HTS for Children and Adolescents

Week 4: Disclosure Counselling for Children and Adolescents

Notes: Content in this week covers Module 7, Session 2 (pages 107-116), in the HTS for Children and Adolescents manual. 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:

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.

Practice

This week pay attention to principles, skills, techniques, and strategies for counselling children and adolescents with regards to disclosure. You will have an opportunity to self-assess, share an experience with your WhatsApp partner, and commit to making a change about the way you provide disclosure counselling. Use your Action Plan to document your challenges and plans related to this week’s topic.

Learning Activities

Podcast: Should I Tell Him? (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. When do you think is the best time for an HIV positive child or adolescent to disclose their status?
2. Who should they disclose to?
3. What are some of the issues that children and adolescents are concerned about when they think about disclosing their HIV positive status?
Check Your Knowledge: Disclosure Counselling for Children and Adolescents (20 min)
Instructions

Complete these quiz questions to check your knowledge on the principles, techniques, and skills of counselling children and adolescents on disclosure.

Answer true or false to the following questions.

1.Disclosure means sharing your HIV status with someone.

True

False

Feedback

True. Disclosure means sharing your HIV status with another person. Disclosing your HIV status is not easy and can be frightening.

2.Disclosure to a child of his/her HIV status is a one-time event.

True

False

Feedback

False. Disclosure to a child about his or her own HIV status is a process that involves ongoing discussions about the disease with the child or adolescent. The gradual sharing of information about HIV status is done in a manner that helps him or her to understand and cope with current life events.

3.Partial disclosure is when you tell a child he or she has an illness but do not name HIV.

True

False

Feedback

True. Young children (usually up to about 6 years old) are given partial disclosure in partnership with the parent or caregiver. The child is provided with accurate and honest information in words he or she understands that helps to explain what it means to have a chronic illness and that it can be treated.

4.Disclosure of one’s HIV status can be both risky and beneficial.

True

False

Feedback

True. Disclosure is one of the most crucial yet one of the most challenging components of counselling children and adolescents with HIV. If disclosure is not handled appropriately, this could cause long-term damage for the child or adolescent and his or her family. However, if it is handled well, you have the potential to equip a child or adolescent, and his or her family, with knowledge, understanding, and coping strategies that will greatly assist with the process of coming to terms with an HIV status.

5.Trust is an important part of disclosure.

True

False

Feedback

True. Children and adolescents who are living with HIV will question themselves: “Who can I trust? If I tell someone, will he or she reject me? Will they abuse or hurt me? Will they tell someone else that I am living with HIV or have AIDS?” Young people need support with determining who they can trust, deciding whom they want to share their status with, and practicing how to disclose.

6.Disclosure is the same for children and adolescents.

True

False

Feedback

False. For children, there is the issue of whether they are aware of their own status as well as the issue of who else they share their status with. Also for a prenatally infected child, the parents or caregivers may have disclosed the child’s status to others before the child was told. For adolescents, disclosure is about who in their lives they are comfortable sharing their status with.

7.Unlike the effects of disclosure on adherence with adults, disclosure does not improve adherence to care and treatment for adolescents.

True

False

Feedback

False. Disclosure to others is associated with better treatment adherence as a result of not having to hide medication and reducing the sense of isolation, which improves mental health overall.

8.Adolescents successfully disclosed their status if the disclosure is done in the presence of the PC.

True

False

Feedback

False. Your role includes guiding adolescents as to the best place to disclose their status, keeping safety in mind. Adolescents may prefer to disclose in your presence, especially if they anticipate there will be technical questions that they may not feel comfortable answering.

9.Prior to disclosure, adolescents should be given a basic test to ensure that they know the correct terminology and facts about the virus, antiretroviral treatment, adherence, and safer sex options.

True

False

Feedback

False. Your role is to provide ongoing education to address living with HIV. A quiz or test prior to disclosure is not appropriate.

Compete the quiz questions to check your knowledge on disclosure of HIV for children and adolescents.
10.What are the possible benefits of children or adolescents disclosing their HIV status? List 6-8 benefits in your workbook, then tap the compare button.

Compare Answer
- May feel relief at learning the cause of their illness; misconceptions about the illness are cleared up
- May improve adherence to medication
- May improve social functioning and school performance
- Can provide emotional support through difficult times and can celebrate with them when good things happen
- Family and friends can provide essential support if they are adequately informed
- Can provide transportation to doctors’ appointments
- Can help in getting an adherence buddy
- Can help put into practice a plan for living positively
- May relieve the stress of keeping secrets to share status with someone
- Will help to reduce the secrecy, stigma, and discrimination surrounding HIV
- Other PLHIV in your community are more likely to follow suit and share their HIV status too
- Health care providers who know their client is living with HIV can offer appropriate care and treatment
- A romantic partner can provide emotional support and help practice safer sex
11.What are some barriers to full disclosure for children and adolescents? Select all that apply.

A. A belief that the child or adolescent will not understand or be able to adjust and cope

B. A desire to protect the child

C. Fear that the child or adolescent will tell other people

D. Stigma and discrimination

Feedback

All of the answers are correct. Parents and caregivers often have their own issues to work through before telling a child his or her status. They may have their own guilt or shame or may not yet feel comfortable with their own status. There is often a fear of adverse consequences for the child or adolescent, which include anger, rejection of the parent or caregiver, and psychological damage. Sometimes the parent or caregiver may have a lack of knowledge about HIV. You may need to first work with the parent or caregiver to help them with their own fears and concerns about disclosure before working with the child or adolescent. You should also counsel them on the negative impact on the child or adolescent of delaying disclosure (depression, blaming themselves for events, inability to trust, interference with treatment and more). Also, sometimes disclosure of HIV positive status has the potential of stigma, violence and abandonment, often at the hands of the people closest to the one disclosing.

12.What do you do if a parent or caregiver refuses to disclose results to a child or adolescent below 16 years old? Select all that apply.

A. Nothing, it is up to the parent or caregiver when and how to disclose.

B. Act in the best interests of the child or adolescent and tell them yourself.

C. Act in the best interests of the child by assessing if they are mature enough to get the results.

D. Act in the best interests of the child by confirming if there is anyone else who can provide support.

E. Act in the best interests of the child by establishing if disclosure of the results will be beneficial.

Feedback

C, D, and E are correct. If the child is under 16 years old and not emancipated, you can disclose status if a mature minor.
13.In the following section, write in your workbook the benefits and risks of disclosure to the people listed. Tap the compare button to check your responses.
- 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, 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.
Compare Answer
Case Study: Susan and Mary, Part 3 (30 min)
Instructions

Complete the case to learn more about counselling children through the disclosure process.

Background

As you recall from Parts 1 and 2 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.

1.What is your role?

A. Offer to make the disclosure of Susan’s HIV status

B. Offer to leave the room

C. Sit in while Mary tells Susan that she is HIV positive

D. Tell Mary that the Zimbabwe policy for disclosing HIV to a child requires an adult along with the PC to be present when Mary tells Susan her results

Feedback

C is correct. You should be clear that the caregiver is the one to provide the disclosure and you are there to help deal with the emotions and information sharing. You should reassure Mary that her wishes regarding disclosure/information sharing will be respected. Mary should be told that you will not lie to Susan and that if Susan asks direct questions, you will give simple direct answers or refer her back to Mary.

2.What skills and techniques do you use to assess readiness of disclosure from caregiver to child? Select all that apply.

A. Questioning skills

B. Reflective listening skills

C. Empathy

D. Empty chair

E. Vacation

F. Role playing

G. Shifting alliance

H. Widening the system

Feedback

A, B, C, D, F, and H are correct. Remember the session is with the caregiver only right now so there is no need for shifting alliance or using vacation. This list of skills and techniques are only some of the ones you can use. There are others to employ, which would be appropriate, such as empowering or summarizing.

3.What is your next step in your session with Mary? Select all that apply.

A. Inform Mary that there is a good chance that Susan will become depressed and Mary should first talk to a close adult friend or neighbor who knows how her parents passed on, tell that person about Susan, and ask him or her to be present when Susan is told she is HIV positive.

B. Assess Mary’s knowledge of HIV by using components of the Soldier Game to ensure that she will provide Susan with accurate information.

C. Thank Mary for making the decision to disclose to Susan and ask her why she feels that now is the right time.

D. Disclosing an HIV positive test result to a child with active TB should wait until at least the initiation phase of TB treatment is completed.

Feedback

B and C are correct. It is important for Mary to understand HIV and have accurate information so she can answer Susan’s questions at home. It is also important for you to know why Mary feels that the time is right to disclose to Susan.

It is not necessary to include an adult from the community when Susan is given her results. Mary may decide to tell a close friend or neighbor but it will be important for you to discuss this further and assist Mary with making that decision. There is no medical reason to wait until after the initiation phase of TB treatment to disclose an HIV diagnosis to a child.
4.How do you assess whether Susan is ready to receive her HIV positive status? Write your responses in your workbook, then tap the compare button.

Compare Answer
- Ask if they have discussed HIV at home, especially the transmission
- Ask Mary if Susan knows about HIV and what she understands
- Ask how well Susan understands her TB treatment
- Ask about how Susan is taking the tablets for TB
- Ask if there are any side effects or challenges with the TB medication
- Ask about Susan’s emotional maturity
- Ask about support systems
- Ask how Susan has coped with the loss of their parents
Keep in mind that you may have some additional responses that are not listed. The main idea is that you want to assess whether Susan seems motivated on her own to take her tablets. You also want to find out how she has handled her TB medication and diagnosis because these are indications of how she can handle the disclosure. Assessing readiness of a child to receive an HIV positive diagnosis involves checking both with the caregiver and the child.
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.

5.From Mary’s response, do you think Susan is ready for disclosure?

A. Yes

B. No

Feedback
The correct answer is yes because:
- She is past the age of disclosure (age 6 is the age of disclosure and Susan is age 8).
- Susan has an understanding of events around her – such as the past with her parents’ illness and death and present with her own medications and response to them.
- Susan has her sister as a support system, as well as the clinic.
- The best interest of the child principle applies to Susan’s situation.
6.What happens next in the counselling session?

A. Tell Mary that she should bring Susan to the clinic next week.

B. Tell Mary she has to stop giving the TB medication.

C. Ask Mary if she has any questions since your last visit or any other thoughts about telling Susan her HIV results.

D. Give Mary the ART to give to Susan.

Feedback

The correct answer is C. While it is important for you to schedule a time for Mary to bring Susan back, you first should begin a follow-up session by asking if Mary had any questions since your last visit. This approach encourages her to share any questions or concerns that occurred since the last clinic visit.

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.

7.How do you begin the session?

A. Welcome Susan and focus your attention on her.

B. Tell Susan that Mary is the one who wanted this meeting and to direct all questions to Mary.

C. Tell Susan that she will be getting another prescription for medicine she needs to take every day along with her TB medicine.

D. Ask Susan “are you taking your TB medication on time?”

Feedback

The correct answer is A. Remember to begin every client or family session with a warm greeting. Acknowledge successes as well as positive body changes, like weight gain, improvement in walking, or strength. You could tell Susan how well she looks, praise her for what she has accomplished so far, and ensure that you focus your attention on Susan.

Your role is to support the client and family member during the difficult time of disclosure. It is not helpful to you or the child to have all questions directed only to the family member. B is not correct because immediately telling a child that he or she will be taking more medication without introducing the reason why will not help the child in accepting, tolerating, or adhering to the medication. D is not correct because this is an example of a closed-ended question, which you should avoid when discussing adherence with either a child or adult living with HIV and/or diagnosed with TB.

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.

8.What do you do now? Select all that apply.

A. Use silence technique.

B. Tell Mary to stop crying.

C. Address the emotions.

D. Tell Susan that Mary is acting too emotional.

Feedback

A and C are correct. Susan is confused and Mary is crying. You should offer a tissue and acknowledge and validate Susan’s confusion, as well as Mary’s emotions. Let them know that they are not alone.

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.

9.As Susan’s PC, what do you think about her response to Mary’s information? Select all that apply.

A. Susan’s reaction is worrisome. You should expect a reaction to her sister crying and at least one question from Susan that will let you know she heard the information.

B. Susan’s reaction is concerning because she did not try to comfort her sister nor is she asking questions.

C. Susan’s reaction may be the way Susan responds to new information and she may be confused by her sister’s crying. It is important for you to comfort Mary and help her compose herself so she does not upset Susan.

D. Children and adolescents will react differently to hearing an HIV positive diagnosis. Susan’s response is the way Susan is processing the information.

Feedback

C and D are correct. Your role is to not only provide support and comfort to the child who is receiving the news, but also to the family member who is disclosing. Disclosing can be a very traumatic experience for an adolescent or adult who is responsible for the disclosure.

10.What can you do in this situation to provide comfort and support to Susan and Mary? Select all that apply.

A. Tell Mary that there is important information that you must discuss and you need Mary to listen carefully so she can answer Susan’s questions.

B. Adjust your body to demonstrate a positive, supporting gesture by moving closer to Susan, maintain eye contact with Susan, and continue talking softly to her.

C. Talk directly to Susan and begin discussing HIV. Reinforce how important it is that Susan knows that she has the virus and that medicine will keep her healthy.

D. Tell Mary that you understand how difficult telling Susan has been and praise her decision. Shift your attention to Susan and periodically ask her if she has any questions, even though she may continue to sit quietly.

Feedback

B and D are correct. Your role is to be prepared for a variety of responses from children and adolescents who have been given a positive test result. Positive body language, such as moving close to the child or adolescent or holding his or her hand are essential steps that will demonstrate comfort and support. It is important not to rush the child or adolescent by moving on with more information until he or she has had time to absorb and understand.

11.After several minutes, Susan asks Mary “does this mean I am going to die like mum and dad” and “do I have to tell my teacher”? Mary looks to you for help with the answers. Select all that apply.

A. Ask Mary “Would you like to try answer Susan or would you prefer that I do and you can add any other information if you wish?”

B. It is important for Mary to learn to handle Susan’s questions. Tell Mary to answer as best as she can, reminding her that you told her about HIV during your last session so she has the information she can give to her sister.

C. Direct the following response to Susan “Those are both very important questions Susan. Mary and I will answer your questions as best as we can and we want you to keep asking questions as long as you want.”

D. Remain quiet and allow time for Mary to formulate the answers she will give Susan. You prepared Mary for this moment so she must be allowed to respond.

Feedback

A and C are correct. Even though Mary looks to you for help with answering Susan, it is important to ask Mary what she prefers before jumping in with your response. It is also essential to communicate to Susan that her questions are important. Encourage her to keep asking questions.

B and D are not correct. Despite providing Mary with information about HIV, she may not remember or she may feel overwhelmed emotionally and not capable of answering Susan’s questions.

12.After normalizing the emotions, what do you do? Select all that apply.

A. Bring Susan and Mary to the clinic nurse to continue the discussion about HIV and the medications Susan will be starting.

B. Tell Susan that you know she has questions. Since there are other people waiting to see you, it is important that she asks the questions now so you have time to answer them completely.

C. Tell Susan that it is OK if she needs time to think about what she has been told. Even though she may not have any questions now, she is free to come and talk to you as well as with her sister.

D. Assess Susan’s understanding of the information that she is HIV positive and help fill in the gaps by playing the Soldier Game.

Feedback

C and D are correct. Some children will have questions immediately and others may stay silent. A quiet child does not mean that he or she does not understand or does not have any questions. Your role is to reinforce that counselling is available to the child and caregiver and that all questions are important and will be addressed openly and honestly. During the Soldier Game address information sharing about HIV transmission, what the infection does to the body, what TB and OIs do to the body, and what ART is and how it works.

Mary asks you what she needs to do for Susan now that she knows her HIV status. Mary is worried that she may not recognize if Susan is sad, angry, or not understanding what she has been told.

13.What is your role following disclosure? Select all that apply.

A. A home visit by either you or a CHW should be scheduled for the next day or two following disclosure to ensure that Mary and Susan are coping and to continue counselling.

B. Ongoing support is provided by community and peer support groups since you and the clinic staff have a limited amount time.

C. Ongoing support is provided by Susan’s healthcare provider, who will be initiating ART and monitoring Susan’s clinical and psychosocial status.

D. Susan should be told that she is free to come and talk to you with or without Mary present.

Feedback

A and D are correct. If possible, a home visit will provide you with important information about their living conditions and may put them more at ease asking additional questions. Susan may not feel comfortable asking questions in front of Mary for fear of upsetting her or being embarrassed. Children should be given the message that they can request a meeting with you alone.

Also, provide information about local support groups available.
14.Counselling will continue through childhood into adulthood. List 2-3 overall goals for the ongoing counselling in your workbook, then tap the compare button.

Compare Answer
- Help children to make choices and decisions that will improve their quality of life.
- Empower them through involving them in their care.
- Assist them to develop goals and to recognise and build on their own strengths.
- Promote children’s sense of self control and self-esteem.
Workbook Activity: Self-Reflection (15 min)

Instructions

Thinking back to the most recent time you have assisted with disclosure of HIV to a child, critically assess how you handled the counselling session. Complete the assessment in your workbook.
Podcast: Marriage, Acceptance, and Love (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. If you were Kelvin’s counsellor, what would you have said to him to empower him to disclose to his wife?
2. How would you continue to work with Kelvin and his wife now that they are a discordant couple?
Video: Modesta (10 min)
Instructions

Watch the video, “Modesta.” In your workbook, write down your answers to the questions below.

Credit: Africaid Zvandiri, Zimbabwe

Questions
1. What was the video about?
2. Why did Modesta’s father lie about taking medication and being in hospital?
3. What was her reaction to her HIV test results? Did her reaction surprise you?
4. 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?
Case Study: George (15 min)
Instructions

Complete the case to learn more about counselling adolescents through the disclosure process.

Background

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.

1.What are the important strategies and/or questions that you should think about using when discussing disclosure to an adolescent who may become or already is sexually active?

A. Review up-to-date information about the adolescent’s medical/HIV status, e.g. most recent laboratory results particularly viral load to ensure his reported “good adherence”, any current medical problems, history of STIs.

B. Begin a risk assessment by asking about sexual history.

C. Limit the discussion to important points like the facts about condom use, avoiding STIs, and the importance of 100% adherence to his HIV medication.

D. Build on a “trust bank” that has developed over time.

Feedback

D is correct. As important as it may be for you to get all of his information to best help him, you want to ensure that he continues to feel trust in you as his counsellor. Ideally, the discussion will be most comfortable for you and George if you have established a “trust bank” meaning that a good trusting relationship has been developed over time, which will enable George to talk freely and comfortably about personal issues. You want to make sure that George always feels as though you are really actively listening and addressing his concerns.

2.What issues do you need to explore with George? Select all that apply.

A. Ask George if he has had sex. Tell him that if he did have sex and did not tell his girlfriend his status or wear a condom, he put her at risk for becoming infected.

B. Remind George that he is still considered an adolescent. However, dating makes him an adult, so he needs to think and make decisions like an adult.

C. Using a trusting and warm approach to this sensitive topic, thank George for sharing this important, good news and ask general, non-sexual questions that will invite him to tell you more about his girlfriend.

D. Use direct, non-threatening questions to find out if George has had sex with his girlfriend and thank him for sharing the information.

Feedback

C and D are correct. The initial reaction and approach you take with George as he is sharing this important and potentially life-changing news is essential for the immediate conversation as well as the long-term relationship you have as counselor and client. A is not correct because while the information is correct, the way the question is being asked and potentially negative tone of the question could lead George not to tell you the whole story, share current or future sensitive issues, or ask personal questions. B is not correct because this reply does not invite George to discuss his feelings or share personal information.

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.

3.How do you encourage him to disclose his status? Select all that apply.

A. Invite George to role-play disclosing his status to you and provide him with feedback about the verbal and non-verbal communication techniques he used, such as appearing nervous by rubbing his hands together, not having eye contact, stumbling with the words he used, and not stating specifically that he is HIV positive.

B. Tell George he can be held accountable and put in jail if he does not disclose his status to a sexual partner.

C. Explain the benefits of disclosure that include honesty with his partner. He should educate her on the facts about HIV while dispelling the myths.

D. Invite George to bring his girlfriend to the clinic. Tell him that you can sit with them while he discloses his status to her and be available for any questions.

Feedback

A, C, and D are correct. You want to encourage, not threaten George to disclose his status to his girlfriend. You have a number of options for how to approach this with him and can offer him choices so that he can decide what feels most comfortable.
4.How would you explain the benefits of disclosure to George? Write your responses in your workbook then tap compare button.

Compare Answer
- Reduction of health risks to your girlfriend and yourself
- Peace of mind
- Not keeping secrets, which can ruin the relationship
- Reducing anxiety that comes from holding secrets
- Getting the relationship to a positive and honest start
- It is empowering and can help your personal growth
- She can become your treatment buddy if she is aware of your status
- Talk about the willful infection law and he could be jailed if he infects her
5.George agrees that he should disclose his status to his girlfriend. What questions do you need to ask George to help him prepare for disclosure? Select all that apply.

A. For how long have you been in this relationship?

B. Do you have a peer support system?

C. Did you tell your mother that you want to have sex?

D. Have you had other sexual partners?

E. Have you ever disclosed before?

F. Are you aware of the possible reactions you may get?

Feedback

A, B, D, E, and F are correct. You want to ask about peer support because relationships can be very stressful. You also want to explore if he has a support system if things do not go well. C is incorrect because, in general, adolescents do not share their sexual desires with their mothers.

6.What are some of the health issues you need to discuss with George? Select all that apply.

A. STIs

B. CD4

C. Negotiating condoms

D. Continued adherence

E. Abstinence

F. Pregnancy

Feedback

The correct answer is A, C, D, E and F. As covered in week 3, you want to talk about SRH issues with him so that he is making good decisions about having sex. It is important that you give George honest information and help him to understand all the consequences of being sexually active.

7.If you are working with an HIV positive adolescent who does not have a history of a STI and reports not being sexually active, how much information should be given about STIs? Select all that apply.

A. You should use a variety of educational tools to discuss STIs. Focus the information on primary prevention by wearing a condom for every sexual encounter.

B. Adolescents learn best by visual aids, so you should use pictures of common STIs and highlight the signs and symptoms as well as treatment.

C. Discussing sexual behaviour and risks of STIs should begin before a child becomes sexually curious or active and be provided in language understood by the individual, be age-specific, and be based on the level of maturity.

D. Discussing STIs or any other aspects of sexual behaviour should only be initiated if the child/adolescent specifically asks for information.

Feedback

A and C are correct. When working with children and adolescents, you need to incorporate a variety of client education tools into their counselling. Assess which ones are working for the individual client you are counselling. Introducing the topic of sexual health, behavior, and prevention of STIs is best if delivered in segments based on the child or adolescent’s understanding and maturity. The topic must be reintroduced periodically to ensure that the information is understood. Encourage any follow-up questions.

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.

8.What is the appropriate response to the information George is sharing?

A. “How many doses of your medication did you really miss? You say one but we both know it’s probably more than that.”

B. “We have talked about not missing any doses of your medication many times before and I warned you that the virus will become resistant to your medicine.”

C. “If you are not able to focus on important things like school and work at home, you are not ready to have a girlfriend.”

D. “Being distracted because of meeting a girl you are attracted to and like is not unusual. Let’s talk about how you are taking your medication now and some new ways you can be reminded to take every dose.”

Feedback

D is correct. It is important for you not to scold or threaten George when he admits to forgetting his medication. This is true for children, adolescents, and adults. Adherence counselling is best achieved by using open-ended questions to elicit as much information as possible about how the client was successful in the past and the reasons for missing doses now. In George’s case, it is clear that he is very happy and enjoying his new relationship with his girlfriend. Strategies that children use for adherence may not work as they get older so it is important for you to help George discover new ways to adhere.

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.

9.What is the correct response to George’s question?

A. This is a perfect opportunity to tell George not to use or trust medical information from the Internet.

B. Discuss with George the importance of adherence to his ART, as he has been doing, and acknowledge that research has shown that excellent adherence will lessen HIV transmission but will not prevent it completely. Condoms must be used for every sexual encounter to protect his partner from HIV, other STIs, and an unplanned pregnancy.

C. Tell George that having sex without a condom is punishable if his partner develops a STI or becomes HIV positive.

D. The role of the PC is to be aware of and knowledgeable of the most recent research findings and communicate those findings to their adolescent or adult patients in terminology that they will understand.

Feedback

The correct answer is B. Clients may have access to and use the Internet to search for information about HIV, and George has certainly come across the latest findings about ART for prevention. It is essential for you to assess and reinforce the importance of condom use every time George has sex.

10.In helping George plan how to disclose, what are some of the considerations you want to address with him? Select all that apply.

A. The best time to disclose.

B. Support systems.

C. A safe place to disclose.

D. Potential risks of disclosure.

E. Being prepared for a conversation about HIV after disclosure.

Feedback

All of the answers are correct. George will want to consider the best time when his girlfriend is calm and has time for a long conversation. It should be done in a location where he feels comfortable and safe, whether it is in a public or private place. George should be ready to talk about living with HIV, the risk of transmission, and how to practice safer sex. And he should be prepared to discuss testing and counselling options. You also need to help George to prepare for a negative response and rejection, including having a support system in place.
Podcast: Disclose Before You Fall in Love (5 min)
Instructions

Listen to these podcasts 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. Why do you think these young people are such strong advocates for positive adolescents to disclose their status when they are dating?
2. Anesu shared in the podcast that he disclosed and it did not go well the first time. How would you provide support to him if he came to the clinic and told you that he was rejected?
3. What have you learned from these stories to share with other adolescents?
Case Study: Precious, Part 2 (10 min)

Instructions

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

Background

This is a continuation of Precious’ visit Part 1. 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.

1.What is the role of the PC when counselling Precious on disclosure?

A. You are the expert when it comes to disclosure, so she should be given the terms and dialogue to use when she discloses.

B. You should provide her with dialogue to use for each specific situation she will encounter, such as what to say to school mates or what to say to others in their village.

C. You should set a strict timeline for when the disclosure should be completed by so she does not procrastinate.

D. You should provide ongoing counselling and guidance so that she can make her own decision about if, when, how and to whom to disclose her HIV status.

Feedback

D is correct. Whenever possible, helping the child or adolescent come to a decision about his or her own care, treatment or psychosocial issues will serve to increase a sense of control and inclusion in decision-making. While you may be more experienced with disclosure, it will not benefit Precious to say exactly what you tell her to say for any situation. There is no strict timeline for disclosure, but if a partner is at risk for HIV transmission, then providing increased counselling to assist with disclosure is an important role for you.

2.Which of the following questions should be considered when guiding Precious in disclosure? Select all that apply.

A. Is there parental permission?

B. Is disclosure to others in the best interests of the adolescent?

C. Will it help her to access care and support?

D. Will it assist in protecting her partner or child from HIV transmission?

Feedback

B, C, and D are correct. These three questions are important for you to consider whenever there is a need for disclosing HIV status. While including a parent or guardian in the discussion about disclosure may be considered, it is not necessary. You should encourage Precious to disclose to her parents, especially if she lives in the same household as them.

3.Identify what best practice approach you should take in this situation with Precious around whether you should delay having a discussion about disclosure? Select all that apply

A. Tell Precious that she has the next week to disclose her pregnancy and HIV status to Tonderai since he is her sexual partner and must have an HIV test. If he does not come to the clinic to be tested, you will have to notify him.

B. Ask Precious what exactly she will tell her parents and what she plans to tell Tonderai so that you have the information needed in case you are asked about Precious.

C. Ask Precious what she thinks the reaction of Tonderai will be to her pregnancy and HIV status, followed by what she thinks her parent’s reaction will be.

D. Ask Precious to pretend that you are Tonderai and have her tell you that she is pregnant and HIV positive. Then have her do the same exercise with you pretending that you are her father or mother.

Feedback

C and D are correct. Helping adolescent girls disclose not only their HIV status, but also their pregnancy status is an important step for them to take as they learn to take control of their care and as relationships are being developed or maintained. Disclosure can provide an added benefit of support for the adolescent in managing her disease and maintaining a high level of adherence. Using role play in this situation is an excellent tool and should be used throughout the disclosure process. Giving Precious a set deadline for disclosure is threatening and may affect the relationship between you and her. Confronting Precious about what “exactly” she is going to say is not useful at this point and will only add to her stress.

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”.

4.What can you include in the counselling you provide to Precious following her response? Select all that apply.

A. Blend probing and reflective questions to ensure that Precious tells you what she is thinking and her next steps.

B. Provide Precious with a written script of what she should say to Tonderai and what she should say to her parents, advising her that she should bring them to the clinic for a formal counselling session after she tells them.

C. Provide Precious with a referral for a professional counsellor since this situation is beyond your skills.

D. Ask Precious to tell you what she will do if she finds out that Tonderai is HIV positive and what will she think or do if she finds out he is HIV negative.

Feedback

A and D are correct. It is important for you to use a variety of counselling techniques when discussing disclosure with an adolescent. If one approach or type of question does not elicit a satisfactory answer, try using another technique or rephrase the question. Asking a “what if” question will help Precious think about possible scenarios and develop approaches that may cover the outcome. It also is a good opportunity for her to verbalize what may be on her mind that is difficult to talk about, e.g., “If Tonderai tests HIV negative then how did I get HIV?” This gives you an opportunity to clarify whether Precious has had previous sexual relationships that would have put her at risk.

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.
Podcast: Telling Him-- What an Awesome Experience! (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. Why do you think Modesta did not disclose her status to her earlier boyfriends?
2. What do you consider to be the most important factor in when a young person should disclose his or her status?
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 this week’s material:
1. Share one of the challenges that you face in counselling adolescents about disclosure.
2. Share a specific strategy that you have or plan to use to overcome this challenge.

Week 4: Disclosure Counselling for Children and Adolescents

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