Integrated HIV Training for Healthcare Workers

Session 4: HTS for Children and Adolescents

SRH for Adolescents

We covered basic SRH earlier in the training, where we focused on adults. In this section we will talk more about SRH in relation to how we talk about it with adolescents. We know that counselling adolescents is challenging and when it is about sensitive topics it becomes even more so. The content in here will help you to find ways to cover the complex issues around SRH and risk reduction counselling for adolescents.

Learning Objectives

By the end of this section, you will be able to:

  • Demonstrate an understanding of the challenges HIV positive adolescents face when discussing SRH practice.
  • Ensure the provision of appropriate sexual and reproductive health rights (SRHR) counselling for adolescents in your context.
  • Demonstrate effective risk reduction counselling skills.
  • Discuss family planning as it relates to adolescents.
  • Describe to an adolescent in an age appropriate manner the structure and functions of reproductive organs in males and females.

Learning Activities

  • Knowledge Check (15 min)

    1Sensuality is knowing how to make your partner feel good.

    2Intimacy is the ability to be emotionally close to another human being and accept closeness.

    3Sexual orientation is the same as homosexuality.

    4Sexual coercion is sexual behavior to influence, manipulate or control a person.

    5Sexual maturation occurs once an adolescent hits the age of 14.

    6A girl can get pregnant if she’s on her period.

    7Once one STI has been identified, it is unlikely another STI is also present.

    8STIs are generally not preventable.

    9HIV is an STI.

    10An individual with an STI is at greater risk for HIV acquisition.

    11Most adolescent girls newly diagnosed HIV positive are already symptomatic and classified in WHO stage 3 or 4.

    12Adolescents diagnosed with HIV do not require healthcare services that are any different than HIV positive adults.

    13Many HIV positive adolescents may accept and benefit from peer support groups even more than adults and should be referred by the PC soon after their diagnosis.

    14Which of the following is the best definition of gender identity?

    15All of the following are ways to check that condoms are safe to use except:

    16What are the modes of HIV transmission for adolescents? Select all that apply.

    17Which of the following are reasons that adolescents engage in pre-marital sex? Select all that apply.

    18Sexual rights for adolescents include which of the following? Select all that apply.

    19What are some indicators that help you identify when you should be discussing sex with an adolescent who is HIV positive? Select all that apply.

    20You are counselling Padaishe, a 17-year-old male client. He expresses that he has sexual feelings for someone of the same gender. What would be appropriate responses? Select all that apply.

  • SRH Basics (40 min)

    View the following lecture about the basics of reproductive health.

    Credit
    UW I-TECH and UW Department of Global Health E-Learning Program
  • Thembani (20 min)

    Thembani is 15 years old. She has a 19-year-old boyfriend and today she discloses to you that she wants to have a sexual relationship. She tells you that all of her friends are sexually active and she feels left out. She wants to show her boyfriend that she is HIV negative so that he will agree to have sex with her. He has told her that he loves her and that the reason she is so special is because she is a virgin. He assures her that he understands she is nervous but he knows this is right and that he wants to spend the rest of his life with her. She feels that it is important that she has an HIV test but does not want her mother to know about her boyfriend or that she is having the test.

    1Is Thembani eligible to consent to an HIV test without her mother’s knowledge?

    2What adolescent traits are prominent in this scenario? Select all that apply.

    3All of the following are characteristics of adolescent girls and older sexual partners except:

    4How would you begin your pre-test counselling session with Thembani? Select all that apply.

    Remember that there are major SRH issues are you will want to discuss in your pre-test counselling session with Thembani. Issues that should be covered are:

    • Understanding puberty: Thembani should be aware of changes in her body and the impact of hormones on her emotions, moods and sexual feelings.
    • STIs: she should be asked about any vaginal discharge or any pains she may be having.
    • Pregnancy: ask Thembani what she knows about pregnancy, conception, ovulation and hormones.
    • Condom use: how to use both male and female condoms correctly and consistently. Also the correct storage and disposal of condoms.
    • Relationships: what it looks like to be in a healthy relationship, knowing her rights, not being coerced into sex.
    • HIV: make sure Thembani understands the basics of HIV, including how HIV can be transmitted and prevention of HIV.
    • Family planning: discuss the different methods available.
    • Peer pressure: talk with Thembani about the fact that the pressure to conform can be powerful and hard to resist. Remind her that sometimes making the right decision may feel unpopular and is difficult to do.
    • Abstinence: discuss the option of not indulging in sex and how she can be in a relationship without sexual intimacy.
    • Hygiene: discuss with Thembani bathing daily, washing only the external genitalia, correctly wiping, awareness of fluids or discharge, and any unusual sensations.
    • Reproductive organs: make sure she understands the organs and functions, as well as menstruation.

    Thembani appears nervous. She looks down when she answers your questions. She tells you her last period was about a month ago but it is hard to remember since her cycles are very irregular. She tells you that the only time she has come to the clinic is for occasional colds or flu and to get her vaccinations. When you ask her if she is having any problems urinating or any unusual vaginal discharge, Thembani puts her hand over her mouth and begins to laugh. “Why are you asking me so many private questions? I just came here for an HIV test. My friends told me it would be quick and they did not tell me they had to answer any embarrassing questions. Maybe I should go somewhere else for the test?”

    5How do you respond to Thembani?

    You decide to ask Thembani questions about school, her friends and things she likes to do for fun. Almost immediately she begins to relax. Her body language changes, shoulders down, posture not as stiff as when she came in. She tells you she loves to hang out with her friends especially when they are all with their boyfriends. But they can’t do that too often because her family and the elders in her village don’t like when she is with boys. When you ask her if she has had any sexual contact with her current boyfriend or in the past, Thembani tells you that he has never been inside of her but they have kissed a lot. Lately he has wanted her to kiss him “down there” and she did once and even though she was feeling good she did not like doing it. Her friends told her that boys expect that from their girlfriends and it the first thing that should be done before you go all the way!

    You ask Thembani if her boyfriend has taken an HIV test. She tells you that he told her he had a test when he broke up with his previous girlfriend and he is HIV negative. She knows he has not been with any other girls since then. Thembani comments, “And everyone knows what someone looks like when they have the virus and my boyfriend doesn’t look sick”.

    6How will you explain to Thembani the importance of partner testing? Select all that apply.

    Thembani seems to be more comfortable talking to you so you again ask her if she is having any problems urinating, any unusual vaginal discharge or abdominal pain. She denies any symptoms but asks you what it means when a girl has “bumps” down there? You ask her if she has any bumps and she immediately tells you no, and adds that her “best friend had to take medicine for bumps down there”.

    7All of the following points are important to cover related to STIs except:

    You ask Thembani if she knows how to prevent getting pregnant. She responds by telling you, “My friends told me to make sure my boyfriend comes out of me before the stuff comes out of his thing. I was told that I could prevent getting pregnant by jumping up and down on one spot after sex and taking a bath to wash out his stuff. They also told me that you cannot get pregnant during your time of month or immediately after. And my one friend got pregnant because she had sex right before her cycle. That’s why you need to keep a record every month.”

    8Before providing information and further explanation to Thembani, what can you do immediately following her statement to ensure that Thembani better understands sexual intercourse?

    9What points are important to cover related to pregnancy? Select all that apply.

    While talking to Thembani you get a sense that she may be questioning whether she really wants to begin a sexual relationship with her new boyfriend. Her non-verbal communication is what is making you suspect that she may be feeling pressured into sex along with her repeating that her friends have told her that “the only way to prove you love your boyfriend and keep him from dating other girls is to have sex with him”.

    10What are the potential physical and psychological consequences for young adolescents who become sexually active? Select all that apply.

    11What are some ways other than sexual intercourse that you can tell Thembani that she can show her affection toward her boyfriend? Select all that apply.

    12All of the following are important points that you can share with Thembani to encourage her to stay abstinent or delay sexual activity except:

    You decide to bring up the topic of abstinence. You ask Thembani if she ever thought about or discussed waiting until she is older to have sexual intercourse. Thembani’s body language changes again, back to when you first started your counselling session. She is looking down and you notice she is crying. Thembani tells you that she has already had sexual relations with her first boyfriend. They stopped seeing each other when she found out he was seeing many other girls. This was in another village when she was living with her grandmother. Her mother found out and made her move back here and that is when she met her current boyfriend. He thinks she is a virgin and now she is not only afraid she will lose him when he finds out she is not, but she is also worried about the HIV test. She was afraid to tell you especially after hearing why it is important to remain abstinent and the risk of STIs. You provide comfort to Thembani again telling her that you are very happy she has revealed this important information and come in for HIV testing.

    13What additional questions do you need to ask Thembani based on this new information? Select all that apply.

    Pre-test counselling is provided to Thembani. She reveals that the last time she had unprotected sex was approximately three months ago but you notice that she hesitates when answering the question. An HIV rapid test is done and the result is negative.

    It has been a long counselling session and Thembani is looking very tired but before she goes you need to talk to her about using condoms if she decides to have sex with her boyfriend. She tells you that none of her friends ever make their boyfriends use condoms because they are too tight and do not feel good for the boy or girl. She tells you that everyone knows that when your boyfriend uses a condom, it causes an infection in the girl because of the material the condom is made of. And “everyone knows that if you jump with your legs apart after doing it, the stuff will come out of you and you do not get pregnant. When I had sex with my first boyfriend, I would push warm water inside me when we were done. That is what my best friend told me to do to stop from getting pregnant and to keep clean”.

    14How do you respond?

    15What information does Thembani need to know about female hygiene? Select all that apply.

  • Precious Part 1 (10 min)

    Precious is 17 years old. She has been with her boyfriend Tonderai for over a year. They both attended the same school although Tonderai dropped out to begin working in his father’s business. Tonderai is 23 years old. They have known each other since they were children as they live in the same village and their families go to the same church. Over the past few months, Precious and Tonderai have been known to “break up” because Precious has heard from her friends that Tonderai talks to and flirts with other girls. Despite their close families, each of their parents have not been supportive of their relationship. The parents think that Precious and Tonderai are too young to be dating. Precious’s parents think that she should concentrate on her school work and try for a scholarship to get into university. Her parents are not aware that they are continuing to date.

    Precious arrives in clinic today complaining that her period did not come this month. The clinic nurse tells you that Precious’s pregnancy test is positive. Precious is crying and the clinic nurse asks you to speak to her about the test results and to offer HIV testing. When you walk into the room, Precious tells you “I can’t be pregnant. Tonderai and I were always careful. Tonderai will be very upset with me and my parents will be very angry at Tonderai”.

    1What is your next step for Precious?

    2What is the intended focus of counselling an adolescent in a situation like Precious is facing? Select all that apply.

    3Review what Precious has said following being told she is pregnant (“Tonderai will be very upset with me and my parents will be very angry at Tonderai”). Is there something in her response that alerts you to potential challenges Precious may be facing and counselling interventions immediately needed? Select all that apply.

    4Precious tells you that she has heard that you can “get rid of the baby” and tells you she wants to go find somewhere to take care of it. How do you respond to this? Select all that apply.

    Precious has calmed down and she knows she must have an HIV test although she asks you several times if she can just come back tomorrow for the test since she is feeling very tired and upset. You bring the clinic nurse back in the room to talk to Precious and she finally agrees. The result is positive. You decide to bring the nurse back in when you tell Precious her results since she seemed to be more relaxed with the nurse in the room. Surprisingly, Precious does not react when she is told she is HIV positive. When asked if she understands what you have just told her she nods her head and says “yes”. She tells you that she suspected this since she heard all of the rumors about Tonderai being with other girls. “At least this is something that I do not have to tell my parents about since they can’t see HIV”.

    Review the response that Precious had when she was told her HIV diagnosis.

    Surprisingly, Precious does not react when she is told she is HIV positive. When asked if she understands what you have just told her she nods her head and says “yes”. She tells you that she suspected this since she heard all of the rumors about Tonderai being with other girls. ‘At least this is something that I do not have to tell my parents about since they can’t see HIV”

    5What are the priority counselling areas that you need to address during this visit?

    6You know that according to the Zimbabwe Constitution, all persons have a right to privacy including the right not to have their health condition disclosed. But what do you need to discuss with Precious about disclosing her HIV status that is in line with the Constitution? Select all that apply.

  • Key Points (5 min)
    • Counselling adolescents around SRH is complex and challenging.
    • It is necessary to be educated on correct terminology so that when providing counselling for adolescents on SRH you are able to be clear.
    • Part of SRH for adolescents is risk reduction.