HTS for Children and Adolescents

Week 3: Sexual and Reproductive Health

Notes: Content in this week covers module 7, session 4 in the HTS for Children and Adolescents manual. In addition, there is some basic reproductive health information which is covered this week. Keep in mind that everyone has their own style of counselling. Some of the questions will ask you to write down your thoughts about different topics in your workbook and then “compare answer”. We have provided sample responses from experts. You may find that you have written something that is not listed. This does not necessarily mean your response is wrong.

Learning Objectives

Upon completion of this week, you will be able to:

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

This week pay attention to counselling adolescents in the context of SRH. You will have an opportunity to share an experience you have had in working with an adolescent and also commit to making a change about the way you provide counselling to adolescents in the future. You will use your Action Plan to document your challenges and plans related to this week’s topic.

Learning Activities

  • Podcast: Red Ribbons and Roses (5 min)
    Instructions

    Listen to this podcast from the book Red Ribbons and Roses, created by a group of HIV positive youth. In your workbook, write down your answers to the question below.

    Credit: Africaid Zvandiri, Zimbabwe
    Questions
    1. How did it feel for you to fall in love for the first time?
    2. How do you think that this experience may be different for a young person who is HIV positive?
    3. When counselling adolescents, how comfortable are you bringing up the topics of relationships, dating and sex?
  • Check Your Knowledge: Sexual and Reproductive Health (25 min)
    Instructions

    Complete these quiz questions to check your knowledge on Sexual and Reproductive Health (SRH) counselling for adolescents.

    1.The strategy for comprehensive PMTCT of HIV includes four prongs: 1) Primary prevention of HIV; 2) Preventing unintended pregnancies in women with HIV; 3) Preventing vertical transmission or HIV transmission from women to their infants; and 4) Providing care, treatment and support for mothers with HIV and their children. Describe in detail how the first 2 prongs of PMTCT (HIV Prevention and Family Planning) relate to your work addressing SRH in adolescents with HIV. Write your response in your workbook, then click the compare button.

    Compare Answer

    Answer true or false to the following statements which define some terms used in SRH and information about STIs.

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

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

    4.Sexual Orientation is the same as homosexuality.

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

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

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

    8.A girl can get pregnant the first time she has sex.

    9.When a boy has an erection he has to have sex.

    10.If someone is taking ARVs, it is impossible for him or her to spread HIV.

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

    12.STIs are generally not preventable.

    13.HIV is an STI.

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

    15.HIV can cause more severe STI presentations.

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

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

    18.Many 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.

    19.Which of the following is the best definition of gender identity? Select all that apply.

    20.What do condoms protect against? Select all that apply.

    21.How do you see that condoms are safe to use? Select the correct response.

    22.What are the modes of HIV transmission for adolescents?

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

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

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

    26.You 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).

  • Video: Sexual and Reproductive Health Basics (60 min)
    Instructions

    View the following short lecture about the basics of reproductive health.

    Credit: UW I-TECH and UW Department of Global Health E-Learning Program
    Questions

    Now that you have viewed the lecture on sexual and reproductive health, answer the following questions from adolescent clients. In your workbook, write down how you would answer their questions. Be sure to answer questions for both boys and girls. Click on the compare button to see examples of correct responses to the questions.

    1.I am noticing some changes in my body, what is going on?

    Compare Answer

    2.What other changes in my body will happen during puberty?

    Compare Answer

    3.Why are you telling me all this about puberty? Why do I need to know this?

    Compare Answer

    4.Why am I having bleeding every month? (Write how you describe menstruation with your adolescent clients.)

    Compare Answer

    5.Why do women menstruate?

    Compare Answer

    6.Is it normal for the penis to smell and have whitish stuff on the tip?

    Compare Answer

    7.How does an erection happen? I thought it only happens if a boy thinks about sex.

    Compare Answer

    8.What is Sperm?

    Compare Answer

    9.What is circumcision?

    Compare Answer

    10.How does someone get pregnant?

    Compare Answer

    11.Aren’t there times of the month when I can’t get pregnant? I could just have sex then right?

    Compare Answer

  • Podcast: Can I Date? (5 min)
    Instructions

    Listen to this podcast from the book Red Ribbons and Roses, created by a group of HIV positive youth. In your workbook, write down your answers to the questions below.

    Credit: Africaid Zvandiri, Zimbabwe
    Questions
    1. What are some of the challenges you face when having counselling sessions with adolescents around SRH?
    2. Samantha raises the issue of statements made by religious leaders which point at HIV as a punishment (“My dear sons, if you are not prayerful and wise you will not marry a girl who fears God, you will end up with a girl who has HIV, and what good will that be for you?”). How would you respond to that if an adolescent brought that up?
    3. How do you respond to an HIV positive adolescent who thinks the only option is to date another HIV positive person?
  • Case Study: Thembani (30 min)
    Instructions

    Complete the case to learn more about counselling adolescents about SRH.

    Background

    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.

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

    2.What adolescent traits are prominent in this scenario? Write answers in your workbook, then tap the compare answer button.

    Compare Answer

    3.Which of the following are characteristics of adolescent girls and older sexual partners? Select all that apply.

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

    5.What major SRH issues are you going to discuss in your pre-test counselling session with Thembani? List 6-8 topics in your workbook then tap the compare answer button.

    Compare Answer

    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?”

    6.How 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”!

    7.Why do adolescents and young adults engage in pre-marital sex? Select all that apply.

    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”.

    8.How 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”.

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

    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.”

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

    11.What 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 or not 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”.

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

    13.What 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.

    14.What are some important points that you can share with Thembani to encourage her to stay abstinent or delay sexual activity? Select all that apply.

    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.

    15.What 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 3 months ago but you notice that she hesitates when answering the question. An HIV rapid test is done and the result is indeterminate.

    16.What information do you need to provide to Thembani to explain an indeterminate HIV test result?

    It has been a long counselling session and Thembani is looking very tired. You ask her if she can come back in a few days to continue your discussion but before she goes you need to talk to her about using condoms if she decides to have sex with her boyfriend. She gives you a look that tells you that she is not happy with what you are about to tell her. 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”.

    17.How do you respond? Select all that apply.

    Thembani is worried that her boyfriend will refuse to wear a condom. “How am I going to tell him to do this? What should I do if he refuses? If I do not have sex with him, he will find another girl and I will be alone”.

    18.What are some ways that you can share with Thembani about negotiating condom use? Select all that apply.

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

  • Podcast: Sex - Thinking for Yourself, Not your Peers! (5 min)
    Instructions

    Listen to this podcast from the book Red Ribbons and Roses, created by a group of HIV positive youth. In your workbook, write down your answers to the question below.

    Credit: Africaid Zvandiri, Zimbabwe
    Questions
    1. What do you consider to be some of the responsibilities that come with having sex?
    2. How can you encourage adolescents to resist peer pressure, without encouraging them to reject their friends, or what their friends say?
  • Case Study: Precious, Part 1 (15 min)
    Instructions

    Complete the case to learn more about counselling a pregnant teen.

    Background

    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”.

    1.What is your next step as the primary counsellor for Precious?

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

    3.Review 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.

    4.Precious 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”

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

    6.As a PC, you 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.

    Precious is brought back to the ANC clinic and you note that her weight is recorded as 43kg and her height is 165cm. Precious looks thin and you ask her if this is her normal weight. She tells you that her clothes have been getting very big on her and for the past few months, she feels sick in the morning but thought that was due to the stress she was feeling about school, Tonderai and her parents.

    7.Based on the height and weight recorded, what nutritional counselling do you need to provide for Precious?

    The clinic is extremely busy today and after the ANC nurse finishes examining Precious, she hands her a prescription for medication that she must begin today and refers her back to you for instructions on the medication and to answer any questions. Precious begins to cry again and tells you that “everything is so rushed. I am so confused and can’t remember anything that the nurse told me. Why do I have to take a pill now? Can’t I wait and talk to Tonderai first?”

    8.What is your response to Precious?

  • Podcast: Pregnant! (5 min)
    Instructions

    Listen to this podcast from the book Red Ribbons and Roses, created by a group of HIV positive youth. In your workbook, write down your answers to the question below.

    Credit: Africaid Zvandiri, Zimbabwe
    Questions
    1. What are some messages you give to adolescents about avoiding unintended pregnancies?
    2. How effective are your messages?
    3. What could you do to be more effective?

    Feedback

  • Action Plan (30 min)
    Instructions

    In your workbook, fill in the Action Plan for this week. There are three parts to fill in.
    Part 1: Describe a challenging case. The worksheet will help you to develop the details.
    Part 2: Create a strategy. From the ideas generated above to address the challenge, choose one and create a strategy to apply in your workplace.
    Part 3: Putting your learning into action. Using the worksheet, you will list out what you learned this week and how you will apply it to your job.

  • Partner Discussion (30 min)
    Instructions

    Using WhatsApp, send your response to the following discussion topic to your partner before midnight on Thursday. By midnight on Saturday, please post thoughtful responses to your partner’s posts. To get credit, forward the discussion to the administrator before midnight on Sunday.

    Discussion Topic: Looking back at the reflection questions from listening to the podcasts earlier in the week, using WhatsApp with your partner:

    1. Share with your partner one of the challenges that you face in counselling adolescents about SRH.
    2. Share a specific strategy that you have or plan to use to overcome this challenge.