Counseling practices in Sexually Transmitted Infections/AIDS: the female health professionals’ perspective

Objective: to analyze the health professionals’ perception about counseling in a Centro de Testagem e Aconselhamento em Infecções Sexualmente Transmissíveis (Center for Testing and Counseling in Sexually Transmitted Infections (STIs) and AIDS) in Maceió, Alagoas. Method: it is a qualitative research, with theoretical framework of the Discursive Practices and Production of Senses in the daily life carried out with the participation of 6 counselors. For research material production, the ‘Conversation Round’ technique and the semi-structured script were used. For material treatment the Discourse Analysis method was used, resulting in the production of analysis categories and Dialogic Maps. Results: in the current policies and actions of STI/AIDS, there is centralization in the procedures of anti-HIV testing and displacement of the professional counselor, undoing the testing and counseling. Final considerations: the study indicates the need to overcome the instrumental and prescriptive models of counseling to produce a dialogical process of care and co-responsibility.


INTRODUCTION
In 1998, the Ministry of Health (MoH), in partnership with states and municipalities, created the services called Serological Orientation and Support Centers (COAS -Centros de Orientação e Aconselhamento Sorológico), which should promote serological testing for HIV and syphilis free of charge, confidential and anonymous, counseling to individuals at risk -tests for hepatitis were performed (1)(2) .
Currently, these services are called Centro de Testagem e Aconselhamento em Infecções Sexualmente Transmissíveis (freely translated as Center for Testing and Counseling in Sexually Transmitted Infections (STIs) and AIDS -CTA). It is recommended that care in these health facilities follow the following flow: a) initially, each volunteer to the test should be guided at the embracement about the tests offered, receive a password, and be registered; b) after this, the user should be submitted to pre-test counseling, individual or collective, and should discuss issues related to the voluntary nature of testing, as well as confidentiality, possible emotional reactions triggered at this stage, notions about immunological window and safer sexual practices; c) if the person agrees to perform the tests, will be sent to perform the test, which takes on average 30 minutes, between the execution and its result; d) the post-test counseling is performed, with the recommendation that the result should be delivered by the same counselor of the pre-test, because it prioritizes the initial link established with the user (2) . Four decades ago, there was the international recommendation on the provision of counseling and voluntary testing as a means to respond effectively and effectively to the HIV/AIDS epidemic (3)(4) .
STI/AIDS counseling is defined as a process in which the professional should establish a space for expressing the demands of the user, creating a sense of trust and facilitating the rescue of his internal resources so that the subject recognizes himself as the protagonist of his story. The main goal to be reached in counseling is the movement to reconstruct HIV/AIDS prevention practices that make sense to the subjects and, therefore, grant them greater autonomy (5) . The counselor's role in CTAs can be carried out by professionals with a higher education or technical background who are adequately trained for this activity, requiring additional training specific and adequate for their performance. This work is structured in three main components: emotional support, facilitating the user's expression of their feelings, in order to encourage their self-esteem and self-confidence; educational support, understanding the exchange of information on STD/HIV, forms of transmission, prevention, treatment and clarification of doubts; and risk assessment, where the counselor assists the user in identifying potential barriers that are hindering a change in their risk exposure behavior so that a potential risk and harm reduction plan can be developed in partnership (2,6) . Despite the relevance of this professional in the attention to STI/AIDS, literature reviews on the universe of CTAs pointed out that the analysis of practice in services, by the counselors' view, was little problematized in scientific documents (7) .

OBJECTIVE
To analyze the perception of health professionals about counseling at a Centro de Testagem e Aconselhamento em Infecções Sexualmente Transmissíveis (Center for Testing and Counseling in Sexually Transmitted Infections (STIs) and AIDS) in Maceió, Alagoas.

Ethical aspects
The research was approved by the Research Ethics Committee and all participants signed the Free and Informed Consent Term.

Theoretical-methodological framework and type of study
This is a qualitative research, with theoretical framework of the Discursive Practices (8) .

Study setting
The research was performed in a CTA, a member of a health facility with a large physical structure, composed of nine specialized units. In the same unit where the CTA was located, it was also comprised the Specialized Care Service (SAE -Serviço de Atenção Especializada), responsible for the follow-up of users diagnosed with HIV/AIDS. At the same time, Alagoas City had 7 other CTAs, but 4 were located in Maceió City. The CTA team was composed of 7 counselors, distributed in the work shifts: morning and afternoon.
Between July and November 2015, the main investigator made weekly visits to the CTA, as a process of acculturation of the researcher. The visits included observation of the environment and the dynamics of the operation of the service, as well as informal conversations with health professionals about the daily work at CTA. After each visit, a field diary was recorded. These records help the research team to define the technique for data collection, selection of participants and production of the first categories of analysis.

Data source
All health professionals who provided STI/AIDS counseling at the CTA were invited to participate in the study, of which 6 accepted to participate.

Collection and organization of data
For the production of the material, the 'Conversation Round' technique was used. It consists of a collective participation mechanism for dialogue on a specific theme, with the objective of socializing knowledge and implementing the exchange of experiences, conversations and knowledge among those involved, seeking to construct, reconstruct and negotiate meanings on the proposed theme (9) . The Conversation Round was coordinated by the main researcher and two collaborating researchers, in a reserved environment, in the premises of the respective CTA, previously scheduled with the participants and with the direction of the health establishment. The semi-structured script was used to trigger the conversations in the Round that requested the participants: a) Tell me about your practices at CTA.; b) Do you perceive any kind of discomfort/suffering in you in the performance of your practices?; and c) How do they understand the organization of work processes at CTA? The Conversation Round took place in November 2015, lasted approximately two hours and, with the authorization of the participants of the research, the conversations were recorded in audio and later transcribed. To ensure participants' anonymity, their names were replaced by names of gems during transcription.

Data analysis
The Discourse Analysis was used to treat the material produced. It suggests the analysis of the dialogues, through the language in use and the senses produced, providing information about the importance given to the topic and raising discussions about communication and the relationship between people in this field of research (8,10) . Analysis categories, understood as linguistic strategies, used in discursive practices to communicate meanings (8) , were produced from the exhaustive reading of the participants' statements, and were thus defined: a) Work Processes; b) Listening Exercise; c) Suffering at Work; and d) Physical Structure. Next, we have produced Dialog Maps, organized into tables with columns and rows, where each category is placed in the header of a column and the transcribed speeches are broken and distributed, sequentially in the lines below, under the column in which the category produce correspondence (11) . The results and the discussion were written from the sequential reading of each of the columns of the Dialogical Map.

RESULTS
The counselors in STI/AIDS in the city of Maceió who participated in the research were women, aged between 42 and 51 years. All of them had higher education, being 3 in Psychology and 3 in Social Work. In addition, it was identified that 1 of the counselors did not have three full years of work at CTA and that the others had worked in this establishment for more than ten years. This difference between the participants, regarding the working time in the service, did not compromise the analysis of the speeches. However, it was identified that the participant with less than 3 years in the service had a smaller contribution only when subjects were dealt with regarding historical situations very particular to this CTA.
During the Conversation Round, some participants recalled that at the beginning of activities in the unit specialized in HIV/ AIDS prejudice was expressed by workers in relations with other professionals of the same health establishment. Rapid tests decreased waiting time by the result from 15 days to 30 minutes and produced effects on the service routines. More recently, there is the possibility of self-testing, marketed in pharmacies. These changes in testing methodology have been reported to be uncomfortable for some counselors, who have increasingly perceived their diminished participation in anti-HIV testing. This is also due to the little investment made in these professionals, in the sense of empowering or motivating them. Faced with a new setting, with the tests of 'pharmacy' , counselors report feeling their professional place threatened.
What now, with this pharmacy test? I remember when I implemented the rapid test, training, investment in the preparation of counseling and I wonder: both investment, careful to embrace this user, often in delicate moments of their lives, a concern for his well-being. Care management for this user receives the diagnosis of chronic disease cure loaded with so much. And this patient who will do this test as it was a pregnancy test? Alone. (Turquoise) For them, anti-HIV testing requires a lot of care by professionals trained in dealing with users. These professionals wonder what effects can be felt if they carry out a test alone with significant repercussion in their life. This discomfort has been responsible for a series of questions within the CTA team about the feasibility of this work methodology and how its implementation still needs to be much discussed.
In the speech of the research participants, the non-valuation of counseling was identified in certain situations by the attitude of some colleagues and the very direction of the service: At embracement, there is a strong concern with quality, from the embracement of the user, through the responsibility of the professional with the user, for the comprehensiveness of the care, listening to their demands and the provision of spaces where the person can express itself (12) . In this sense, the attention given to the form of the embracement and the link expected in the interlocution between the health professional and the user: There is no way I will answer that way, every person is a person, comes with their problems, their life situations, never comes the result that we give, it will be the same for anyone. (Pearl) HIV/AIDS counseling involves dealing directly with varied situations and often far from our values and lifestyles. It is observed that in certain cases where issues such as incest, pedophilia, homosexuality and others appear, an emotional charge is usually demanded from the team, and the counselor is often faced with a challenging and generative experience of suffering. [ The way counselors found to ease their discomfort was through the search for support among themselves in order to share the anguish and try to strengthen themselves to continue to carry out their activities. However, they note that this alone is not enough to account for the demand produced and they demand specific work in this direction, with the development of collective moments in which they can share their difficulties and exchange experiences.
Research participants discussed how the architecture and layout of the physical space produces certain behaviors or modes of organization specific to work. They recalled that, for a long time, the STI/AIDS care unit had a different access, which prevented the contact of users and professionals of this unit with those of others. They associate this to the disease stigma and to the health care model based on fragmentation and sectoriality. Ruby and Amethyst provide examples of how (lack of ) physical structure would be causing mismatch in industry routines, generating unexpected flows and making it difficult to deliver quality advice. These discomforts experienced by the team are attributed to the lack of a flow of care for users who intend to carry out the test or simply to obtain some information.

So this issue of the room is really very important because when you go without a room, you stay there in the hallway. And it creates an embarrassing situation. (Amethyst)
[...] because as there is no room for everyone and we take turns, sometimes the user sees that counselor to whom they told things about their life, now in the collection room, for example. And then you can think, "will they keep the secret?". (Ruby) The research participants also reported concern in situations in which the pre-test counselor transited the corridor because she had given her room to another colleague so that she could also carry out her work.

Work Processes
Reports of health workers who felt fear, concern, rejection and discrimination at the beginning of the AIDS epidemic in Brazil were also found in another study, which identified the era in which professionals refused to attend to avoid contact with these patients, they requested resignation, transfer or were absent at work (13) . As also present in the speeches of the participants of the research, the stigma attached to HIV/AIDS, and everything else that is linked to it, indicates the difficulties encountered in integrating into the work processes of different health teams or services. Recent studies have identified reports of health professionals who admit to sharing stigmas and prejudices linked to HIV/ AIDS, raised in work processes, impacting work management and health care (14)(15) . The fear of contamination, transmission of the virus and the risk of contagion appears in the social representations of professionals of reference services in HIV/AIDS, being this a challenge for the qualification of health practices (15)(16) .
In addition, the research participants reported concern about the decentralization movement in the rapid test, initiated in 2003 by the Política Nacional em DST/Aids e Hepatites Virais (freely translated as Brazilian Policy on STD/AIDS and Viral Hepatitis), since this has implied the displacement of the figure of the counselor, no longer as an indispensable agent. In this 'complaint' , there is talk in addition to the changes in the technology of testing, because issues emerge such as the disinvestment itself in the counselor, in counseling. It is observed that the current discourses on the policies of access and expansion of the offer of the HIV diagnosis did not include the practice of pre-test counseling (17) .
There is a shift from counseling of the affective-relational model to a techno-centered, rational instrumental model, where testing technologies take the lead role. Emphasis is placed on the relationship, the development of light technologies, as a link between the subjects, and centrality to HIV testing is guaranteed (4,6) and its application to as many people as possible. There is, in this context, an overlapping of the biomedical paradigm on psychosocial practices, allied to the transformations of the productive process in the area of Health, where hard technologies are prioritized, in this case, HIV testing technologies (3) .
However, the decentralization process of HIV testing corroborates with Goal 90-90-90 advocated by WHO/UNAIDS, which aims to test an increasing number of people in order to identify early HIV more briefly its treatment, meaning: 90% of the population tested, 90% of those on HIV treatment and 90% of those with undetectable viral load (18) . A study on the process of decentralization and specialized orientation of rapid tests carried out in the city of Porto Alegre, indicates the advances in the direction of the expansion of the supply and its consequent coverage. However, it emphasizes that this movement has not been consistently maintained, as well as more effective continuity and follow-up, in order to guarantee both the counseling and the quality diagnosis for users (19) .
When the 'intrusions' reported by the participants, which frequently occur in this service, cause the identification of the relations of power produced in the establishment by means of words or actions that express strength, persuasion, control and regulation, although this power may be exercised unconsciously and deliberately (20) . This implicit dimension of power relations helps to understand how individuals are affected by them, as well as, often, fail to perceive these affectations in the face of the naturalization of relationships established in work processes. According to Agate and Ruby, one can see how these relations of power are often reproduced in the service still marked by an inheritance strongly characterized by the hierarchization of work, be it between director and worker or between this and the user himself, and how this affects the work routines, fragmenting the proposed care for the user and producing stress situations for this worker.

Listening Exercise
The word to hear means "to listen; give attention to; to hear, to feel, to perceive "or" to become or to be attentive to hear; give ear to; apply the ear carefully to perceive or hear" (21) . It is understood, from the words of the participants of the research, that the 'success' or 'failure' of the counseling process in the CTA would be strongly associated with the type of bond, adequate reception and, above all, respect for iniquities of each person. The counselor's legitimate concerns about the counseling issue are corroborated by the Programa Nacional de IST/Aids e Hepatites Virais (freely translated as Brazilian STI/AIDS and Viral Hepatitis Program) in the counseling issue when it is suggested that the counselor's work be structured into three main components: emotional support, educational support and risk assessment, seeking to facilitate the expression of their feelings and encourage their self-esteem and self-confidence (2,6) . The dialogue between the counselor and the user should be guided by listening to the demands and doubts that the latter can raise about sexuality and AIDS (17) .
According to the theoretical framework and clinical management, the process of listening assumes different positions in counseling in an attempt to help the subject in their conflict situations (22) . However, the official technical recommendations for the practice of counseling propose the active listening of the feelings, attitudes and values of the subjects related to the diagnosis of STD and HIV (3) . It is highlighted that the posture, the bond and the type of relationship established between user-counselor and its articulation with prevention practices influence behavior changes and adherence to STD treatment by the patients (23) . A study carried out with female sex workers pointed out the importance of the listening process in STI/AIDS counseling, as a way to increase the condom inclusion behavior in the sexual relations of these with their clients (24) .
Developing counseling from listening to user demands, combining conventional HIV/AIDS and relational knowledge, such as communication and empathy, seems to be the current challenge for professionals and managers of CTAs (3) . Referring to the biomedical epidemiological discourse, it is common for the user seeking the CTA to position themselves in the places of promiscuity, risk, guilt and accountability based on the experience of their sexual practices, and counseling may be a moment of deconstruction of HIV/AIDS stereotypes and re-signification about risk and guilt, which favors the more autonomous construction of self-care with its sexuality (25) . From this perspective, counseling moves away from the prescriptive and mechanistic model of health, and invests in listening in the production of care, providing space for investment in the caregiver-cared for relationship, taking into account the singularities of each subject, their diversity and the creative capacity to be and to be in the world. For this, it is necessary the constant improvement of the health professionals for the communication with users (26) . Training processes are also needed for counselors that include reflection on the conflicts and tensions present in listening during counseling (6) .

Suffering at Work
Health workers identify the existence of a psychic overload in STI/AIDS services, through listening to stories suffered, full of prejudice and discrimination, coupled with the difficulties of addressing sexuality and sexual practices as one of the main difficulties encountered, both personally and professionally (14) . In this sense, the research participants reported some important psychological effects, such as the feeling of helplessness, anguish, impotence, among others, experienced as a product of counseling.
However, in Ministry of Health manuals dealing with the training and performance of HIV/AIDS counselors, emphasis is placed on the maintenance of attainable and standardizing attitudes and practices (6) . Given this, the development of work processes together with training processes is a challenge for CTA managers and professionals, which would contribute to the qualification of work practices, and to the counselor's occupational health (3) . This qualification should be offered to counselors, to interpret different social dynamics related to sexuality, to make sense of the multiplicity of sexual practices and to analyze the discursive crossings involved in this practice (25) . Some participants of the research reported taking care of their occupational health, financing with their own resources their technical and professional improvement and also the private psychological care to work the issues raised in the daily setting life of the CTA. The search for specialization courses or a second vocational training by CTA counselors to extend their symbolic resources was also identified in another study (3) .

Physical Structure
Some studies have identified problem situations since the beginning of the CTA implementation process, such as: reduced number of rooms; poorly ventilated environments; high index of deterioration of the physical structure of the centers; lack of sites with greater privacy for users who will undergo tests or awaiting results; insufficient number of accommodation to accommodate the demand of users, among others (1,(27)(28)(29) .
Overall, concerns about the physical structure at CTA, reported by survey participants, concerned insufficient room for counselors and lack of an exclusive and trained embracement. The Programa Nacional de IST/Aids e Hepatites Virais (freely translated as Brazilian STI/AIDS and Viral Hepatitis Program) recommends that CTAs be built in spaces with large flow of people, easily identifiable and accessible to users, physically separated from other health facilities, ensuring privacy and composed of exclusive multiprofessional teams. It is suggested a minimum physical structure for its adequate functioning, basically consisting of: collection room, waiting room, archiving room, counseling room, individual meeting room, collective activity room, management room or support (2) .

Study limitations
From the theoretical framework of this study, scientific research is conceived as a reflexive and critical social practice. As such, it affirms its limitations for the production of knowledge in the very characteristics of scientific doing: procedural (unfinished and continuous), partial and contextual (8) .

Contributions to the field of Health
The study made it possible to see that, in the contemporary setting of STI/AIDS policies and actions, there is a centralization of HIV testing procedures, with the intention of disseminating its widespread use. On the other hand, there is the displacement of the professional counselor, considered now a practice no more essential, undoing the dyad 'testing and counseling' .

FINAL CONSIDERATIONS
The analysis of counselors' statements on STI/AIDS on their practices identified a complexity of elements that produce effects both in the quality of the work they develop and in the health of these professionals. There is a growing decentralization of the tests for basic, specialized and high-level health care establishments, associated with disinvestment in the training of counselors and limiting their work to the instruction of users. Nevertheless, this study corroborates that counseling, as a listening tool, based on the bond and respect for the iniquities of the people, is fundamental for the continuity of the care for users who seek the CTAs to guarantee comprehensive care for their health. For this, it is fundamental the preparation of the counselor for the singular listening and the reframing about sexuality.
Professionals reported experiencing suffering associated with daily work. It is suggested that the CTAs adopt in-service training strategies and spaces in which counselors can share their difficulties and analyze the work between peers. The methodologies of participative spaces of training and of significant learning can contribute in this process.
It was also identified that the architecture of the CTAs has repercussions on the organization of the work process and that the absence of an adequate embracement environment. The insufficient number of rooms for the number of professionals, which end up crowded in the establishment, directly affects the quality of services offered to users.
It is considered that the study indicates the need to overcome the instrumental and prescriptive models of counseling, in order to produce a dialogical work, based on the relationships of care and co-responsibility. It also includes, as a contemporary phenomenon, the overlapping of instrumental rationality over the relational perspectives of health production, with the prioritization of HIV tests and the risk of counseling no longer composing this setting.