience of multiple loss, survivors often benefit from a direct confrontation of the reality of the loss (Nord, 1997) that precedes the grieving process. Bower, Kemeny, Taylor, and Fahey (1998) studied the effects of finding meaning in the experience of bereavement through deliberate processing of the loss. They reported that recently bereaved HIV+ men who discovered personal meaning in their loss showed a plateau in the decline of CD4T cell levels (an immunological marker of HIV progression) and had a lower rate of AIDS-related mortality over a 4- to 9-year follow-up period. When working with survivors of multiple loss, support should be provided, and clients should be encouraged to express emotions associated with the loss and be empowered to find a way to regain a sense of control and mastery in order to prevent feelings of helplessness or "shattered meaning" (i.e., an inability to find meaning in the losses or impact of AIDS on the gay community, Schwartzberg, 1993). Many of the suggested counseling techniques discussed here are equally applicable to group settings. Supportive group therapy has been found to be an effective technique for addressing the emotional impact of AIDS-related concerns, both for those who are HIV seropositive and for bereaved survivors who may or may not be HIV+ (McKusick, 1988).

Unfortunately, clients are likely to be faced with additional losses (Nord, 1997). Grief work will be interrupted by new losses, inhibiting the process of working through accumulated grief. However, anticipating these losses can be reframed as an opportunity to start the grieving process early. Proper good-byes can be said and unfinished business can be resolved. Thus, although the grief process never actually "ends," survivors can find a sense of peace in knowing they took a proactive stance in dealing with loss rather than a passive, helpless stance.
- Springer, Carrie and Suzanne Lease; The Impact of Multiple AIDS-Related Bereavement in the Gay Male Population; Journal of Counseling & Development; Summer 2000; Vol. 78 Issue 3

Personal Reflection Exercise Explanation
The Goal of this Home Study Course is to create a learning experience that enhances your clinical skills. We encourage you to discuss the Personal Reflection Journaling Activities, found at the end of each Section, with your colleagues. Thus, you are provided with an opportunity for a Group Discussion experience. Case Study examples might include: family background, socio-economic status, education, occupation, social/emotional issues, legal/financial issues, death/dying/health, home management, parenting, etc. as you deem appropriate. A Case Study is to be approximately 50 words in length. However, since the content of these “Personal Reflection” Journaling Exercises is intended for your future reference, they may contain confidential information and are to be applied as a “work in progress.” You will not be required to provide us with these Journaling Activities.
The article above contains foundational information. Articles below contain optional updates.

Personal Reflection Exercise #1
The preceding section contained information about treating multiple bereavement in HIV positive gay men. Write three case study examples regarding how you might use the content of this section in your practice.

What did Bowler et al discover about HIV+ men who discovered personal meaning in their losses? Record the letter of the correct answer the Test

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The article above contains foundational information. Articles below contain optional updates.
Starting infant treatment within days of birth does not improve viral suppression
Very early HIV treatment resulted in long-term viral suppression in barely one-third of South African infants started on treatment within days of birth, according to a study published in EClinical Medicine. Infants diagnosed and started on treatment ten days after birth did better than infants who started treatment a day after birth, the study found. The study was designed to test the feasibility of very rapid diagnosis and treatment initiation after delivery, and to investigate factors associated with lack of success of this strategy.
A walk-in clinic with social care improves HIV outcomes for patients with complex social needs
The Max Clinic in Seattle in Washington State, USA, addresses risks of patients’ non-attendance by amending clinic arrangements to fit the patient. Researchers who interviewed patients at this clinic found high levels of patient satisfaction and improvements in patients’ viral loads, according to a study in the June issue of AIDS Patient Care and STDs. These improvements were achieved by meeting patients’ social needs as well as their clinical needs.
‘If you only have to take a pill once a day to protect yourself…it’s a miracle’: experiences of PrEP for women who inject drugs in the US
Among a group of women who inject drugs in Philadelphia, many saw pre-exposure prophylaxis (PrEP) as a beneficial way of preventing HIV infection, resulting in a decision to accept free PrEP. Women who believe that PrEP is beneficial see HIV as a severe threat to themselves personally. However, for a small number of women in the study, barriers such as HIV-related stigma, fear of side effects and worry regarding continued PrEP access outweigh perceived benefits and result in a decision to decline free PrEP.
Spanish study raises possibility that old-style tenofovir might protect against COVID-19
Rates of COVID-19 are lower among people with HIV taking antiretroviral therapy compared to individuals in the general population, Spanish researchers report in the online edition of the Annals of Internal Medicine. Moreover, the incidence of COVID-19 was especially low among HIV-positive individuals whose antiretroviral combination included tenofovir disoproxil fumarate (TDF).
COVID-19 casts a shadow over progress on TB
Efforts to contain the COVID-19 pandemic have inadvertently affected tuberculosis (TB) programmes and other aspects of non-COVID healthcare, according to two recent commentaries, published in Annals of Clinical Microbiology and Antimicrobials and Tropical Medicine and Health. The linkages between COVID-19, TB and HIV are most pronounced in sub-Saharan Africa, where TB is the leading cause of death for people with HIV. Nonetheless, the impact has also been felt in the high income setting of the United Kingdom (UK).

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