HIV Epidemic in SouthEast Asia

1
Testing and counseling for children and
adolescentsDr Suomi Sakai Representative, UNICEF
Cambodia Joint WHO/UNICER/UNAIDS Technical
Consultation on Scaling up HIV Testing and
Counselling in Asia and the Pacific Phnom Penh,
Cambodia, 2-6 June 2007
2
CRC Principles Important to HIV Testing

• Best interests of the child shall be the primary
  consideration in all actions concerning children
  (article 3)
• Right to non-discrimination (article 2)
• Right to life, survival and development (article
  6)
• Right to have views affecting the child heard and
  given due weight, in accordance to age and
  maturity of the child (article 12 and 13)
  

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Issues Needing Guidance for HIV Testing of
Children

• Informed consent / childs participation
• Testing
• Disclosure
• Treatment if needed
• What support needs to be in place
• Counselling
• Child
• Parents
• Handling information on childs HIV status to
  ensure confidentiality
• How to get consent/ensure confidentiality for
  child without parent legal guardian
• Support to Most at-Risk Adolescents

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Children, adolescents and young people
Age 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
18 19 20 21 22 23 24
Adults 18
Children 0-17 (CRC)
Young people 10-24 (WHO, UNICEF)
Adolescents 10-19
Youth 15-24 (UN)
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Children, adolescents and young people
Age 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
18 19 20 21 22 23 24
Adults 18
Children 0-17 (CRC)
0 - 4
5 - 9
10 - 17
Young people 10-24 (WHO, UNICEF)
Adolescents 10-19
Youth 15-24 (UN)
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Citizenship, rights, responsibilities, age
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Legal and ethical considerations in testing
children

• Under what circumstances is testing of children
  conducive and to whom?
• Once the results are known, how and what benefits
  are available for the child who tests HIV
  positive?
• How will the knowledge of HIV positive serostatus
  be used to ensure access to care and support for
  the child?
• Few countries have specific policies and
  guidelines addressing HIV testing among children,
  how to elicit informed consent from children, or
  guidance on how to ensure the best interest of
  the child are considered
• Lack of country level operational guidance

8
Other considerations based on age

• Younger children (5-9)
• Mostly infected through vertical transmission
• Parents may be reluctant to test child if they
  are not tested or are reluctant to disclose their
  own status
• Testing predominantly initiated by health care
  providers and/or parents
• Child may not be able to understand
  stigma/discrimination
• May not be able to keep information confidential
• Older children (10-17)
• Majority infected through sexual intercourse or
  injecting drug use
• May be reluctant to get parental consent
• Mostly seek testing and counseling themselves

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Possible benefits of HIV testing among children

• Early identification of HIV-infected children
  enabling early access to treatment and care
• Identification of uninfected children, enabling
  prevention measures to ensure they stay
  uninfected
• Eliminates anxiety and stress of parents of HIV
  negative children, and among HIV positive
  children relief of knowing the truth rather than
  being worried about the unknown
• Facilitates life-planning for families and/or
  children who are HIV-infected
• Contributes towards governments achievement
  towards commitments on international agreements
  on children and AIDS

10
Possible disadvantages of HIV testing among
children

• Young children many not fully understand the
  situation, or only understand the negative
  implications
• HIV positive diagnosis is associated with
  feelings of anger, resentment, anxiety,
  hopelessness and depression
• Young children may disclose their HIV status to
  others without being aware of the negative
  ramifications, such as stigma and discrimination

11
Disclosure to child of his / her HIV positive
status

• Helps a child to cope with illness through
  addressing fears and concerns with the support of
  parent(s) or caregivers
• Facilitates the childs involvement in planning
  care, educational and psychosocial needs
• Enable an older child to learn about safe sex
  practices and to take responsibility for
  prevention of further transmission, if sexually
  active or injecting drugs
• Challenged by lack of guidelines for the most
  appropriate age or most appropriate methods for
  telling a child his / her HIV status

12
Skills required for counseling children

• Assessing maturity for understanding benefits and
  risks of testing and for providing consent
• Age-appropriate communication
• Disclosure
• How to inform a child of his / her HIV status
• Counseling for adherence of HIV medication
• Talking to children about death
• Assessment of sexual abuse and rape
• Parent / caretaker counseling
• Ongoing psychosocial counseling

13
Challenges for Obtaining Consent to Testing

• No parent or guardian is available (orphans,
  abandoned children, street children)
• Refusal by parent(s) to provide consent for
  testing of a child (HIV positive status of an
  infant or young child normally indicates HIV
  positive status of a parent(s)
• Laws and policies related to consent are absent
  or unclear, or contradictory
• Legal age of consent is set at a higher age than
  average age at which adolescents become sexually
  active or experiment with drugs - may inhibit
  willingness to test

14
Challenges in counselling of children

• Requires skills that differ from counselling
  adults on HIV
• Lack of professional child psychologists and
  counselors in the region (eg Myanmar- one
  specialist Child Psychologist)
• Need for specialised child counsellors and
  training in child counselling techniques
• Need for specialised training for counselors
  working with children /adolescents engaged in
  injecting drug use, commercially sexually
  exploited / sexually abused children, and boys
  having sex with boys

15
Recommendations for increasing access to HIV
testing among children

• Inclusion of children in national policies
  related to HIV/AIDS and, specifically policies on
  HIV testing
• Scaling-up of training of health care providers
  on issues surrounding HIV testing of infants and
  children, including establishment of capacity for
  virological testing and child counselling
• Development of practical guidance notes on HIV
  testing and children, with focus on consent,
  confidentiality and counselling
• Continue to address stigma and discrimination
  experienced by children infected and affected by
  HIV/AIDS

16
Recommendations for increasing access to HIV
testing and counselling among adolescents

• Scaling-up access to youth-friendly HIV testing
  and counselling services, especially for
  most-at-risk and vulnerable adolescents (young
  sex workers and clients, adolescents who inject
  drugs, boys/men who have sex with boys/men)
• Integration of HIV testing and counselling of
  adolescents integrated into adolescent
  reproductive health programmes (mainstream
  youth)

17
Good Practices

• Develop clear definition of Best Interest in
  legislation
• Lower age of consent coupled with community
  sensitization
• Develop clear guidelines on the criteria for IV
  testing in children
• Develop confidentiality handbook for staff
  coupled with training

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How to come to national consensus on

• Whose consent is needed to test, to disclose, to
  provide treatment if necessary
• What special measures for children need to be in
  place before testing
• What consideration are needed for Most at Risk
  Adolescents
• What considerations are needed for children
  without parent or legal guardian (e.g. street
  children)

What regional/global guidance is needed?