Module 3 Part 3_ Counselling - Continuation.pptx

Health

1. 3-3: HTS Counselling – Continuation: Special Groups

2. Module 3 Contents – Counselling continuation HTS for Special Groups Couple HTS HTS for Children & Adolescents Youth Friendly HTS

3. PITC Considerations for Special Groups Key populations Vulnerable populations

4. Key populations Key populations: are defined groups who due to specific higher-risk behaviours, are at increased risk for HIV in South Sudan. These guidelines refer to the following groups as key populations: Sex workers, People in the uniformed services, Truck drivers and other migrant workers, People in prisons and other closed settings, and Men who have sex with men (MSM).

5. Understanding Vulnerable populations In the context of South Sudan, these are groups of people who are particularly vulnerable to HIV infection in certain situations or context. This includes: Refugees, Internally displaced persons (IDPs), Survivors of sexual assault, Adolescents (particularly adolescent girls), Orphans, Street children, People with disabilities

6. Key and Vulnerable Populations South Sudan targets the following groups as key Populations and Vulnerable Population as they are at higher risks of being infected and affected by HIV key Populations Vulnerable Population Female Sex Workers (FSWs) Men having Sex with Men (MSM) Long Distance Truck Drivers (LDTDs) Boda-Boda Drivers, Migrant Workers and Uniformed Forces) Intravenous Drug Users(IDUs), transgender people people in prisons or in closed settings. adolescents especially girls, orphans, street children people with disabilities (PWD) Survivors of Sexual assault Internally Displaced Populations(IDPs) Refugees  

7. Factors leading to high risk behaviors Age social mobility gender environment in which they live e.g. poverty, gender discrimination, lack of health services and lesser legal, social or policy protection resulting in limited ability to access HIV prevention services. Economic situation

8. Other vulnerable groups that are a priority in HIV prevention strategies include: Children and Adolescents (10-19yrs) Pregnant and breast feeding women Couples and sexual partners

9. Principles of HTS for key populations These principles are similar to all HTS programmes and emphasize WHO “5Cs” and only need be tailor made to suit Key population’s needs. Recall exercise : Who remembers the 5Cs??

10. Considerations for Special Groups Human Rights: All key populations are entitled to full protection of their human rights, which include the 5Cs principles of counseling including non-discrimination, security of person and privacy, recognition and equality before the law.  Convenient locations and scheduling: Due to specific peculiarities of the different key populations and illegality of some of their activities, HIV testing services need to be provided at locations and scheduled at times most convenient for the population, including at night testing sometimes referred to as “ moonlighting”, Testing at border points or trucking stops for distance truck drivers Use of peers both for mobilization and performing of HIV testing services Integrated Service Provision: Provision of integrated services is necessitated by the existence of such co-morbidities as HIV/SRH, HIV/Hepatitis B virus; HIV/mental conditions, HIV/TB and Hepatitis C virus (HCV) infections. These are a “silent epidemic” affecting more people than HIV. Both infections are especially common among IDUs due to sharing of contaminated injecting equipment. A vaccine is available for HBV but not for HCV.

11. Other considerations include:   Linking HIV-negative key populations to prevention services, including PrEP , should be a priority Intensified TB case finding, along with HTS, also is particularly beneficial among key populations. These populations are highly vulnerable to TB, particularly in countries with high burdens of both TB and HIV Retesting at least annually is recommended for all people from key populations but it can be after 3 months if they report risk of exposure

12. Reasons for HTS for key and vulnerable populations Key Populations have high rates of HIV Infection Many do not know they are infected Treatment for HIV is becoming more available Having unprotected sex, multiple and concurrent partners and using drugs place individuals at higher risk to HIV infection Prevention messages and risk reduction counseling can substantially affect HIV transmission HTS provides an important opportunity to link most key populations to other services that are integral for reducing their risk behaviours (e.g. drug treatment, mental health, etc.)

13. Module 1 Contents – Understanding PITC PITC for Special Groups Couple HTS HTS for Children & Adolescents Youth Friendly HTS

14. Define Couple HIV Testing and Counselling (CHTC) This refers to HTC for two or more sexual partners together. They could be married, cohabiting, regular sexual partners or intending to have sex. They undergo counseling and testing in the same sitting and receive results together. The service is intended to facilitate mutual knowledge and disclosure of one’s HIV status to their sexual partner(s). Couples should not be coerced into being counselled together but should be given opportunity to make informed decisions about it.

15. HIV Epidemic and Couples The majority of persons living with HIV are in stable, long-term relationships. 50% of all HIV-positive persons who are in stable relationships have a partner who is HIV-negative. In discordant couples, 65–85% of new HIV infections are acquired from a married or cohabiting partner.

16. Test Results Definition Concordant Negative Concordant Positive Discordant

17. Categories of Couples Presexual Engaged Married or cohabitating Polygamous

18. Key Components of the CHTC protocol

19. Conditions for Receiving CHTC Services Before receiving CHTC, couple must agree to: Receive their HIV test results together Make decisions about mutual disclosure together Discuss HIV risk issues and concerns together Participate equally in discussion Respect and support each other

20. Concept of Couple Counseling Four important concepts of couple counseling Counseling session should focus on solution not problem The session should focus on present and future not past The counselor must assist in the defusing on blame and tension Remember past is past and cannot be changed

21. Couple Counseling skills Identified by Experts Demonstrate neutrality and concern for both couples Convey respect and regard for both couples and the relationship Facilitate balanced participation by both couples Model appropriate communication and listening skills Facilitate dialogue between the couple Raise difficult issues for the couple to content with Mitigate tension and avert blame

22. SOLUTION FOCUSED MODEL Believe that effectively delivered brief intervention can make a difference. Couple who volunteer for couple session have invested in the process It is the couples present and future that is most important It is most important to build and focus on strength rather than weakness

23. Cont --- The focus is on solution rather than problem Couple who choose to come know what needs to be done to address risk. The counselor validates feelings however emphasize on action Believe that small behavior changes lead to big changes

24. Johari Window When I share myself with others and am open to feedback from others, I begin to change.

25. JOHARI WINDOW OF COUPLES Johari Window - named for its creators, is a useful tool for understanding how counselor can help us live more effective lives. The four "panes" of the Johari Window represent four parts of our Self .

26. Cont --- My Public Self is what I show others about me. My Hidden Self is what I choose to hide from others. My Blind Spots are parts of me others see but I do not. My Unconscious Self are parts of me I do not see nor do others. We all have these four parts of Self , as shown in the Johari Window diagram, but their respective sizes vary in each of us.

27. Cont --- Known to Self Not Known to Self Known to Others Not Known to Others

28. Cont --- 1. The "open" represents things that both I know about myself, and that you know about me. For example, I know my name, and so do you. 2. The "blind" represents things that you know about me, but that I am unaware of. So, for example, some thing on my face, if you now tell me, then the window has open quadrant's area. 3. The "hidden" represents things that I know about myself, that you do not know. As soon as I tell you that I love so and so, I will then feel more comfortable disclosing more intimate details about myself. And this process is called: "Self-disclosure.“

29. Cont --- 4. The "unknown" represents things that neither I know about myself, nor you know about me. For example, I may disclose a dream that I had, and as we both attempt to understand its significance, a new awareness may emerge, known to neither of us before the conversation took place. The process of enlarging the open quadrant is called self-disclosure.

30. 1. Self-Awareness The counsellor should have self awareness of his/her beliefs, biases, feelings, perceptions and reactions. Counsellor Self-Awareness Assists the counsellor to provide high quality services to all couples Ensures that the counsellor's values, beliefs and experiences do not influence his/her interaction with couples - remain non-judgmental

31. Cont --- Reduces the potential for the counsellor to bias the couple’s decision Helps, the counsellor understand that he/she is not responsible for the couple's test results or the couple relationship Allows the counsellor to really hear and understand the couple's issues and concerns and to offer genuine-empathy and support Enhances the ability of the counsellor to skilfully effectively manage the CHCT session Empowers the couple

32. 2. Capacity to Tolerate Intensity Couple relationships are dynamic and complex and in CHCT the couple is required to address difficult and emotionally laden issues. The counsellor needs to have the capacity to tolerate this intensity and maintain a reasoned and supportive stance with the couple. The counsellor facilitates difficult conversations and invites the couple to deal directly with challenging issues.

33. 3. Ability to both Validate and Challenge The counsellor must have the ability to validate the couple's feelings and perceptions while also challenging them to address the realities of HIV in their lives, their community and to take action to reduce the risk of transmission of HIV.

34. 4. Capacity to Hold Two Seemingly Contradictory Ideas Simultaneously It is essential to understand the couple's strengths and weaknesses. - For example, the counsellor acknowledges the wish of the couple to preserve the relationship while they struggle to accept the behaviour changes required to protect one another. - Engaging in behaviours that increase the risk of HIV transmission may be both pleasurable and painful.

35. BUILDING ALLIANCES The first task of the counsellor is to build an alliance, a partnership with the couple. This serves as the foundation that permits the couple to engage in the session, explore issues, disclose and address challenging HIV related issues. A counsellor supports an alliance by offering genuine warmth and by extending kindness and compassion!

36. Forming an Alliance: "As much an attitude as a technique“ A.C.E. Acknowledgement- Describes the couple's awareness that the counsellor acknowledges their strengths, courage and experience Competence - Refers to the couple's sense that the counsellor has the skills and experience to guide and support the couple through the CHCT process Empathy - Describes the couple's sense that the counsellor genuinely understands and appreciates the couple's experience and feelings

37. Mitigating Tension and Averting Blame Normalize feelings, reactions and experiences. Effectively use silence while conveying a supportive and calm demeanour. Remind the couple that HIV infection is common and one may have become infected at any time and that absence of infection is simply good fortune.

38. Cont --- Reinforce that the session focuses on the couple's present and future and that the past is in the past. Express confidence in the couple's ability to constructively deal with difficult issues - reflect on their strengths and their history together. Admire the couple's willingness to contend with the challenges of HIV in their lives.

39. Cont --- Redirect and reframe questions and discussion that is blaming or potentially hostile - identify underlying non- hostile feelings (fear, anxiety, concern). Calmly and gently name and acknowledge the behaviour being observed. Remind both members of the couple of their roles, responsibilities and expectations outlined at the beginning of the session.

40. Benefits of Couple Counselling

41. Module 1 Contents – Understanding PITC PITC for Special Groups Couple HTS HTS for Children & Adolescents Youth Friendly HTS

42. HIV Testing Services for children and adolescent The session objective is providing HTS to children and adolescent. What is a “Child”? A “child” is any individual under the age of 18 years (UN Convention on the Rights of the Child, 1990). According to the World Health Organization (WHO): “adolescents” are individuals in the 10–19 year age group “youth” are individuals in the 15–24 year age group “young people” combines both adolescents and youth and include the 10–24 year age group.

43. HIV Counseling in Children and Adolescent Children and youth have unique vulnerability to HIV infection, and as their ability to comprehend HIV/AIDS issues differs from that of adults, this population deserves special consideration. Counselling for HIV is a confidential dialogue between a child/adolescent/parent/caregiver and a service provider aimed at enabling the child/adolescent/parent/caregiver to cope with knowledge of HIV status and make informed decisions pertaining to HIV and AIDS and to cope with related stressors.

44. Counseling Approach for Children & Adolescents Children manifesting HIV/AIDS related symptoms should be tested.   Parents of these children should receive provider-initiated counseling concerning testing their child, when the clinician believes it necessary, irrespective of the child’s age and ability to understand.   One or both parents/guardians should consent to the testing.   The result should be given to the parent/guardian in a post-test counseling session.   The test result may be explained to the child in a manner that is adapted to his/her level of understanding.   The child’s understanding of his/her condition should always be updated according the age until s/he reaches adulthood at which time s/he should be specially counseled.   The parent or guardian should always accompany the child in counseling session to act as the support system for the child/adolescent

45. Scenarios that can be used in child and adolescent counseling: Counsellor meets with parent/guardian first then with parent/guardian and child/adolescent together Counsellor meets with parent/guardian first, then with the child/adolescent and lastly with parent/guardian and child/adolescent together Counsellor meets with parent/guardian and child/adolescent together, then meets with them separately

46. Informed Consent Refers to a child/adolescent or parent/caregiver being given an opportunity to consider: the benefits and potential difficulties associated with having access to information regarding the child’s /adolescent’s HIV status; an understanding of the HIV testing procedure; and Taking a decision for the child/adolescent either to be tested or not tested for HIV. The child or parent/caregiver should be able to consider the implications of a positive HIV test result on the child’s/adolescent’s life and the life of his or her family.

47. ‘Best interest of the child’ principle The child/adolescent can be tested without the consent of the parent/caregiver if it is in the best interest of the child. Situations may arise when the counselor may need to override the parent’s/caregiver’s decision to refuse the test if knowledge of the child’s/ adolescent’s HIV status is in the best interests of the child such as when the child is ill. In such cases, the health worker can exercise the ‘and seek approval from the person in charge of the clinic or hospital to perform the HIV test.

48. Informed Consent for different age groups 0-18 years : At this stage the child may have the capacity to understand the implications of the test. However, the law requires that consent for HIV testing be obtained from the parent or guardian, unless the child is a emancipated or mature minor. Emancipated minors are young people under age 18 years of age who are married, pregnant, parents, engaged in behaviour which puts them at risk, or are child sex workers are considered capable of giving their own consent for HTS , and do not need a parent or guardian’s consent. Child/adolescent to assent to the test and actively participate in the counselling session. HTS of those who are under 18 years and are not emancipated minors, should be done with knowledge and consent of a parent or guardian. Verbal consent is sufficient.

49. Informed Consent for different age groups… cnt ’ For those under 18 years of age who have no parents or guardians, parental/guardian consent will not be required before testing is done but the young person will be asked to sign a declaration that they have no parents or guardians. HTS services will be provided in consultation with social services’ providers or institutional heads. 18+ years : Anyone 18 years of age and above requesting HTS should be considered able to give full, informed consent. Providing information about the HIV status of a child should be done only if necessary in the interest of the child with his parents’/guardian’s consent; and only to trustworthy teachers who have received training in HIV counselling.

50. Pre-Test Information/Counseling Session is the process during which a child/adolescent and caregiver undergo confidential counseling before testing to make an informed consent about whether or not to have the child/adolescent tested for HIV. The session can be directed to the parent/caregiver if the child is below 7 years of age and to the child if aged 7 years and above and developing normally.

51. Post Test Counseling Session must be provided for both HIV positive and HIV negative Children & adolescents ( see Handout)

52. Disclosure Is the process of informing the child/adolescent of his or her own HIV status or informing someone else about the child /adolescent’s HIV status. This Disclosure is determined by readiness of the parent/caregiver to talk about it and readiness of the child/adolescent to understand and change their lives because of the knowledge of his/her status. The counselor needs to do a thorough assessment to ascertain that the child or adolescent is mature enough and ready to receive results

53. Disclosure as an ongoing process: HTS counsellors should be trained on a child developmental approach to gradual disclosure of HIV status for younger children. Young children should be told their status incrementally to accommodate their cognitive skills and emotional maturity, in preparation for full disclosure.

54. Disclosure as an ongoing process: Partial disclosure starts with revelation to a child sometimes as young as 6 years without mentioning “HIV” or “AIDS” and can use age appropriate communication and counseling techniques. Progressive disclosure is when more and more information about the child’s HIV status is shared with the child/adolescent as he/she develops and matures.

55. Disclosure as an ongoing process: Full disclosure is when the child is given all the information about his/her HIV status. This helps the parent/caregiver and child / adolescent to understand the implications of the results of the HIV test (whether HIV positive or HIV negative), and how to cope with the results. Help Children/Adolescents to make decisions around if, how, to whom and when to disclose their HIV status. Full understanding of the possible consequences of disclosure and non-disclosure should be highlighted.

56. Follow up Counseling, Care and Support The follow up counseling are key for both HIV positive and HIV negative children/adolescents to help them cope with either a positive or a negative HIV status. Several sessions sometimes including the family members may be needed. Children/Adolescents on antiretroviral therapy (ART) will also need adherence counseling and sustained psychosocial support.

57. Connections to Post Test Services and Referral This is a two-way process that creates and maintains linkages between the health/HTS facility and the community to ensure that children/adolescents access HIV prevention, treatment, care, support and other relevant services after HTC. Children/Adolescents should also be referred to join support groups.

58. Module 1 Contents – Understanding PITC PITC for Special Groups Couple HTS HTS for Children & Adolescents Youth Friendly HTS