The Human Immunodeficiency Virus (HIV) is portrayed as one of the most challenging health problems worldwide; its diagnosis plays a crucial role in the life of an individual and it provides a comprehensive outlook of a person’s treatment adherence. Therefore, it is highly important to offer the user an exceptional care and provide crucial information while sharing the results of the diagnosis. Counselling sessions allow people not only to be educated about the Human Immunodeficiency Virus, but also to bring forth the possibility to discuss myths, clarify different uncertainties and promote self-care. The main objective of the this study was to design a structured instrument for the HIV counselling process provided along with the HIV rapid test. An evidence-based approach was followed in order to combine scientific evidence, the critical assessment of the bibliographic data and the specific information provided by the health personnel in charge of the counselling process at the beneficiary institution. The procedure was carried out following the steps suggested by the National Center of Technological Health Excellence (2012) of Mexico to update Clinical Practice Guidelines (CPG) as well as the methodology of Evidence-based Practice in Psychology. As a result, a Clinical Practice Guideline with a humanistic approach was developed, taking into consideration the user’s needs identified through qualitative research techniques along with the criteria referred to the counselling and diagnosis process of HIV established by the Mexican Official Standard for HIV NOM-010-SSA2- 2010. The study is a significant contribution to psychology due to the fact that it is an input that improves the counselling process by systematizing its practice and the psychologist role in order to lessen the variability and offer a better service.

Keywords: HIV, counselling, humanism, protocol, evidence, adherence, clinical guideline

Being notified with a Human Immunodeficiency Virus (HIV) positive result implies a significant emotional impact. The result generally leads to the presence of negative emotions such as anxiety, fear, frustration, confusion, etc.^1–6   Based on the diagnosis considerable effect, the health personnel providing it should focus on interventions that diminish such negative emotional impacts. This could be done by identifying and working through the barriers the person holds in order to proceed to an assimilation phase of the diagnosis and begin the necessary treatment in an effective manner.^1–4 The steps to be followed in order to inform and prevent people about HIV in Mexico are regulated by the Official Mexican Standard for the infection of HIV (NOM-010-SSA2-2010). The norm specifies and establishes the importance of providing diagnostic test results from rapid test confidentially along with a counseling process in which the user is accompanied throughout the process of diagnosis and treatment. The objective of such specification minimizes negative emotional and psychological impact in the user, allowing the necessary orientation to reinforce a more adaptive outlook to the changes and difficulties that might be encountered in the personal, social and familiar context. The support provided along such guided orientation process promotes the adherence to treatment in case there is a positive result in the diagnosis. The psychological models and techniques used for the prevention and diagnosis of HIV in other countries are very diverse. In the U.S. and the United Kingdom, counseling models such as cognitive behavioral and systemic, or blocks of information considered to be “essential”, are used. This puts the specific needs of the patient aside when the illness is being diagnosed.^7,8 For that reason, there is a need to adapt this methodology in order to include humanistic and emotional aspects that are adequate for the treatment of the illness. Counseling focus on personal growth has become essential.⁹ This is why the humanistic focus has been increasingly included on the counseling process for people who have HIV, especially if the emotional and social burden that comes with the diagnosis is taken into account.¹⁰ Through this focus, the individuality and autonomy of the person has a priority as well as the subjective aspect of how reality is perceived.^11,12 Counseling sessions are a more effective strategy when they are designed in a collaborative manner in which patients are involved. This way an opportunity is given to the person to discuss private information such as sexual practices more confidently. Counseling has also helped patients who live with HIV to adhere to antiretroviral treatment.^{13, 14} According to Ballester,¹⁵ the information available regarding the illness and the health personnel’s attitude have an important influence on a patient acquiring care conducts. The World Health Organization¹⁶ has recognized that empathic conducts from the personnel as well as conducts that promote the active participation of the person who lives with HIV on their own treatment can increase adherence to it. Professional behaviour and socially supportive attitudes from the health personnel will influence the perception that the person living with HIV has on the seriousness of the illness and on the sensation of being accepted.^17,18 The formal establishment of counselling services has been one of psychology’s most significant achievements for such health problem. Counselling sessions have proved to be an efficient tool to educate about HIV, clarify myths and erroneous beliefs, allowing the promotion of self-care. In addition, the incorporation of a humanistic approach to the counselling process with people who live with HIV has provided positive results, due to the collaborative work between the counselor and the user. The humanistic approach allows the users to practice a more accurate decision making process, concerning their lifestyles, and placing different goals to acquire preventive and health care behaviour.^19–21

Humanistic counselling

Humanistic Counselling is based primarily on the assumption that every human being is efficient and has the necessary resources to self-actualization and achieve personal growth .²² Therefore, this type of counselling focuses on helping the client develops the necessary coping abilities to deal with a specific illness or adverse situation. It also works as a way to promote an interiorizing process of the circumstance that is being experienced, allowing the person to become aware of his/her abilities to confront possible consequences. The orientation given throughout the counselling process also tends to focus in empowering the client and establishing a collaborative relationship between the client and the counsellor. Any type of hierarchy among them is left aside during this process.^23–25

Humanistic counselling in people who live with HIV

A humanistic counselling approach can be very useful when working with people who live with HIV. This approach concentrates primarily in the exploration of the client's internal resources and the way such resources could be used to cope with their current condition. Integrating such approach to the HIV counselling process grants multiple benefits. First, it allows the counsellor to work mutually with the client in a specific decision-making process concerning the client’s lifestyle. At the same time, it can be used to set up different goals to promote the acquisition of preventive behaviours and health care.^19–21 There are several types of counselling models within this kind of approach that have proved to be exceptional in diverse settings. These are also known as Best Practices due to their remarkable results with clients.^19,20

Egan’s skilled helper model

The “Skilled Helper” Model has a humanistic approach and has been promoted internationally due to its possible use in a large variety of counselling contexts. Its main purpose is to explore the diverse personal alternatives the client holds to cope with the current situation being faced focusing on problem solving abilities while encouraging a collaborative relationship between the counsellor and the client.^26–28 This model has proved to have a major impact while working with people who have HIV, demonstrating significant behavioral changes in the client.²⁶ The model includes three stages:

Exploring skills

In the first stage, the client’s current situation is reviewed along with the establishment of a collaborative relationship, and the exploration of the client’s skills to use them in the next two stages. The counselor encourages the user to explore new perspectives in order to help them modify their thinking patterns, perceptions or negative attitudes concerning their behaviours. This stage focuses on setting up priorities and an action plan development.^27–29

Understanding skills

The second stage focuses on helping the clients to have a complete comprehension of their situation and begin formulating possible goals in order to facilitate a decision-making process while making proper use of their abilities.^27–29  Brainstorming and divergent thinking analysis are some of the strategies applied when working with decision-making and goal achievement since they allow the exploration of various available options and help the user become aware of the factors that might facilitate or interfere with the goals mapped out. ^27–29

Acting skills

The third stage has the objective to help the clients encounter their reality with their corresponding personal strategies. ^27–29

Treatment advocacy

Treatment Advocacy is a holistic model whose main objective is to promote the user’s antiretroviral treatment adherence through the client’s empowerment, which would consequently establish a self-care commitment that will allow the acquisition of healthy habits. Through this model, the counselor has the responsibility to refer the user in order to facilitate the necessary medical services along with the treatment of the user’s condition and health care. In addition, the counselor carries out a follow-up plan to witness the user’s process and to be able to mediate in any crucial circumstance.³⁰  Particularly, Treatment Advocacy assesses the user’s current situation by identifying the principal postures that might be influencing their decision making in order to guide them through a reflexive process within these postures and facilitate a more adequate decision-making process. Moreover, Treatment Advocacy grants importance to the rapport established with the user since it is a tool that allows empowerment and goal achievement. ³⁰

Evidence-based practice in psychology

Psychological practices involve different types of interventions in multiple places for a variety of patients. In this particular case, intervention is defined as all of the direct services offered by psychologists in healthcare, including those who provide assessments, diagnosis, prevention, treatment, psychotherapy, and consultation. When referring to settings where Evidence-based psychology is carried out, it involves hospitals, clinics, independent practices, schools, military facilities, public health institutions, rehabilitation centers, primary care centers, counseling centers and nursing homes (American Psychological Association Presidential Task Force, 2006).Many of the current strategies used emerged from different types of trial and error and clinical hypothesis testing which amounts to a large part of the clinical practice´s scientific characteristics. However, when testing clinical hypothesis a series of limitations may appear which is why it is necessary to integrate the clinical expertise with the best available research.³¹ Evidence-Based Practice in Psychology (EBPP) is an approach that combines effective research findings with the specific expertise in clinical settings. It also takes into consideration the patients’ characteristics and context as well as their cultural background and preferences. EBPP’s main purpose is to promote exceptional psychological practices to improve healthcare quality and effectiveness. To keep up-to-date with information pertinent to their practice, experts need updated and empirically validated clinical guides.^32,33

Data collection techniques such as a focus group and a semi-structured interview were used in order to update the previous methodology of the counseling process. The techniques were directly used with the healthcare personnel in charge of providing the counseling process at State Council for AIDS Prevention and Control in Monterrey, Mexico (CAPASITS). The design of the Clinical Practice Guideline was grounded on an evidence-based methodology where elements such as scientific evidence, meticulous assessment of bibliographic content, and the information obtained from those in charge of the counseling process were taken into account in order to minimize the probability of biased recommendations along the content.

The procedure followed the steps suggested by the National Center of Technological Health Excellence³⁴ for the updating of Clinical Practice Guidelines (CPG) through the methodology of Evidence-Based Psychology, which follows six stages.

Prioritization for a CPG update

Looking to complement the established criteria by the Official Mexican Standard for the Human Immunodeficiency Virus (NOM-010-SSA2-2010) with a client-centered methodology, a bibliographic investigation about the better counseling practices with a humanistic focus on people who live with HIV was made. Also, a focus group and interviews with the personnel who were in charge of the counseling sessions took place.

Bibliographic investigation

The article revision was completed taking into account diverse inclusive and excluding criteria. The articles contemplated were those published between the years 2010 and 2015 that would endorse the best counseling practices with a humanistic approach for patients living with HIV, taking into account the empirically valid practices criteria. The databases used for the articles revision included “Academic Search”, “Health Business Elite”, “Medic Latina”, “MEDLINE”, “Psychology and Behavioral Sciences Collection”, “LGBT Life” among others related to the topic, using keywords such as ‘Humanistic Counseling’, ‘Counseling HIV’, ‘Successful Humanistic Counseling’, ‘Counseling Protocols HIV’, ‘Lifestyle HIV’, ‘Confronting HIV’, ‘Adaptation HIV’, ‘Counselor-Client Relationship’, Consejería  Humanista’, ‘Consejería VIH’, ‘Buenas Prácticas Consejería Humanista’, ‘Protocolos Consejería VIH’, ‘Estilo de Vida VIH’, ‘Afrontamiento VIH’, ‘Adaptación VIH’, and ‘Relación Consejero-Cliente’.

Focus group

A single-session focus group was conducted on September 3rd, 2015 with three counselors from CAPASITS who had a minimum of six months experience. The session lasted 67 minutes and was used to obtain basic information about the counseling process, the counselors’ experience with users, and the different contexts and sociodemographic information about the people who have had the rapid test done.

Structured interview
A structured interview with the personnel in charge of the psychology area of CAPASITS took place on September 7th, 2015, lasting 31 minutes. The same questions of the focus group were discussed throughout the interview. 

Establishment of a work group for the CPG update
The work group was formed by the research team from Universidad de Monterrey.

Justifying the update of a CPG

In Mexico, health clinics coordinated by COESIDA offer diagnostic services through a rapid test that includes a counseling session in which general topics regarding HIV are discussed with the person. However, there was a need to adapt the methodology of that counseling in order to cover adequate humanistic and emotional aspects of the illness.

Update of the CPG

The information obtained through the investigation using the search protocol facilitated the adaptation of the practices to the content of the counseling guide to update.

Validation of the updated CPG

In order to estimate the quality of the CPG for its use as a methodological strategy and establish the kind of information that was necessary to include, the Appraisal of Guidelines Research and Evaluation (AGREE II) was applied to the health personnel in the institution and to the research team.

Integration of the updated CPG with the Master Catalogue

For the complete integration of the updated CPG with CAPASITS, a training session with the health personnel was carried out on December 2015 in order to model the clinical practice counseling according to the proposed parameters in the updated tool.

Appraisal of Guidelines Research and Evaluation (AGREE II) is an instrument used to evaluate and report the variability in the quality of the Clinical Practice Guideline through six quality domains:

1. Scope and Purpose
2. Stakeholder Involvement
3. Rigour of Development
4. Clarity of Presentation
5. Applicability
6. Editorial Independence

This tool is composed of 23 separate items that could be assessed through a 7 point scale, 1= Strongly Disagree and 7 = strongly Agree.³⁵

Qualitative techniques

For the qualitative analysis of the information, the Miles and Huberrnan³⁶ matrix analysis was used. It was found that the institution didn’t have a guide, protocol or consensus about how counseling was supposed to be done, neither they took into account the characteristics of the users of this service: the counseling was the same for all users without adapting the content to their situation, varying according to the experience and knowledge about HIV of the counsellor.

The categories resulting from the analysis were taken into account to structure the content of the CPG:

1. Context: Users’ reason to take the rapid test.
2. Population: By sex, age (children, young adults and mature adults), marital status, sexual orientation, and practices.
3. Frequency: Number of times the user attends to take the rapid test in a given period.
4. Content: Issues addressed in counselling.
5. Modality: Group, couple or individual.
6. Purpose: Objective of counselling (informative, prevention, etc).
7. Result: Individuals’ reactions to the reactive and nonreactive result.

Clinic practice guide

The resulting guide is based on the NOM-010-SSA2-2010, the Humanistic Counseling, and Good Practices in HIV counseling. The contents were addressed according to user context and sociodemographic differences; a series of techniques and resources for the counselor based on the Egan’s Skilled Helper Model were included. The structure is shown below:

Introduction

The reason and the objective that gave origin to the CPG are mentioned. This section also brings a series of steps for the counsellor to follow.

Module 1: Where does the content come from?

This section includes the state regulations of the Official Mexican Standard for the infection of HIV, the basis of the structure of the CPG, and the Good Practices in counselling gathered.
Module 2: Steps for the counselling session
The steps for a counselling HIV session are developed in this section.  Steps are:

1. Building a relationship with the user
2. Introduction to counselling,
3. Rapid test
4. Getting to know the user
5. Considering the person’s context
6. What should be brought up during the counselling session
7. Rapid test results
8. Remission
9. Closure

A content chart is also included orienting the development of the session according to user’s context (Figure 1).

Figure 1 Counseling process flow diagram of "Counseling Guide for Rapid HIV Testing"

Module 3: Couple counseling

This module includes the steps, techniques, modalities, and information that is given in a counselling with couples. This includes serodiscordant couples and seroconcordant couples.

Module 4: Group Counselling

This section contains all previous modules information. It mentions how results of the rapid test must be given and how to divide the group based on those results. The group is used as a supporting tool with and for all its members.              

Module 5: Content of the counselling session

The information that must be included in a counselling session is mentioned here. This section takes into account important factors like the definition of HIV, ways of transmission, and the rights of the people with HIV. There is also a space devoted to frequently asked questions. The themes are divided into counselling previous to the rapid test result and after the result.

Module 6: Remission

This section includes an address book of public and private institutions where the user can be referred in case of needing specialized attention, both medical and psychological. A brief description of each institution and the remission criteria are provided.

Module 7: Checklist

This section includes elements in a checklist format that allow the counsellors to verify if the counselling session has been conducted properly. The counsellors may ensure they integrated all suggested elements.

Supporting material

This section includes information about the correct use of the Supporting Material directed to the user and the counsellor. The material consists of 12 flashcards visually showing the content of the counselling before and after the rapid test results. There are also cards for the counsellors that summarize the counselling steps, the abilities and strategies needed, and the three stages of Egan’s Model. 

Validation of the updated CPG

This validation was conducted by the psychology coordination of the health institution, using the AGREE II tool. The points obtained were 6.7 out of 7, which indicated that publication and use criteria were met. The psychology coordinator of the institution also revised the content of the CPG in order to corroborate that the information was correct and complete. Necessary changes were made after the validation in terms of content and fluency.

The primary and final result was the completion of the Clinical Practice Guideline, targeting the main objective established by adapting the methodology of the counseling process while having the rapid HIV test into a humanistic approach, taking into consideration users’ main needs as well as theoretical evidence. The Clinical Practice Guideline meets the urgent demand for a more structured tool with a humanistic approach that minimizes the variability in counseling time frame and content throughout the process, taking into account users’ personal context, their emotions, and their sociodemographic characteristics. Considering all of these aspects will allow the users to be aware of their own resources and take more favourable healthy actions.^21–25 In order to update the Clinical Practice Guideline, Evidence-Based Psychology (EBP) was taken into consideration throughout the research. Therefore, Good Practices were reviewed to grasp a favourable humanistic counseling approach, specifically for HIV counseling. It has been proven that through the practice of EBP, the healthcare quality could improve integrating varied theoretical evidence to health staff clinical practice.^37,38 Another important finding points out that not all counseling practices found were adequate, and therefore, not applicable in Mexican counseling context. In addition, most counseling methodologies excluded humanistic techniques, as illustrated by Home-Based HIV Counseling³⁹ and Community Based HIV Counseling ⁴⁰ focus, primarily, on handling and covering preventive information about HIV. As a part of the revision of Good Practices, Egan’s Skilled Helper Model was the primary tool considered. Such model has been implemented in various counseling contexts around the globe, including HIV counseling, and it has been issued in different Control and Prevention of Illnesses Centers.²⁶ The three main phases of the model were adapted to cover the counseling process, in order to reinforce different abilities of both, counselor and users, to favor a collaborative relationship as well as the promotion of healthy behavior. In addition, Egan’s model emphasized counselors’ positive attitudes and values and the appropriate way to put them into practice. ^26–29 Another good practice that was partially applied in the Remission Module was the Treatment Advocacy Model with the aim to ensure the adherence of the persons with HIV when referred to health specialists capable of attending their specific medical needs.³⁰ This model will contribute to handling users’ physical discomforts effectively as well as doubts about HIV that the counselor may have to answer. The benefit of the guide is that despite the limitations in the time assigned for the counseling, the counselor may be able to accomplish a humanist approach while making the user's experience significant allowing to achieve a range of skills that contribute to their quality of life and health.²⁹

This project contributes to an improvement in the counseling process as well as decreased variability in practice to provide better service. Using this guide, the professional in charge can be able to implement a humanistic approach in counseling by using techniques that allow the users to acquire a range of skills that contribute to their quality of life and health. Among the limitations found was the lack of bibliographic information about the humanistic counseling applied to HIV as well as good practices in this discipline, which represents a broad field for future research as well as projects that promote Psychology Evidence-Based in the field of Clinical and Health Psychology. Other limitations were related to the data collection process. It was difficult to bring together all counselors due to the demand of their work. The information gathered through interviews and the focus group was limited due to the briefness of responses from the counselors and the lack of time to deep into them. It is suggested to implement a monitoring process coordinated by specialists in counseling related to HIV focused on identifying strengths and opportunities within the counseling process from a humanistic approach in order to integrate the key elements that provide a better service. The evaluation of the process can be done by taking into account biological indicators, such as the decreasing viral load in users with HIV and the increase of T-CD4 lymphocytes, or the adoption of self-care behaviors by the user after counseling.

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1. Anderson M, Elam G, Gerver S, et al. It took a piece of me: initial responses to a positive HIV diagnosis by Caribbean people in the UK.AIDS Care. 2010;22(12):1493-1498.
2. Carrasco Aldunate P, Araya Gutiérrez A, Loayza Godoy C, et al. How to understand the experience of persons living with HIV: Implications for clinical practice and research. Aquichan. 2013;13(3):387-395.
3. Fuentes MC, Gutiérrez T. Efecto psicológico en pacientes tras el diagnóstico de VIH/sida.Complejo Hospitalario de Jaén, Spain, 2014; p.1-179.
4. Gutiérrez T. Efecto psicológico en pacientes tras el diagnóstico de VIH/sida. Complejo Hospitalario de Jaén, Spain; 2014;p.1-179.
5. Martínez J, Lemos D, Hosek S. Stressors and sources of support: the perceptions and experience of newly diagnosed Latino youth living with HIV. AIDS Patient Care and STDs. 2012;26(5):281-290.
6. Suárez D, Peñate A, Crespo Y et al. La inteligencia emocional en personas que viven con VIH. Duazary. (2009);6(1):10-24.
7. Augustine Nwoye. Memory and narrative healing processes in HIV counseling: A view from Africa. Contemporary Family Therapy. 2008;30(1):15-30.
8. Ratigan B. Counseling people affected by HIV and AIDS. In: Palmer S, Mahon Mc G, editors. Handbook of counseling, British Association for Counseling, UK, 2010;p.1-599.
9. Kalichman S. Preventing AIDS: A sourcebook for behavioral interventions. Lawrence Erlbaum Associates. (2014):1-180.
10. Ellis C, Carlson J. Cross cultural awareness and social justice in counselling. NY: Routledge, New York, 2009; p.1- 335.
11. Hornby G. A humanistic developmental model of counseling: A psycho-educational approach. Counselling Psychology Quarterly. 1990;3(2):191-204.
12. Schuman C. Counseling and the Humanist Worldview. In: Andrew Copson, AC Grayling , editors. The wiley blackwell handbook of humanism. Wiley Blackwell, England. 2015;p.1-464.
13. Bentz L, Enel P, Dunais B, et al. Evaluating counseling outcome on adherence to prophylaxis and follow up after sexual HIV risk exposure: a randomized controlled trial. AIDS Care. 2010;22(12):1509-1516.
14. Huan X, Tang W, Babu GR, et al. HIV Risk-Reduction Counseling and Testing on Behavior Change of MSM. PLOS One. 2013;8(7): e69740.
15. Ballester R. Aportaciones desde la psicología al tratamiento de las personas con infección por VIH/SIDA. Revista de Psicopatología y Psicología Clínica. 2005;10(1):53-59.
16.  Suiza. Adherence to long term therapies. World Health Organization, USA. (2004);p.1-211.
17. Villa IC, Vinaccia S. Adhesión terapéutica y variables psicológicas asociadas en pacientes con diagnóstico de VIH-SIDA. Psicología y Salud. 2006;16(1):51-62.
18. Witteveen E, Van Ameijden E. Drug users and HIV-combination therapy (HAART): factors which impede or facilitate adherence. Substance use & misuse. 2002;37(14):1905-1925.
19. Mearns D, Thorne B, McLeod J, et al. Person-centered counselling in action. Thousand Oaks, SAGE Publications, UK. 2013;p. 1-240.
20.  Contest convened by PAHO on good practices in the expansion of counseling and voluntary testing in the MSM population in the Andean countries (Venezuela, Colombia, Ecuador, Peru and Bolivia), Panamerican Health Organization, USA. 2010.
21. Rivero L, Carvalho J. Contributions and Limits of the Use of Person-Centered Therapy (PCT) for the Theoretical Foundation of HIV/aids counselling. Temas en psicología. 2013;21(3):1089-1106.
22. López MA. La psicoterapia humanista. Revista Psicología. 2009;30(2):1-33.
23. Cooper M. Welcoming the other: Actualizing the humanistic ethic at the core of counselling practice. Counselling Psychology Review. 2009 ;24(3):119-129.
24. Ellis C, Carlson J. Cross cultural awareness and social justice in counselling. NY: Routledge, New York. 2009; p.1- 335.
25. House R. An approach to time limited humanistic-dynamic counselling. British Journal of Guidance and Counselling.  1997;25(2):251-263.
26. Dewing S, Mathews C, Schaay N, et al. It's important to take your medication everyday okay?" An evaluation of counselling by lay counsellors for ARV adherence support in the Western Cape, South Africa. AIDS Behav. 2013;17(1):203-212.
27. Egan G. The skilled helper: A problem-management and opportunity-development approach to helping. 10th ed. Pacific Grove, Australia, 2014; p.1-440.
28. Richter LM, Van Rooyen H, Solomon V, et al. Putting HIV/AIDS counselling in South Africa in its place. Society In Transition. 2001;32(1): 148-154.
29. Nelson P. An easy introduction to Egan’s skilled helper solution focused counselling approach. 1st ed. USA. 2007; p.1-5.
30. Mutchler MM, Wagner G, Cowgill BO et al. Improving HIV/AIDS care through treatment advocacy: going beyond client education to empowerment by facilitating client-provider relationships. AIDS Care. 2011;23(1):79-90.
31. APA Presidential Task Force on Evidence-Based Practice (2006) Evidence Based Practice. Am Psychol61 (4): 271-285.
32. Chambless DL, Olllendick TH. Empirically supported psychological interventions: Controversies and evidence. Annu Rev Psychol. 2001;2(1):685-717.
33. Northey WF, Hodgson J. Empirical studies in family therapy. Journal of Family Psychoterapy. 2008;9(1):50-84.
34. Centro Nacional de Excelencia Tecnológica en Salud, Metodología para la integración de guías de práctica clínica. Recuperado de, Mexico. 2012; p.1-69.
35. Consorcio Agree  AGREE II Instrument: Instrument for the elaboration of Clinical Practice Guidelines. Spanish. 2009;p.1-59.
36. Miles M, Huberman M. Qualitative data analysis: An expanded sourcebook. Sage Publications, USA. 1994;p.1-480.
37. Frías M, Pascual J. Psicología clínica basada en pruebas: Efecto del tratamiento. Papeles del Psicólogo. 2003;85(24):11-18.
38. Moriana J, Martínez V. Evidence-based psychology and the design and assessment of efficient psychological treatments. Revista de Psicopatología y Psicología Clínica. 2011;16(2):81-100.
39. Doherty T, Tabana H, Jackson D, et al. Effect of home based HIV counselling and testing intervention in rural South Africa: cluster randomnised trial. BMJ. (2013);13(1):346-348.
40. Suthar A, Ford N, Bachanas P, et al. Towards universal voluntary HIV testing and counselling: a systematic review and meta-analysis of community-based approaches. PLOS Medicine. 2014;10(8):1-23.