Session 4: HTS for Children and Adolescents

Children and Adolescents and HIV

In order to effectively meet the needs of children and adolescents, it is important to have a good understanding of their growth, development and psychosocial needs. This module introduces participants to the impact that their own personal attitudes, values and beliefs can have on their approach to working with children and adolescents. It then aims to equip participants with knowledge and understanding of the way children and adolescents think, feel and respond to different events in their lives and the factors which influence this. Finally it explores the impact of an HIV diagnosis on children and adolescents.

Learning Objectives

Demonstrate self-awareness in the provision of quality HTS for children and adolescents.
Assess your own personal values and beliefs that influence the provision of HTS.
Demonstrate an understanding of legal and ethical issues encountered in HTS for children and adolescents.
Describe the different needs of children and adolescents.

Learning Activities

Introduction (10 min)

View the following short video of 3 children talking about the importance of getting tested early for HIV.
Credit
Africaid Zvandiri, Zimbabwe

Providing HTS to Children and Adolescents

More than 90% of HIV-infected children (aged 0-14) acquire their infection through mother to child transmission of HIV, also known as vertical transmission. However, children and more so adolescents can also acquire HIV through horizontal transmission. Horizontal transmission can occur through either sexual transmission, which includes sexual activity, coerced sex or sexual abuse, or parental transmission which refers to non-sexual transmission most commonly found among adolescents involved in injecting drug use, traditional practices (e.g. female genital mutilation), unsafe medical procedures and blood transfusions.

When you encounter children and adolescents, they will be from across a broad age range, at varying developmental stages, with different life circumstances and experiences and with vastly different needs. Many are particularly vulnerable with demanding counselling needs.
Rufaro (15 min)
Rufaro, a mature orphan, is 15 years old. She is HIV-positive and lives with 2 siblings: one is negative and the other is positive and on treatment. They attend school and live in the same hut together, which has one room for sleeping, cooking and eating. The roof is leaking. The clinic and school are 12 km away. They do not have electricity or water; they get their water from a borehole 2 km away. Firewood is scarce, so they use cow dung for fuel, which they collect on the way to and from school. Whenever possible the siblings attend church. Rufaro cares for her younger siblings. The one who is on ART has many health issues. Consequently, Rufaro misses a lot of school.

Answer the questions below about Rufaro and her family and the impact of HIV.
1What stressors is Rufaro dealing with? Select all that apply.
1. Physical
2. Emotional
3. Social
4. Behavioral
A, B, and C are correct. It is clear that there are multiple stressors that she must deal with physically, emotionally, and socially.
2From the following list, identify the possible social stressors Rufaro may be dealing with. Select all that apply.
1. Poor access to healthcare
2. Fear
3. Helplessness
4. Missing school
5. Poverty
6. Lack of food
A, D, E, and F are correct. Fear and helplessness are emotional stressors.
3What are the physical, psychological, social, and spiritual needs for Rufaro and her family? Consider how you would work with Rufaro to address these four areas. Match the type of need with the suggestion for handling it.
Ask if the children have a support system and if they do not, provide linkages to support. Encourage them to attend church more often. If possible, help them share their situation with the church leadership, who may be able to mobilize support for the children from the church membership. Find out who is paying for school fees and uniforms and, if needed, connect them to local services. The roof needs to be repaired for shelter to be sound. Contact Kraal head or see if a local NGO who deals with children can help. Alternatively, see if faith-based organizations are available to provide assistance. Further assess food and clothing needs.

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4What adolescent friendly counselling techniques will you use with Rufaro? Select all that apply.
1. Building a relationship
2. Empowering/ Empathy
3. Empty chair
4. Storytelling
5. Play
6. Externalising
A, B, D, and E are correct. There are many techniques that you can use to counsel Rufaro. While you want to make sure that you are establishing rapport and making a connection, it is important that you pay attention to using techniques that work for the situation.

“Externalising” is incorrect because there are no adverse behaviours that Rufaro is engaging in. The other techniques will allow her to feel safe in telling her story and everyone each has their own style and way of counselling.
5Give examples of how you might use the following 5 counselling techniques with Rufaro. Match the technique with the example.
Ask Rufaro to tell you a story of her life and pay attention to the tone and non-verbal cues that will allow you to discover the important, interesting, and challenging aspects of her life. Be inviting, thank her for coming in, discuss the weather, ask how they traveled to the clinic. Ask if there are any relatives on either the maternal or paternal side who can assist when things get tough. Use the Soldier Game or role play life experiences. Tell her that she is strong and very determined in single-handedly taking care of her younger siblings / let her know that you can imagine what she is going through.
6You wonder if Rufaro is sexually active. What do you do next?
1. You decide not to explore this and wait to see if she brings this up in future sessions.
2. You ask, “Rufaro, are you having sex with anyone?”
3. You ask, “Some of your age mates surely have boyfriends, what is your opinion on this?
4. You comment, “Surely you must have a boyfriend who is helping you with your upkeep since you are not working.”
C is correct. This response shows that you respect her as an individual by gently raising the topic in a nonjudgmental way.

It is important to not presume that she is or isn’t sexually active. You also do not want to be too direct, which may make her uncomfortable or come across as judgmental.
The Right to Have Children (10 min)
Listen to this podcast from the book Red Ribbons and Roses, created by a group of HIV positive youth. Think about the questions below.
Credit
Africaid Zvandiri, Zimbabwe

Questions
1. What did the people in the stories say about their right to have a baby?
2. How did they care for themselves and their baby?
3. What was the result?
4. How can you support HIV positive people who want to have babies?
Knowledge Check (15 min)
1What is the definition of a child? Select all that apply.
1. Anyone 12-18 years
2. Anyone still staying with his/her parents/caregivers
3. Anyone going to school
4. Infants
5. Anyone who is 1-8 years
6. Anyone below 18 years of age
A, D, E, and F are correct. Anyone below 18 years is a child regardless of their living situation, or whether they attend school.
2All of the following are reasons why adolescents have changes in thinking, problem solving, social skills, and relationships except
1. There is rapid development of the body
2. There is rapid growth of the brain
3. There is abstract thinking
4. There is a decrease in emotional control
D is correct. Typically, adolescents have an increase in emotional control.
3Describe how the characteristics of adolescents listed below can have a positive or a negative effect on their prevention, care, support, and treatment of HIV. Match the characteristic with the effect.
Can make an adolescent more active in self-care or they may not want to listen to you. Can be a positive in a support group but can be negative if an adolescent is coerced into unprotected sex. Can be positive if the adolescent is interested in information about HIV and new experiences (including sex) or negative if the adolescent is inquisitive and engages in high-risk behaviours.
4Children can develop behavioral problems as a result of not being able to express their feelings.
1. True
2. False
True is correct. They may act out these feelings by being aggressive or withdrawn.
5Children do not understand complex issues and have no feelings.
1. True
2. False
False is correct. All children think and feel. If we do not allow them to express themselves, they will not develop into secure and confident adults.
6A child living with HIV may become clinically depressed after a parent dies.
1. True
2. False
True is correct. They may feel guilty, angry, or sad. Their experience needs to be acknowledged and processed. They may have a big change in socio-economic circumstances.
7Children should not talk when adults are present.
1. True
2. False
False is correct. This hinders self-expression. Children need to learn how to communicate with adults.
8Children living with HIV may have low self-esteem.
1. True
2. False
True is correct. A poor sense of identity and low self-esteem is sometimes the consequence of feeling different due to having a "taboo" illness like HIV.
9Children should not say the names of sexual organs.
1. True
2. False
False is correct. Children are curious. If we don’t tell them about sexuality in an appropriate way, they may learn the wrong things from the wrong people, or get an unbalanced view of sexuality. Children should not be made to feel guilty about their own sexual organs, rather caregivers should tell them in a gentle way what is appropriate behavior.
10Children should not go to funerals or they will be haunted by spirits.
1. True
2. False
False is correct. Children need to understand that all things die. They need to feel sad and grieve. Shielding them can hinder their acceptance of what happened and deny them the opportunity to express their grief.
11Boys should not be allowed to cry.
1. True
2. False
False is correct. All children cry, and it’s normal. If boys who show emotion are shamed rather than supported, this can lead to self-destructive behavior. Crying is a form of communication. The inability to express how one feels can lead to feelings of helplessness, frustration, and anger.
12Girls do not need as much education as boys.
1. True
2. False
False is correct. Treating girls as less important than boys means that they may be regarded with less respect, and may have fewer opportunities for education or employment. If girls do not feel they have equal value to boys, they may not learn to value themselves nor develop self-confidence.
13Adolescents are aged 10-19.
1. True
2. False
True is correct.
14An adolescent is an individual for whom most services are provided by caregiver.
1. True
2. False
True is correct, except in the case of an empancipated minor.
15All adolescents are capable of making sound decisions.
1. True
2. False
False is correct. While some adolescents are capable of making sound decisions, many benefit from the guidance of their caregivers.
16Adolescents are in the age of confusion.
1. True
2. False
True is correct. This is the age where they are fascinated by anything without establishing the basis for the fascination.
17An adolescent is someone who is always independent.
1. True
2. False
False is correct. While some adolescents may be independent, the majority rely on an adult to meet their basic needs for safety, support, and love.
18An adolescent finds solace with friends outside the home.
1. True
2. False
True is correct.
19Adolescents are easily manipulated.
1. True
2. False
True is correct. Adolescents are easily influenced by their environment and could be prone to impulsive behavior.
20Adolescents can be temperamental because of hormones in their blood system.
1. True
2. False
True is correct. Adolescents are experiencing hormonal changes that may affect behaviours and how they may handle situations.
21All vertically infected adolescents are ill.
1. True
2. False
False is correct. Illness is only determined by the level of the viral load in their blood system, not the mode of transmission.
Legal and Ethical Issues of a Child (15 min)
Chengetai is 5 years old. He has been unwell for the past year with recurrent ear infections, diarrhoea, and herpes zoster. His mother, Joyce, was advised by her local clinic that she should bring Chengetai to you for HIV testing. During the pre-test information session, Chengetai’s mother informs you that she has changed her mind and does not want him to be tested.
1What do you do next? Select all that apply.
1. Ask the mother about her status.
2. Tell the mother that you suspect that Chengetai has gotten HIV through vertical transmission.
3. Review booking system to get history of the child’s health.
4. Ask the mother about her concerns related to testing.
A, C, and D are correct. You want to check in with the mother about her own care during pregnancy and if she knows her own status. You should also check the records to see what you can find out about previous visits and treatment. You also want to explore with the mother more about her personal life to see if you can find out what her concerns are for testing Chengetai.

It is always important for you to be nonjudgmental and not make assumptions on the mother’s status by stating that you suspect vertical transmission. The child could have been sexually abused.
You spend some time in discussion with Joyce and you ask her questions about her family life and her access to the clinic. She responds that she was not booked because she is the fourth wife of a 60-year-old polygamist, who is the leader of an apostolic sect and does not believe in conventional medicine. She delivered in a clinic by default because she was visiting her sister when she went into labour. She was offered an HIV test, which she refused, but allowed them to do whatever they deemed necessary for the baby, including BCG vaccine. She told you that they gave her information on breastfeeding and check-ups.

2You can see that Joyce loves her child and is concerned about his health because she has brought him to clinic. She expresses several concerns.

Match the concern with an explanation to address it.
“When I test positive then that will mean that I am considered dead.” “When you test me you will introduce your own blood, which is infected, and then you tell me that I have HIV.” “HIV is due to witchcraft and my husband is the leader of the Apostolic so I am immune to HIV.” “I’m not HIV positive because I’ve heard that women who are HIV positive cannot have children.” “I’m afraid my husband will divorce me because I came to the clinic. He will think that I disobeyed him. He doesn’t want me to visit clinics because it goes against his religious beliefs.”

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3Joyce expresses concern that if Chengetai tests positive, everyone will think she has HIV too. What would you tell Joyce about confidentiality? Select all that apply.
1. “You are correct that if your baby tests positive, you will likely be positive.”
2. “Only nurses who are responsible for initiating a child on ART will know that he is HIV positive.”
3. “No one has access to a child’s records except the responsible service provider. The records are kept in locked cabinets and the staff understand the issue of confidentiality.”
B and C are correct. Joyce’s main concern is confidentiality and you need to reassure her about who will have access to this information. Later you can address vertical transmission.
4Which of the following would you do to encourage Joyce to get Chengetai tested? Select all that apply.
1. Using the guiding principle of “best interest of the child” you should counsel Joyce on reasons why it is important to test.
2. Tell her that it is considered child abuse to not have Chengetai tested.
3. Explain that if Chengetai is positive and does not know it, he is at an increased risk of getting sick and not developing well.
4. Stress the positive facts about “living with HIV,” such as the medications and care available if he is positive.
A, C, and D are correct.
Best Interests of the Child

A guiding legal and ethical principle for counselling children and adolescents is that the best interests of the child shall be a primary consideration. The principle applies when:
- A child and adolescent is ill and diagnosis will facilitate appropriate care and treatment
- A child and adolescent is a survivor of sexual abuse
- A child and adolescent has been exposed to HIV through vertical or sexual transmission
- A child and adolescent expresses concern that given an HIV positive result, he or she will be denied access to care and treatment by the parent/caregiver
- A child and adolescent is concerned about MTCT
This principle may be used under these circumstances in order for the provider to ensure that the child and adolescent is provided with adequate care and support, sometimes in conflict with the parent/caregiver. When counsellors face legal and ethical dilemmas, this principle guides the counsellor in how to manage the situation. If the counsellor acts in the best interests of the child and adolescent at all times, the child and adolescent will be protected and legal and ethical principles will be upheld.
1Does Chengetai’s situation apply to the principle “best interests of the child”?
1. Yes
2. No
Yes.
2Select all that apply under the “best interest of the child” principle.
1. To an orphan whose caregiver is willing to give consent.
2. To a child/adolescent who is a survivor of sexual abuse.
3. To a pregnant adolescent.
4. To a child/adolescent who is ill and a diagnosis will facilitate appropriate care and treatment.
5. To a child below 16 years who is mature enough to understand the implications of HIV diagnosis.
6. To a child/adolescent that has been exposed to HIV through vertical or sexual transmission.
B, D, and F are correct. The “best interest of the child” principle may be used under certain circumstances in order for the provider to ensure that the child and adolescent is provided with adequate care and support, sometimes in conflict with the parent/caregiver.
3Chengetai’s mother still refuses the test. What do you do?
1. Tell her to return to the clinic in 4 weeks to see the visiting doctor.
2. Go to the sister in charge and inform her of the situation. The sister in charge can intervene and give consent to have the HIV test performed.
B is correct. If you tell Joyce to return, there will be a good chance that she won’t, and Chengetai could become very ill and possibly die. The procedure to have the best interest of the child principle implemented is to bring the case to the sister in charge who has the authority to have the child tested.
4What would be the possible reasons to justify a decision to postpone or not test a child? Select all that apply.
1. Significant emotional distress to the child that she can’t participate
2. Imminent risk to the safety of the child
3. Lack of social support to assist the child to cope with a positive result and its implications
4. There are other clients waiting for services, and the appointment had already lasted too long
5. Evidence the child has been coerced into coming
A, B, C, and E are correct. During the pre-test information session, if the counsellor feels that testing is not in the best interest of the child or adolescent, then the counsellor may use discretion to postpone testing.
5Select all statements that pertain to the rights of the child principle.
1. A child has the right to have sex whenever she/he feels ready
2. A child has the right to have his or her basic needs provided for
3. A child has the right to life
4. A child has the right to be unruly
5. A child has the right to freedom of expression
6. A child has the right to participation and protection
B, C, E, and F are correct. Child rights are ethical principles that bind service providers to do all that is necessary and available to provide the best possible care for children and adolescents.

Chengetai’s mother has agreed to get him tested. You recognize that since she has agreed to testing her child, it may be a good opportunity for her to get tested as well. Now you would like to provide counselling to encourage her to get tested.
6What could you say to Chengetai’s mother to encourage her to get tested? Select all that apply.
1. Explain that even if Chengetai tests negative, it does not necessarily mean that she is also negative.
2. Provide ongoing support and counselling to her and encourage her to ask questions. Address any concerns and misconceptions that she may be having.
3. Explain that if she is positive and does not know it, she is at an increased risk of getting sick and not being able to look after her family.
4. Stress facts about living positively with HIV and the support services available instead of the idea that “everyone dies from HIV”.
All are correct.
Joyce agrees to take the test.

You conduct pre-test counselling with Joyce before giving her the HIV test. The next section presents statements you would say to her during your session.
7Select which general statements you would say to Joyce during her pre-test counselling session.
1. “It’s important that you and your husband know whether you are positive or negative so that you can stay healthy.”
2. “All information is confidential and will be shared only with health workers directly providing care for you and your child.”
3. “If your test result is positive, it will not be necessary to take medication since you were negative last year and the virus has not done any damage to your body.”
4. “If your result is negative again this year, it will not be necessary for you to have another HIV test in the future.“
A and B are correct.
8Select which statements you would say to Joyce during her pre-test counselling session about disclosing her status.
1. “If you choose to disclose to your husband, there are some strategies that we’ve found to be helpful to our patients in the past. Would you like to discuss some of them today?”
2. “Encourage your husband to get tested, too, so you can both stay healthy.”
3. “Who else are you going to share your HIV test results with?”
4. “If you do not agree to disclose to your husband, we will not be able to do the test.”
A, B and C are correct. During your pre-test counselling you should give Joyce many opportunities to ask questions and express her concerns, including those related to disclosure, partner testing, and MTCT risk. Note: we will cover disclosure in more detail in week 4.
9You decide to conduct a risk assessment. You will ask Joyce all of the following questions except:
1. Do you have other children and if so, have they been tested?
2. Have you or husband been treated for STIs?
3. Is he the only man you have had sexual intimacy with?
4. Have you had sex without your consent? (sexual abuse)
5. How old were you when you lost your virginity?
E is correct.
During a risk assessment, you should explore many issues, including abuse and family life. Although a client like Joyce may be coming in for a specific reason, it is often the case that other issues will arise around the health and safety of not just the child but also the entire family. Though you should always address the presenting issue, you should also be ready to also address any additional concerns.
Legal and Ethical Issues of an Adolescent (10 min)
Sibongile is 15 years old. She has attended your facility alone, requesting an HIV test. During pre-test counselling, she shares with you that she has a 17-year-old boyfriend, Peter.
1Can Sibongile get an HIV test today without consent from her parent?
1. Yes
2. No
3. I need more information
C is correct. You need to get more information on Sibongile to assess whether she meets the qualifications for a “mature minor”.
2Sibongile is under 16 years of age. Consent is required before providing HTS for a child who is under 16 years of age unless she is considered a mature minor or an emancipated minor. Only then can she give informed consent for a test. What do you ask Sibongile to determine if she is a mature minor? Select all that apply.
1. Tell me why you are making the decision to come for HTS alone, which a lot of your peers leave to their parents.
2. Can you tell me more about yourself and family?
3. It is everyone’s right to know her HIV status, and we have guidelines that govern how we provide the service.
4. Where are your parents? Why are they not with you for this important decision?
A, B and C, are correct. We should applaud and not condemn people who seek medical care and advice. As you explore with Sibongile whether she is a mature minor, questions should be about assessing her ability to understand and consent for testing. You want to see if she has the capability of making an informed decision.
Sibongile reports that she and her boyfriend are sexually active. She is a double orphan (both parents have passed away) and has a young brother and sister she takes care of. You discover that she is having sex with her boyfriend so that he helps her with upkeep.
3Which of the factors below do you consider determinants that Sibongile should be treated as a mature minor? Select all that apply.
1. According to the rights of sexual reproductive health
2. She appears old enough to understand the implications of sex and sexuality.
3. Her ability to appreciate the seriousness of HTS and the test result and to give informed consent.
4. Her physical, emotional, and mental state appear stable and mature.
5. The degree of responsibility that she has assumed for her own life, such as heading a household and living independently from a parent/caregiver.
B, C, D, and E are correct. Sibongile shows many indications that she is mature and able to make an informed decision. The rights of sexual reproductive health states that people above 16 are allowed to give informed consent and she is only 15.
4Does Sibongile qualify as a mature minor?
1. Yes
2. No
A is correct. Sibongile is sexually active and heading a family so she qualifies as a mature minor who can be tested without parent/caregiver consent.
5You learn that Sibongile is having unprotected sex with Peter. What do you counsel her about this? Select all that apply.
1. Discuss the implications of unprotected sex: STI, HIV, unwanted pregnancy.
2. Remind her that she is too young to be having sex and she should stop immediately.
3. Educate her about STIs and relationship of STI and HIV: Both are sexually acquired. There is a high risk of acquiring HIV because STI distorts the natural history of HIV—STIs accelerates the progression of HIV.
4. Conduct a condom demonstration of both male and female condoms. (Stress the importance of correct and consistent use of condoms. Dispel the myth that being in a relationship for some time does not mean that you can trust your partner to stop using condoms.)
A, C, and D are correct. It is important to counsel an adolescent and educate them on truth so that they do not use incorrect information gathered from others. Topics for discussion can include the above plus:
- Talking about the implications of getting pregnant at this age (such as dropping out of school, pregnancy complications, abortions which are illegal, but still happen, preterm deliveries, delivery complications)
- Mentioning the importance of monogamy (having just one partner): Importance of having sex not based on material things but of the heart. Dealing with things which matter to empower the self.
- Discussing sexual reproductive health issues such as hygiene and the menstrual cycle.
- Conducting regular pre-test counselling with a risk assessment.
- Educating her about the basics of HIV.
6What questions would you ask Sibongile to assess her social support? Select all that apply.
1. I can see that you are really seasoned in issues of looking after your siblings. Would you mind sharing with me how you do it?
2. How are you managing your day-to-day support?
3. Is your relationship with your boyfriend just so you can get support for your family?
A, and B are correct. You do not want to ask questions that would be judgmental and push Sibongile away. You want to find out which of her and her siblings’ needs are being met and explore ways to address any gaps that come up during the session.
Key Points (5 min)
- Self-awareness is important in the provision of quality HTS for children and adolescents.
- The legal and ethical issues encountered in HTS for children and adolescents are complex and can be challenging to navigate.
- Children and adolescents have different needs than adults to address.

Session 4: HTS for Children and Adolescents

Children and Adolescents and HIV

Learning Objectives

Learning Activities

Providing HTS to Children and Adolescents

Best Interests of the Child