Uganda National Paediatric HIV Counselling Curriculum Skills for Health Care Staff Working with Children, Adolescents and Caregivers May 2012

Climate Setting First, form 6 teams – Introductions: name, cadre, place of work – Choose a team name – Discuss 4-5 of your GREATEST challenges in providing counselling to children and adolescents

Climate Setting Electing Course Officers Team-Led Daily Feedback Ground Rules Logistics

Overview Course goal, objectives and outline Overview of paediatric HIV in Uganda Key interventions for addressing Paediatric HIV In this introductory module, we will discuss:

Course Goal This course is designed to strengthen health worker knowledge and skills for counselling children, adolescents and caregivers on issues around HIV testing, care and treatment.

Course Objectives By the end of this 5-day course, trainees should be able to: Explain the importance of EARLY infant diagnosis and treatment in order to reduce infant mortality. Identify the role of effective counselling as part of a comprehensive approach to the care and treatment of HIV infected infants, children, and adolescents. Appropriately use MoH Tools and Guides (Job Aids) to counsel HIV-exposed or infected children, adolescents and their caretakers.

Course Objectives (2) By the end of this 5-day course, trainees should be able to: Demonstrate confidence, knowledge and skills to communicate with and counsel HIV-exposed or infected children, adolescents and their caregivers. Effectively address disclosure, positive living, and stigma and discrimination as key parts of the process for every counselling event. Recommend specific actions to improve HIV clinic systems that will result in more effective provision of paediatric HIV counselling services.

Course Outline Introduction: Course goal, objectives, key interventions Module I: Essential Background Paed HIV Counselling Module II: Feeding and HIV Testing for Exposed Infants Module III: HIV Testing and Counselling Module IV: Preparing to Start ARVs and Supportive Adherence Counselling Module V: Living with HIV Capstone: Putting it all together It is not enough to have theory; we must practice skills

Activity: HIV Fact Check Form 2 teams– move to opposite sides, stay standing Facilitator will read a question – When your team has the right answer, JUMP – The first team to JUMP enthusiastically will have the opportunity to answer the question – If the answer is wrong, the second team has an opportunity to answer – Correct answer= 10 points

Paediatric HIV in Uganda GlobalUganda People Living with HIV33.3 million1 million Children living with HIV2.5 million (7.5%)146,000 (14.6%) Total New Infections2.6 million132,500 New Infections in Children 370,000 (14%)25,000 (18.8%)

How Paediatric Infections Occur 95% are the result of MTCT – 5-20% during pregnancy – 20-60% during labour/delivery – 10-20% during breast feeding This is important because infants are an especially vulnerable group.

Growing Adolescent Infections Represent a growing % of new infections 30% of the PLHAs worldwide are below 25 years, which includes adolescents Adolescence is a difficult stage of passing from childhood into adulthood. It entails physical changes and sexual attractions which can bring insecurity and anxiety. With HIV positive adolescents, issues around sexuality can be even more complicated

Brainstorm Activity What key interventions do you think are the most important for addressing paediatric HIV?

MoH Key Interventions and Guidance Prevent mother-to-child transmission (PMTCT) Increase availability of early infant diagnosis (EID) services Identify HIV-infected infants and children and link them to care Provide quality care and treatment, including ART Promoting family-centred care model Communication Strategy

National PMTCT Guidelines Option A

Dosing Schedule for Infant NVP Prophylaxis 16 Infant Age NVP Daily Dose (10 mg/ml formulation) Birth to 6 weeks Birth weight 2.0 to 2.5 kg 1 ml once daily Birth weight > 2.5 kg 1.5 ml once daily >6 weeks to 6 months2 ml once daily >6 months to 9 months3 ml once daily >9 months to end of breastfeeding4 ml once daily

Why is it Critical to Get Children on Treatment? Children are more vulnerable: At 1 year30% At 2 year50% At 5 year66 – 75% At 10 years85%

Children are Vulnerable—Mortality If 10 HIV positive children are born today, and none get care…

Family-Centred Approach The family possesses solutions– spend time getting to know them, ask about problems and solutions Help the family to define the problem Inquire about solutions the family has applied (how families approach medication adherence in general) Remember to look for & utilize the family’s strengths in the treatment process (e.g. utilize mother’s perfectionist style to benefit the treatment) Let the family know you will partner with them to make treatment easier and successful.

Getting Children into Care 42,000 children eligible for ART in Uganda Only 41% have started treatment (as of Sept 2009) Although adult uptake is increasing, number of children on ART is lagging behind – Low service uptake – Adherence challenges

National Paediatric ART Communication Strategy The goal is to improve the quality of life of HIV+ children and adolescents by increasing uptake and adherence to ARVs and prevention of transmission and re-infection. Phase one: (August 2011) 1.Caretakers of children who are at risk of being HIV+ (focus on uptake) 2.Caretakers of children and adolescents on ARVs (focus on adherence) Phase two: (TBD but materials exist from campaign in 2008) 1.Adolescents on ARVs (focus on adherence) 2.Sexually active HIV+ adolescents (focus on prevention)

Communication Strategy and Branding of Service Points

Barriers and Facilitators to Uptake of Services Barriers – Caregivers are not aware that children born HIV+ can and should be tested – Caretakers (as well as health workers) assume all children born HIV+ will die early – Caregivers may fear of stigma and discrimination Facilitators (help to overcome the barriers) – Uptake increases when caregivers: are aware of services, believe the services will make a difference, believe their peers/family/friends will think well of them and that services are not difficult or costly

Barriers and Facilitators of Adherence Barriers– mainly around caregivers as gatekeepers to treatment – Caregivers finding it difficult to support treatment: not worth the effort; too busy; worried about disclosure/stigma; not involving other caregivers Facilitators (help to overcome the barriers) – Disclosing to child, seeing improvement in child when taking medicine, good relationship, good social support from family, health care workers, treatment supporters

Counsellor’s Role in Supporting the National Communication Strategy Phase 1: Communication Channels – Radio (shows, spots, jingle, diaries) – IEC materials (posters, caregiver booklets) – Community mobilisation to create demand You are a critical part of the team that will: – Get IEC materials to the right people and places – Provide non-judgmental, friendly and accurate interpersonal communication – Make sure that they continue to come for services – Help mobilise your communities for the services – Save lives of HIV positive children!

Posters

MoH Key Interventions and Guidance Prevent mother-to-child transmission (PMTCT) Increase availability of early infant diagnosis (EID) services Identify HIV-infected infants and children and link them to care Provide quality care and treatment, including ART Promoting family-centred care model Communication Strategy