1. Module V: Living with HIV In this module, we will discuss: Unit I: Addressing Psychosocial Issues Unit 2: Positive Living Unit 3: Referrals and Support Groups

2. Counselling: Living with HIV Who is this counselling for? – Patients who have received a positive HIV test result and may or may not have started taking ARVs Goals: – Assess the child’s support network – Identify barriers to positive living – Explore disclosure issues – Discuss coping strategies – Identify needed referrals for additional support

3. Understanding the Process Review your Counselling Observation Tool– Living with HIV

4. Module V: Living with HIV Unit 1: Addressing Psychosocial Issues By the end of this unit, participants should be able to: Perform an effective psychosocial assessment Identify common challenges facing HIV+ children and counsel on child rights, stigma and discrimination, sexual abuse Identify strategies to support children and caregivers who are in a crisis situation

5. Assessing Challenges ASSESS Children, just like adults, have complex psychological and social needs which need to be addressed It is important that these needs are identified and addressed in a holistic manner If these needs are not addressed, it can lead to increased stress and anxiety

6. Challenges Faced by HIV+ Children ASSESS What challenges do HIV+ children face: – At home? – At school? – In the community?

7. Understanding Child’s Challenges— Psychosocial Assessments ASSESS Why is a formal psychosocial assessment important for children with HIV? – To identify areas that promote and/or inhibit maximum independence and functioning – To develop an effective treatment plan – To identify possible barriers for adherence – To identify appropriate referrals

8. Brian Video Clip ASSESS Discussion questions: What questions did the counsellor ask to identify psychosocial issues for Brian? How did those problems affect Brian’s life? How does the counsellor support Brian to identify solutions for his problems? What support is needed by Brian and his family to cope with the situation?

10. Discussion: Assessment Questions ASSESS Looking at these areas: – Living situation – Available Resources (financial) – Support systems: community, school, family, church – Emotional, physical conditions What questions should we ask to assess these issues?

11. Common Challenges ASSESS Be prepared to assess and address challenges– there are strong links between mental and physical health Some of the most common challenges that HIV+ children face include: – Stigma and discrimination – Sexual abuse – Grief and Loss These can be challenging for counsellors to address

12. Challenge 1: Stigma and Discrimination ADVISE What kinds of stigma and discrimination do HIV+ children commonly face?

13. Coping with Stigma ASSESS and ADVISE Using job aids, role play this scenario in triads: Kenneth, 7 years, comes home from school each day feeling sad. His grandmother, Norah, says that Kenneth told her that the boys at school call him names. They do not want to sit next to him at school and refuse to allow him to play football. What can you suggest to help Kenneth and Norah address that situation?

15. Challenge 2– Child Sexual Abuse What are we referring to when we say “child sexual abuse”? – Abuse occurs when an adult forces or coerces a child into sexual activity (touching, oral-genital contact, penetration with fingers) – Inappropriate sexual language, watching in a sexual way, child pornography – Abuse between peers can occur through use of power or coercion – Often the abuser is someone that the child knows

16. Claire Video Clip Discussion: How does the counsellor encourage Claire to talk about what has happened to her? How does the counsellor show support for Claire? Do you think Claire is in crisis right now? Why or why not?

17. Child Sexual Abuse– How to Address It ASSESS and ADVISE If the abuse has occurred recently: Assess how the abuse occurred, frequency Encourage child to talk to trusted adults Suggest talking to police and a clinician Abused children may also need: A safe environment to talk, ongoing counselling, support to tell caregiver Clear information about child rights Support groups for sexually abused children

19. Helping Children Understand that Sexual Abuse is Wrong ADVISE It is important to teach children: – About basic sexual education – About their rights and who to talk to when their rights are not respected – That their bodies are their own – That sexual advances from adults are wrong and against the law – To say “NO” when their bodies are touched – About the difference between good & bad secrets – About safe places and times for sexual expression

21. Challenge 3– Grief and Loss ASSESS In addition to other challenges, HIV+ children may face the loss of a parent, caregiver and/or loved one This may mean a loss of safety, security, stability Talking about death can be difficult and adults tend to avoid talking to children– counsellors have an important role in helping children understand death Healthy for children (and adults!) to be able to express their grief openly Ask children about loss, encourage them to express what they feel through stories, play, drawings

22. Reflection Exercise On a piece of paper, write the name of the person most dear to you. Think about that person as you fold the paper a few times. Close your eyes, envision that person.

23. Children and Grief Children definitely experience grief YET they experience it differently than adults

24. Expressions of Children’s Grief ASSESS Clinging, crying, desire to be alone– behaving differently than normal Some express the death through play “Deep pockets of sadness” when something reminds them of the parent that has died – Longing to be held once more by mother or hear the gate open when father comes home from work Some do not show pain– it may remain inside Feelings may not be easily shared with peers who have not experienced a similar loss

25. Understanding of Death varies by Age ADVISE Explaining death by age: – Birth to 24 months – 2-4 years – 5-6 years – 7-8 years – 9-12 years – 13-18 years

26. Issues for the HIV Positive Child Child will also think of their own infection and death The child may have already experienced a number of losses The extended family and peers may abuse, taunt or stigmatize the child– this may be displaced anger over the loss of the parent Address the child’s own illness and fears about death openly

28. When a Challenges Becomes a Crisis A crisis is any event where the client has an emotional reaction and feels unable to cope A crisis intervention is active, direct, brief and occurs shortly after the crisis has happened The focus is on giving the child, adolescent and caregiver as much support as possible The client may not be thinking clearly and may need your guidance and direction immediately

30. REVIEW What 3 questions should a counsellor ask as part of a psychosocial assessment? How can a counsellor support children who are experiencing challenges such as stigma and discrimination, child sexual abuse or grief and loss? How is a crisis intervention different than a usual counselling session? Addressing Psychosocial Issues

31. Module V: Living with HIV Unit 2: Positive Living By the end of this unit, participants should be able to: Explain key concepts of positive living Use the paediatric HIV flipchart to counsel clients on positive living Counsel adolescents on sexual health using flipchart and adolescent booklet

32. Promoting a Positive Attitude Part of living positively is having a positive attitude. There are many children living with HIV and living well Discuss that the child will need to do certain things that would help him/her keep strong and healthy but otherwise the child can be treated as he/she always has been.

33. What is positive living? In pairs, brainstorm some of the positive living strategies that you know. After 3 minutes, each pair will need to share an idea.

34. What is Positive Living?

37. Positive Living Mini Role Play – Elizabeth, 6 yrs, tested positive 2 months ago. She had been chronically ill before getting Septrin and is just starting to feel better. She has come to the clinic today with her parents for a follow-up visit. Using your paediatric HIV flipchart, role play this scenario in triads:

38. What is Positive Living for Adolescents? Sexual health Avoiding risk behaviours such as cigarettes, drugs, alcohol

41. Growing Up

42. Being Safe

43. Reducing Risk

44. Closing

45. Demostration: Giving Test Results

46. Talking about Sexual Health– Role Play Adolescents need clear, direct communication about this important stage in their lives. – Esther, 14 yrs, comes to the clinic to collect her Septrin. She mentions that her boyfriend has been saying that he is in love with her and thinks they are ready for sex. Remember to use your Paediatric HIV Flipchart and Adolescent Booklet!

49. Adult Profiling Chart

50. REVIEW What are 4 positive living strategies that counsellors should recommend to clients? What are 3 important topics to cover when counselling adolescents about sexual health? Which job aids can help you counsel clients on positive living? Positive Living

51. Module V: Living with HIV Unit 3: Referrals and Support Groups By the end of this unit, participants should be able to: Explain why referrals are a key part of counselling HIV+ children, adolescents and caregivers Identify several common referrals for HIV+ children, adolescents and caregivers Identify strategies for starting support groups for HIV+ children

52. Agree on Actions to Be Taken AGREE After assessing challenges and advising on options, it is important to start developing an action plan around issues important to the caregiver/child Identify the most important issues to address first Discuss sources of support within the family, at the clinic and in the community Allow the caregiver and child to decide what is best for them

53. Referrals in Your Area ASSIST and ARRANGE What referrals do you regularly make as part of your counselling activities? What other support services would you like to identify in your area to better meet the needs of HIV+ children, adolescents and their families?

54. Support Groups ASSIST and ARRANGE Support groups are a key intervention: An informal group of participants who face similar problems Offered to willing participants– participation should always be voluntary Has anyone here started a support group? What advice do you have on starting them?

55. Unique Girls Video Clip ASSIST and ARRANGE Discussion – How does the counsellor encourage the girls to feel open and comfortable? – What does the counsellor do when one of the girls is hesitant to talk? – What lessons have you learnt from this group of girls?

56. REVIEW Why are referrals an important part of the counselling process? What are several key referrals that are important for HIV+ children and caregivers? What are several key referrals for HIV+ adolescents? Referrals and Support Groups

57. Discussion: Reviewing the Process Observation Tool– Living with HIV

58. Key Messages from this Module HIV+ children face many challenges that need to be assessed and addressed by a counsellor. It is important to perform regular psychosocial assessments to understand how the counsellor can best meet clients’ needs. Children and caregivers need to be reminded of the importance of positive living– play, rest, regular clinic visits, OI prevention, good nutrition, social support.

59. Key Messages (2) Caregivers may need support to talk openly with adolescents about HIV, sexual health and risk behaviours. Adolescents themselves need clear and direct information from counsellors about sex. Referrals for other services are a critical part of effective counselling.