1. Using the Tools: Recap Activity 1.What key messages do you give to an HIV+ mother who is still breastfeeding and the infant’s first PCR is negative? 2.Is one positive PCR test enough to start a child on ART? How do you explain this to the caregiver? 3.What do you say to an HIV positive mother with her 3 month old infant who is breastfeeding?

2. Module III: HIV Counselling and Testing In this module, we will discuss: Unit 1: Pre-Test Counselling Unit 2: Post-Test Counselling—Negative Result Unit 3: Post-Test Counselling—Positive Result

3. Counselling for HIV Testing Who is the counselling for? – Patients who have been referred from the clinician and need to know if they have HIV Goals: – Help patients understand HIV transmission – Explain the testing process and possible results – Get informed consent for caregiver and child – Provide a clear test result: positive or negative

4. Module III: HIV Counselling and Testing Unit 1: Pre-Test Counselling By the end of this unit, participants should be able to: Explain the steps in pre-test counselling for children Demonstrate skills used for HIV pre-test counselling with young children and adolescents Explain how age of consent is important in counselling Understand the connection between the Observation Tool and the flipchart.

5. Pre-Test Counselling for Younger Children Children aged 18 months up to 12 years Wide range of developmental levels and understanding of HIV, AIDS and transmission Parent or guardian may or may not wish to have child present Counselling must address BOTH child’s and caregiver’s understanding

6. Start with Assessment ASSESS Level of understanding about HIV (child & caregiver) Motivations for testing and child’s understanding of why they visited the clinic today Discuss involvement of the child in the session – Explain benefits – Address fears – Obtain consent Why is it important to involve the child in the counselling session?

7. Assessment with the Caregiver Alone ASSESS Ask to speak to caregiver without the child present – Prepare for another person to sit with the child while you speak to the caregiver Determine reasons for bringing child to facility and confirm understanding services offered Assess if HIV test is in the child’s best interest

8. Risk and Younger Children ASSESS What risk factors may need to be addressed when a younger child is brought for testing? Assessment can be done with or without the child present If concerns of sexual abuse arise, contact supervisor for assistance

9. Benefits of Testing ADVISE The clinician has referred Margaret and her nephew, Elias (4 years), for pre-test counseling. Margaret is afraid to have Elias tested for fear that if he tests positive, he will never have a normal life. How can you help her understand benefits of testing? What are the benefits for her, as the caregiver?

10. Ensuring that the Younger Child Understands the Process ADVISE Test will show if HIV virus (germ) is in your body Your caregiver will be involved in some parts of this session, and during some parts we will talk alone. Is that ok with you? Test will involve a small prick to take a bit of blood from your finger When your results are ready, I will call your caregiver into the room and we will discuss the results. Then we will explain the results to you.

11. Agree and Assist AGREE Caregiver and/or adolescent (12 and older) signs the consent form for testing – Should encourage the adolescent to involve a caregiver when possible ASSIST Clarify who test results should be shared with Probe how the counsellor can support disclosure of results

12. HIV Testing ARRANGE Offer relevant referrals, based on risk/needs Discuss when and how client will receive results. If client is waiting for the results, use the time to probe other HIV issues For purposes of keeping the discussion short and useful, client’s concerns and questions should guide the discussion.

13. Sharon Video Clip Use your Observation Tool to reflect on how the counsellor prepares Sharon for the test. Discussion What did the counsellor do to build rapport with Sharon? And with her mother? What steps in pre-test counselling did you observe the counsellor covering with Sharon? How was the vacation technique used in this session?

18. Role Play: Triads--10 min. Sam, 10 years old comes to you with his auntie, who is his caregiver. He has never been tested for HIV before but has had TB and poor growth. As the counsellor asks about parents, it is clear that it is possible that he was infected through PMTCT. He has noticed that he is sicker than other kids and when he heard about HIV testing for children on the radio, he asked his auntie to go.

19. Role Play Debrief How well did the counsellor use the flipchart? Counsellors, how did you feel during this role play? Consellors, did the Observation Tool and flipchart help you?

20. REVIEW What are the steps in HIV pre-test counselling? At what age can a child agree to his/her own HIV test without a caregiver present? How are the Observation Tool and the flipchart connected? Pre-Test Counselling

21. Module III: HIV Counselling and Testing Unit 2: Post-Test Counselling– Negative Result By the end of this unit, participants should be able to: Explain the goals of post-test counselling Use effective counselling skills for reducing risk with an HIV-negative client Use the flipchart to counsel adolescents to identify risks and safer behaviours

22. Goals of Post-test Counselling Give HIV test results to the clients Counsel for healthy living – If negative result, how to stay negative through risk reduction – If positive result, counsel on positive living, support, care, and treatment

23. Giving HIV Negative Results ASSESS Confirm who should be involved in the session Assess readiness to receive results ADVISE For younger children: – Give results first to the caregiver alone, then assist caregiver to explain results to younger child For adolescents (12 and older): – Give results to the adolescent first, then probe if and how to tell the caregiver and others

24. Explore Reaction to the Test Results ADVISE Discuss the window period, if applicable Depending on response to the test result, correct myths or misperceptions about HIV – (Turn to child) Can you tell me what it means to be “HIV negative” (depending on age and experience shared above)? – (Turn to parent/guardian) Anything else you would like to add to what (insert name of child) has said? What kinds of misperceptions might a client have with a negative test result?

26. Identifying Risks What are the circumstances younger children (age 2-11 years) face that would put them at risk of acquiring HIV? What are the circumstances that adolescents (12-18 years) face that may put them at risk for HIV?

27. 5 As to Reduce HIV Risk 1.ASSESS – Exposure/Identify risks – Knowledge and motivation to avoid HIV infection 2.ADVISE – Provide key information/knowledge 3.AGREE – Identify safer goal behaviours – Supports for safer goal behaviours

28. 5 As to Reduce HIV Risk 4. ASSIST – Identify barriers – Discuss strategies to overcome barriers – Practice skills: e.g. assertiveness 5. ARRANGE – Referrals, follow up appointments, etc. What questions would you ask the adolescent during each of these steps?

29. Adolescent Sexual and Reproductive Health Adolescents need basic information about puberty, relationships, sexual health, how to keep themselves safe, etc. You may find that to reduce a risk, you need to provide that information. The flipchart is written for positive youth, but since much of the content is the same, feel free to use the content you need with any young person.

36. Closing: ASSIST and ARRANGE ASSIST Determine how counsellor can support implementation of the risk reduction plan ARRANGE Offer referrals Schedule follow-up testing, if needed Document the counselling session in the patient’s file

38. Demonstration: Post Test Counselling--Neg Jasmine, 15 year old girl – She has come for an HIV test. She lives with her aunt and uncle. During the session Jasmine discloses having had 2 sexual partners, which were voluntary. She is now in a post-test session to receive a negative result. While the counselling session is going on, identify the risks and write them in your participant’s guide while observing the counselling process.

39. Debrief: Reducing Risk What were Jasmine’s risks? What issues do you think should raise a red flag? What was the safer goal behaviour agreed upon by the counsellor and Jasmine? How did the counsellor explore Jasmine’s motivation to avoid HIV infection? What were her supports, barriers and strategies for implementing goal behaviours?

40. REVIEW What are the two goals of post-test counselling? How does counselling a client to reduce risk help a client to stay HIV negative? How can the flipchart help you counsel HIV negative adolescents? Post-Test Negative Result

41. Module III: HIV Counselling and Testing Unit 3: Post-Test Counselling– Positive Result By the end of this unit, participants should be able to: Explain HIV positive results to the child and caregiver in a clear and simple way. Identify messages for HIV positive adolescents about reducing transmission risk Discuss how to support disclosure to children and others.

42. Post-Test Counselling for HIV+ Results Counselling for HIV+ results is complex Counsel on – Result of test (HIV+) – What result means to child/caregiver – Immediate needs – Positive living – Support and disclosure

44. Providing Results and Review Meaning ADVISE State results clearly and simply For younger child, give results to caregiver alone – “(Child’s name) is HIV positive. This means (name) is infected with HIV.” – Confirm disclosure plan– discuss when/how to involve the child If adolescent, give results directly and ask about desired caregiver involvement Allow time to absorb meaning

45. How to Say It– Giving Positive Results to Younger Children ADVISE The results of this test say that you have an illness. That means that you may get sick sometimes. You have a germ that lives in your blood. Another name for a germ is a ‘virus’. What do you know about germs and illness? [When child is ready] The name of the virus you have is HIV. What do you know about HIV? The virus (HIV) can harm healthy cells that protect you from sicknesses. Viruses can make you sick. Medicines are necessary to keep you healthy.”

46. How to Say It– Explaining MTCT ADVISE HIV was in your blood when you were born. Your mom has the same virus and you got it from your mom. You cannot get this virus or give it to anyone else just by being close to them. It is ok to play, go to school, and hug your friends and family. They will not get the virus just because you are close to them.

47. How to Say It–Disease Progression ADVISE When your healthy cells are damaged by the virus (HIV), your body has trouble staying healthy– you may have a bad cough, diarrhoea, or other diseases. You can take medicine to fight this bad virus (HIV) in your blood. The doctor might decide to give you medicine now, or wait until later. If you take your medicine every day, your healthy cells can grow back and you can stay healthy and strong.

48. Assess Coping and Acknowledge Difficulties ASSESS Ask if client(s) are doing OK Help younger child understand what crying of caregiver means Address fears directly – “Can you tell me what you are worried about?” – “This seems a little scary right now but you and your family will learn how to manage this germ so you can stay strong and healthy.”

49. Role Play—Caregiver Guilt Parent may feel guilty for child’s HIV+ status How could you address issues of caregiver guilt? What counselling skills would be most useful?

50. Planning to Reduce Risk -- Positive Result ADVISE Discuss options for reducing risk with the goal to remain healthy and prevent transmission For younger children, work with caregiver and child together to develop a feasible plan For adolescents, talk to them directly about healthy living, sources of support, sexual health AGREE Agree on a plan for reducing risk

51. Sexual and Reproductive Health Messages for Positive Adolescents Delay sex/abstain Show love and affection with partners in other ways other than having sex Disclose to your partner before getting sexually involved Use a condom to avoid STIs, pregnancy and co-infection

52. Explore Disclosure ASSIST with scenarios – Caregiver to child about child status – Caregiver to partner/other caregivers about child status – Caregiver to child/adolescent about the caregiver’s status – Adolescent to caregiver – Adolescent to sexual partner ASSIST with options – Self-disclosure vs. Counsellor-supported

53. Disclosure Options ASSIST ‘Counsellor-supported’ disclosure steps: – Explain counsellor involvement – Emphasize the client’s desire to reveal HIV status – State test result, explain meaning – Discuss importance of disclosing to child and other family member(s) – Make plan of action

54. Supported Disclosure – Child ASSIST Role play with the client on what will be said Share feedback Ensure clarity of disclosure. State clearly that the child is infected with HIV Assure client that you will be there to assist when discussion becomes difficult Make action plan of next steps based on client’s expectations of discussion

55. Role Play— Post-Test Counselling Return to your triads: counsellor, child, caregiver/observer. 10 min to role-play, 5 min feedback – Esther, 8 yrs, lives with her aunt. Her results are positive. Her aunt preferred NOT to include Esther in the pre-test session, but now would like to disclose to her.

56. Supported Disclosure—Adolescents ASSIST Same general process as with parent disclosing to child Support adolescent to disclose to one person who they trust and can support them Emphasize that disclosure to at least one other person is very important– we all need someone to support us in our journey

57. Closing: ARRANGE ARRANGE Starting ART might not be immediate. Refer the child/caregiver to a clinician for an assessment, including CD4 testing Children who are HIV+, but not yet started on ART need ongoing counselling and support – Positive living, nutrition, Septrin adherence – Disclosure support for the child’s changing life – Stigma and discrimination

58. Support and Referral ARRANGE Sources of support and referral may vary based on the needs of the child/caregiver and the community 1 st referral will be to HIV care provider Brainstorm with clients other sources of support that may be available to them Provide written contact referral information when possible Document counselling on the HCT card

62. Reviewing the Process Let’s quickly review our Observation Tool– – HIV Testing– Pre and Post-Test Results

63. Josephine Video Clip Use your observation tool while watching this clip. Discussion: – What issues for adolescents were highlighted? – What counselling skills and techniques did you see being used? – What support does Josephine need? – What are essential elements to include in a risk reduction plan for HIV-positive adolescents?

64. Treasure Hunt—Flipchart What do all adolescents need to know about? What do young HIV positive people need to know before they are sexually active? What do young HIV positive people need to know once they are sexually active? How can the flipchart help you raise the issue of sexual debut with adolescents?

65. Homework: Treasure Hunt Review the flipchart for the whole process of pre and post testing (pink section). Write down exactly which pages you would go to for counselling in these sitatuations: 1. testing HIV exposed infant 2. testing child who turns out to be positive 3. testing a child who turns out to be negative 4. testing an adolescent who tests HIV positive and needs SRH counselling

67. REVIEW How do you explain HIV positive results in a clear and simple way? What risk reduction issues need to be addressed with adolescents? How can you support disclosure of positive results to the child? Post-Test– Positive Results

68. Key Messages from this Module HIV testing should always be accompanied by counselling appropriate for the child’s age. Younger children need clear and simple explanations of the testing process. Disclosure plans for younger children (under 12 years) should be discussed with the caregiver before testing begins.

69. Key Messages (2) Adolescents (12 and older) can consent to their own testing and do not need a caregiver present. Discussion of risk reduction is an important part of the pre-test and post-test. When giving post-test results, a clear plan for reducing risk should be developed and documented. Children who are HIV positive benefit from referrals to care and other sources of support.