Session 4: HTS for Children and Adolescents
Disclosure for Children and Adolescents
Disclosure counselling, like other types of counselling needs some special considerations when working with children and adolescents. In this session we will talk about how to go about supporting disclosure when working with these special groups.
Learning Objectives
By the end of this section, you will be able to:
- Describe the key principles of sharing information and counselling children and adolescents about their HIV status.
- Identify the key principles of supporting adolescents to make decisions about if, when, how, and to whom they should share information about their HIV status.
- Demonstrate counselling skills that assist children, adolescents, and families to disclose their HIV status.
Learning Activities
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Knowledge Check (10 min)
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Benefits and Risks of Disclosure (5 min)
All children with HIV need information about their own HIV status at different stages in their lives. Whether the child has been disclosed to or not, the multidisciplinary team has a collective responsibility to ensure that every child and adolescent with HIV receives on-going information and counselling, at the right time and in the right way. The quality of information and counselling which children and adolescents receive will directly impact on their clinical and psychosocial well-being and must therefore form the foundation of HIV treatment, care and support for children and adolescents.
In addition, as children and adolescents with HIV grow up, they will face decisions in their lives about with whom, when and how to share information about their own HIV status. The multidisciplinary team needs to understand the rights and needs of children and adolescents and to have developed skills to assist each individual in the right way.
There are both benefits and risks for disclosure to different people. Tap on each of the groups of people below to see what the benefits and risks are.
Family and friends
Benefits: They could provide support and assistance.
Risks: They might react negatively, reject the child or adolescent, call names, or become violent.Service providers
Benefits: They would provide access to prevention, treatment, support and care services, and timely information on HIV and prevention issues.
Risks: They might judge or tell parents or guardians.Teachers/school
Benefits: They might provide support, help the child or adolescent keep up with schoolwork, and remind the child or adolescent to take medications.
Risks: They might judge, tell others in school or try to keep someone from attending school.Religious leaders
Benefits: They might provide support, spiritual guidance, or help the child or adolescent cope with emotions.
Risks: They might react negatively, shun someone, or tell parents or guardians.Sex partners
Benefits: One can discuss prevention strategies with a sex partner and go for testing and counselling together. Partner might provide support and love.
Risks: Partner might react negatively, call names, leave, or become violent. -
Susan and Mary Part 3 (20 min)
As you recall from earlier parts of this case, Susan is 8 years old and has tested positive for HIV. She has been brought to you by her 15-year-old sister, Mary, who has tested negative. Their parents are both late and they are living alone. Susan is NOT aware of her status. Mary has brought Susan in for a follow-up visit. She tells you that she thinks it is the right time to disclose so that Susan can understand why she needs to take medication and be more responsible for her own health. She mentions that the nurse has said it is time to begin ART alongside her TB treatment. “Susan has been taking her TB medication and knows that it is for the coughing but when we introduce the ART, I want her to understand what that is for.” She tells you she doesn’t know where to begin the conversation with Susan and needs help.
Mary tells you that Susan has been very good with her TB medications and has actually been the one who reminds her when she needs to take the tablets. She tells you that Susan knows that their parents were both very ill before they passed on but doesn’t know why they died. Susan was 6 years old when they passed on and was very upset when they were ill because no medicine helped. Mary explains that since Susan started her TB medication 2 weeks ago, she has stopped coughing and feels much better and doesn’t understand why her parents couldn’t have tablets to fix them. Mary tells you that since the pre-test counselling, they have not discussed HIV and only talked about TB.
You end the session by scheduling a return visit for Susan to come with Mary so you can be present during the disclosure. You thank Mary for coming in and for being supportive of her sister.
Mary returns with Susan the next day and you bring them into the counselling room.
Mary says to Susan: “Susan, remember the first day that we were here and we played the Soldier Game about HIV and then you had blood taken?” Mary explains to Susan that her results came back positive for HIV. Susan looks confused and Mary is overwhelmed and begins to cry.
Susan is looking at Mary as she is quietly crying. She does not say anything and continues watching her cry. You ask Susan several times what she is thinking and she doesn’t answer. You ask her if she understands what Mary has told her and she continues to sit quietly, looking at Mary, and still does not answer you.
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Modesta (10 min)
Watch the video, “Modesta.”
CreditAfricaid Zvandiri, ZimbabweThink about the following questions.
- What was the video about?
- Why did Modesta’s father lie about taking medication and being in hospital?
- What was her reaction to her HIV test results? Did her reaction surprise you?
- How do you think an adolescent would feel if they found out they were infected with HIV from their parent, but their sibling was not infected?
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George (15 min)
George is 17 years old, HIV positive, and has known his status since he was 8 years old. He has been on treatment for 5 years with good adherence and good support from his family. George comes to the clinic for a regular checkup. During your session with him, he lets you know that he is now dating a young woman who is the same age.
George tells you that he has not discussed HIV with his girlfriend. He has not disclosed his status, nor does he know hers. He also shares that he would like to have a sexual relationship with her but has not yet.
While talking with George about his new girlfriend, he tells you that he finds that he is “daydreaming “and forgetting things like books for school and tasks that his parents ask him to do. He noticed this after he started hanging out with his new girlfriend. He also tells you that he forgot to take his medication one time during the past weekend when spending time together.
You reinforce with George how disclosure to his girlfriend can help him with adherence so she can be his treatment buddy. He says that is a good reason to disclose and tells you that he feels confident she will be supportive. George tells you that he has read on the Internet that people who are HIV positive and taking their medication every day are less likely to transmit HIV to their partner, so it is not necessary to wear a condom. He asks you if this is true and for your advice.
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Precious Part 2 (10 min)
As you may recall, Precious is 17 years old. She has a boyfriend, Tonderai, who is 23 years old. In the first part of the clinic visit, Precious was informed that she is pregnant and HIV positive. Precious is clearly very upset, confused, and tired. You think that maybe Precious is feeling overwhelmed, since she is starting ART today. You wonder if you should continue talking to Precious about disclosing to Tonderai and her parents or if you should wait to have the discussion about disclosure at her next visit.
Precious tells you that she will tell Tonderai only that she is HIV positive, but is not sure if she will tell him that she is pregnant. “Anything can happen. Maybe I won’t stay pregnant so then he would never have to know. I want to know if he is HIV positive and gave it to me. That’s what is important to me now. I have no idea what I am going to tell my parents. I can’t think about that now”.
Whenever possible, you should avoid telling clients what to say in a specific situation such as disclosure. You can provide certain language to avoid, e.g., “You did this to me.” Precious is not in need of professional counselling. She is not exhibiting signs of severe depression or suicidal tendencies. She is in need of ongoing counselling and support that you can provide.
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Key Points (5 min)
The process of sharing information with children and adolescents about their HIV status is based upon the following principles of disclosure:
- The best interests of the child
- Respect for the views and wishes of the family, parent/ caregiver
- A process, beginning with the first contact with the child and planned together with the family/caregiver
- Each child’s individual needs, understanding and maturity but the process may begin from 6-7 years
- The child’s need for honest, accurate, consistent information
- Child friendly techniques and participatory approaches