Advice-giving difficulties in voluntary counselling and testing: a distinctly moral activity

Advice-giving in voluntary counselling and testing (VCT) is demanding as it involves the discussion of difficult topics such as the morality of sexual risk and behaviour. We conducted a detailed exploration of how the giving and receiving of advice is managed in VCT, and how this is achieved against the backdrop of the competing public health and counselling imperatives that shape VCT practice. Informed by social constructionism and adopting a discursive approach, a sample of 27 videotaped simulated VCT sessions in South Africa were analysed. Two prominent advice strategies were identified. The combined effect of the discursive techniques used in the "making appeals strategy" (using a question which morally obligated the client to respond, drawing on the clients' views about condom use in framing the advice and finally evoking the client's responsibilities to protect others) eventually resulted in the uptake of the counsellor's advice. In the "prescribing rules for living" strategy, little attempt was made to include the client's concerns and views in the advice formulation instead the counsellor relied more on her authoritative, persuasive and professional position to enforce behaviour change - this led to client resistance of the advice. In both strategies, when confronted with certain contextual triggers counsellors invariably up-graded their advice in moral terms. In the first strategy, the moral upgrade had a positive effect on the outcome, in the second, it did not. VCT involves talk about HIV sexual risk behaviour. As such, a moral context is likely to be evoked in these conversations. The challenge is to assist counsellors to address the moral questions surrounding HIV risk in a way that places responsibility not blame onto clients.