Presentation on theme: "HIV/AIDS & Maternal, Newborn, Child and Adolescent Health Departments WHO, Geneva Rachel Baggaley Jane Ferguson Alice Armstrong Amolo Okero Wale Ajose."— Presentation transcript:
HIV/AIDS & Maternal, Newborn, Child and Adolescent Health Departments WHO, Geneva Rachel Baggaley Jane Ferguson Alice Armstrong Amolo Okero Wale Ajose Kathleen Fox Kate Noto
Journey of life for children with HIV – from diagnosis to adulthood Knowing and sharing your status
Why HTC services need to be expanded for children and adolescents Infants – great progress in PMTCT, less infants with HIV but… many mothers are unable to or do not access PMTCT EID often poor – many infants slip through the net 1– >5% transmission still occurs Children – many missed 'Slow progressors' Nosocomial transmission and traditional practices Adolescents – poorly served by current efforts Horizontal transmission (esp. girls, early marriage, coerced sex, age-disparate sex) Vulnerable adolescents, street children, young sex workers, drug users, and MSM Knowing and sharing HIV status – issues for children and adolescents WHO – Knowing and sharing your status HTC issues to address How to deliver acceptable services How to increase uptake in HTC Disclosure to child or adolescent Disclosure by adolescent to others Consent – parental vs. self Linking to prevention and care
HTC – adolescents experiences & views What do adolescents think Associated with being bad Rejection, shame, gossip Unfriendly, judgmental health workers Inconvenient times and locations Parental consent to test a barrier What do adolescents want Enabling environment – role models, media messages to encourage testing Health worker 'respect' friendly, supportive, understanding, away from health centers Ability to self-consent Listen to their voices
HTC issues for children and adolescents Factors which increase uptake Routine testing / PITC (USA, Zambia) ↑ Home based VCT (Zambia, Uganda) ↑ Rapid testing (USAx3, England) ↑ Education (USAx2, Australia) ? Social Networking (USA, Australia) ↑ Provider factors Computerized testing prompts (USA) ↑ Adolescent-friendly health services (Uganda & South Africa) ↑ Outreach with "Motivational Interviewing" (USA) ↑ (Incentives) Where to deliver? Clinics Home Schools Outreach
Disclosure of HIV status In many settings disclosure to children is late and unplanned Increased availability of ART highlights need for HTC and re-examination of process of disclosure Increased identification of ‘slow paediatric progressors’ Increasing numbers of children on ART surviving into adolescence Disclosure to children often delayed because of: – parents/health workers fears about child reaction – parents worried children/adolescents will disclose to others – lack of guidance for & training of health workers – perceived & actual community stigma – parental guilt Disclosure of parents status to children often delayed because of: – parents/health work WHO - Knowing and sharing your status Most adolescents state they 'wished they had known earlier'
WHO guidelines on disclosure Available evidence indicated positive outcomes for an HIV infected child that has been disclosed to: better adherence to medicines less self-reported psychological distress reduced mortality risk Disclosure leads to better communication and extended discussion in the family WHO - Knowing and sharing your status
WHO guidelines on disclosure Children of school age should be told their HIV status younger children should be told in a manner that accommodates their cognitive skills & emotional maturity Children of school age should be told the HIV status of their parents/carers: younger children should be told in a manner that accommodates their cognitive skills & emotional maturity Disclosure to children is a process not an event Decision on who does the disclosure should be guided by the intent to improve/promote the child’s welfare & minimise risk to their well-being, & quality of the relationship between child & parent/caregiver Other factors in communities need to be addressed in parallel… stigma & discrimination access to paediatric care & treatment WHO - Knowing and sharing your status
Key issues on disclosure for adolescents WHO - Knowing and sharing your status Adolescents should make their own decisions about disclosure Onward disclosure should not happen until the adolescent is ready Inform adolescents of rights & responsibilities re disclosure especially in education, workplace & sexual relationships Being an adolescent with HIV can be isolating → having someone to share status often beneficial Encourage support from someone they trust Support them in deciding who to tell & how Support & shared experiences with other adolescents with HIV can be beneficial Be aware: placing too much emphasis on disclosing, especially to parents or sexual partners, could discourage adolescents from engaging with services.
Consent to HIV testing A review of national policies of 42/53 African countries WHO - Knowing and sharing your status Provisions stipulating age for consent for HTC in policy# Existence of specific age of consent (Yes)21 No specification of age of consent (No)19 No mention of age of consent12 Age specified of consent for HIV testing in countries (n=21)# 12 years [Lesotho, South Africa, Uganda]3 13 years [Malawi]1 14 years [Liberia, Guinea]2 15 years [Ethiopia, Senegal]2 16 years [Namibia, Zambia, Zimbabwe]3 18 years [Djibouti, Sierra Leone, Swaziland, Tanzania, Burkina Faso, Cameroon, Central African Republic, Cote d'Ivoire, Democratic Republic of Congo, Togo] 10
Consent issues Most countries reviewed had no formal policy Where they do the majority require parental consent <18yrs Lack of consistency in age of consent for sexual activity, medical procedures & HIV testing Many countries have 'exceptions' – counsellor discretion, pregnant, married, parents themselves. 'at risk of contracting HIV', head of a household, street children, sex workers, etc. Even where policies do exist, health workers have to make difficult judgements regarding eligibility to consent & worry about legal consequences Where countries (Uganda, Lesotho, South Africa) & US states (Connecticut and New Jersey) have lowered consent – ↑testing with no significant adverse outcomes WHO - Knowing and sharing your status
Next steps Outcomes following HTC for adolescents – systematic review underway Outcomes following disclosure by adolescents – systematic review underway Attitudes to HTC – adolescent FGDs – Zimbabwe, South Africa, Philippines; ongoing…Central Asia and Eastern Europe Attitudes to provision of HTC to adolescents – health workers/counsellors FGDs – Zimbabwe, South Africa, Philippines; ongoing…Central Asia and Eastern Europe Guidance on Adolescent HIV care (incl. retention and adherence) Including adolescent attitudes to HIV care – Any case studies or unpublished data available for sharing – please send to Rachel Baggaley or Kathleen Fox – Any adolescents or networks able to support/pilot test adolescent survey – please Kathleen Fox