HIV Nursing Matters / Page 4 Complications of Long-Term HIV and and Being Exposed to HIV Infection

HIV Nursingg matters

A Magazine of the Southern African HIV Clinicians Society

The psychosocial challenges of HIV positive youth- the silent epidemic The Sexual and Reproductive Health Needs of Adolescents Living with HIV Voluntary Medical Male Circumcision and Adolescents

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inside Guest editorial Health Needs of Adolescents Dr Harry Moultrie 4 Living with HIV 26 Voluntary Medical Male Message from the Circumcision and Adolescents 30 president Tool to aid disclosure for HIV positive adolescents to their Dr Francesca Conradie 6 HIV Nursing romantic partners 34 Improving engagement, retention matters News of care and ARV treatment adherence What are PMTCT Options 8 amongst adolescents 38 focuses on Youth & Adolescent Dietician’s column Love life report New Year’s resolutions with FAD Youth Friendly Services programme Issues dieting 10 in some public health clinics 42 Current issue Behavioral, Psychiatric, and Profile Cognitive Problems in Adolescents CHIVA South Africa Organisation 46 on cover with Perinatal HIV Infection 14 The psychosocial challenges of HIV Dealing with stigma within Youth What to do 49 Friendly services 18 positive youth- the silent epidemic The psychosocial challenges of HIV positive youth: the silent epidemic 22 Where to go 50 The Sexual and Reproductive Health Needs of Adolescents Living with HIV Clinical update The Sexual and Reproductive Voluntary Medical Male Circumcision and Adolescents

March 2013 / page 3

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incidence of 5.5 (95%CI 4.3-6,6) per 100 women years.

ALHIV require access to adolescent guest editorial friendly services which address their lescent health care utilisation rates are specific needs. These include HIV unfortunately limited, the high preva- diagnosis; diagnosis and treatment lence of teenage pregnancy and cura- of complex clinical conditions arising ble STIs amongst school-going children from chronic HIV and/or ART expo- indicate that clinics are not delivering sure; sexual and reproductive health adolescent friendly sexual and repro- services including Pap smears and HPV ductive health services.The reintroduc- vaccinations and, most importantly, tion of school health services through screening, diagnosis and treatment for the Integrated Schools Health Policy mental health conditions and psycho- could dramatically improve access to social problems. health services for children and adolescents as there are approximately 8 Anecdotal reports suggest that access times as many schools as health clinics to HIV Counselling and testing for ado- Dr Harry Moultrie in South Africa. In order to realise this lescents remains challenging despite potential however the ISHP needs to clear guidance from the Children’s Adolescence is a developmental deliver sexual and reproductive health Act (Act 38, 2005) that children 12 stage during which children transi- services that are adolescent friendly years and older with sufficient maturity tion into adults through progressively and which are effectively co-ordinated can independently consent for an HIV developing their autonomy and tak- with clinic services. test. Slow progressors often remain ing responsibility for their own lives, undiagnosed into older childhood and including their health. It is a time of The population of South African chil- adolescence.A study of perceptions of intense physical, psychological and dren with HIV is ageing into adoles- risk and acceptability of PICT amongst emotional change. Risk-taking is part cence as a result of a maturing HIV adolescents and their caregivers con- of adolescent development. Many of epidemic; earlier paediatric diagnosis; cluded that providing information of the important determinants of adult ill provision of antiretroviral therapy (ART) late diagnosis of MTCT in adolescents health such as harmful alcohol use, to HIV-infected children and increased could facilitate uptake of PICT as HIV- tobacco use, unhealthy diet and lack coverage of the PMTCT programme infection in this population was widely of physical activity have their origins with better regimens.In addition to the assumed to be exclusively sexually in adolescence. Adolescence is also emergence of adolescents with perina- acquired and which carried significant generally the period in which sexual tal HIV-infection, recent estimates indi- stigma. activity commences and sexual identi- cate that young women aged 15-24 ties are developed. The safe develop- years in South Africa have the highest Adolescents with perinatal HIV infec- ment of healthy sexual identities is par- incidence of HIV of any demographic tion (PHIA) often have complex medi- ticularly challenging for adolescents group in the country, with an estimated cal conditions related to both long-term living in South Africa as a result of the HIV and ART exposure. The majority generalised HIV epidemic and gener- of current PHIAs in South Africa are ally unhealthy gender norms. likely to have been initiated on ART Anecdotal reports suggest that after 5 years of age. As a result of their access to HIV Counselling and All adolescents need positive adult role testing for adolescents remain delayed commencement of ART, many models and safe and enabling environ- challenging despite clear guid- current PHIA would have already had ments which provide opportunities to ance from the Children’s Act advanced HIV disease at the time of exercise healthy choices. Adolescents (Act 38,2005) that children 12 commencing ART. In particular HIV- also require access to adolescent years and older with sufficient associated neuro-developmental delay, friendly services which address their maturity can independently cognitive deficits, attention disorders sexual and reproductive health needs consent for an HIV test. and psychiatric disorders are of including prevention, diagnosis and concern in PHIA. In addition, less com- treatment. While routine data on ado- mon but important renal and cardiac

HIV Nursing Matters / page 4 complications of long-term HIV and and being exposed to HIV infection. ART exposure need to be diagnosed Mental health issues such as depres- and managed. sion and traumatic life events have been implicated in adolescent sexual Clinical management is often further and substance abuse risk behaviours complicated by HIV drug resistance and ability to maintain adherence to mutations. As a result of the prolonged medication. In South Africa, nearly high viral loads in children the dura- a quarter of adolescents reported bility of ART regimens is shorter and feelings of sadness, or hopelessness in the development of drug resistance the preceding 6 months and 21% had The Team mutations more likely. A review of attempted suicide, with 29% of these Guest Editorial: Dr Harry Moultrie outcomes of children on ART in South requiring medical treatments. Gender Africa demonstrated that the three year based violence is very common in President: Dr Francesca Conradie probability of virological failure in chil- South Africa, with orphaned and vul- dren is 19.3% (95%CI 17.6 – 21.1%). nerable children at greater risk. Mental Editorial Advisory Board: Of concern is that only 38% of chil- and psychosocial services need to be Dr Elizabeth Mokoka dren with confirmed virological failure specifically capacitated to be gender Ms Stacie Stender Dr Natasha Davies in this study had been switched to sec- sensitive and to be able to address the Dr Liezl Smit ond line therapy, with a median time psychosocial consequences of gender Ms Laurie Schowalter from failure to switch of 5.7 months based violence. Ms Nelouise Geyer (IQR: 2.9–11.0). While this delay is Dr Michelle Moorhouse partly explained by the previous South This edition of HIV Nursing Matters is African guidelines which advocated focused on Youth and HIV. Monica Contributors: Monument Trust for a more conservative approach to Nkwanyana shares some lessons Advertising: Chriss Nyalungu switching therapy than current guide- learned on how best to structure HIV E mail: [email protected] lines, ongoing viral replication in the and sexual and reproductive health Tel: (011) 341 0162 presence of ART is associated with services in order to minimise stigma. drug resistance. Brian Zanoni draws our attention to the Article/Letter submission: importance of screening adolescents Ms Nonhlanhla Motlokoa PHIA face considerable challenges in with perinatal HIV infection for behav- E mail: [email protected] achieving autonomy as a result of both ioural, cognitive and mental health Tel (011) 341 0162 problems which can result in poor psychosocial and physical manifesta- For more information contact tions of HIV as a result of high rates adherence to ART, loss from care and/ SA HIV Clinicians Society of developmental delay, orphaning, or substance abuse.While disclosure Suite 233 Post Net Killarney recurrent bereavement, and increased of HIV status to older children and Private Bag X2600 vulnerability to violence and abuse. In adolescents has received considerable Houghton particular there is a high prevalence attention in recent years, disclosure 2041 www.sahivsoc.org of physical delay, including stunting by adolescents living with HIV to their Tel: Tel +27(0) 11 341 0162 and sexual maturation in PHIA which romantic and sexual partners has Fax: +27(0) 11 341 0161 can result in internal and external received comparatively little attention. E-mail: [email protected] stigma and discrimination. A review Shanaaz Randeira tackles this chal- of children attending Harriet Shezi lenging topic in a superb article which The opinions expressed are the opinions of Children’s Clinic at Chris Hani Barag- provides guidance on a 5-step process the writers and do not necessarily portray wanath Hospital in 2010 indicated to support disclosure by adolescents the opinion of the Editorial Staff of HIV Nursing Matters or the Southern African that more than 50% of children over to their partners. CHIVA’s adolescent HIV Clinicians Society. The Society does the age of 5 years had lost at least programme profile provides inspira- not accept any responsibility for claims one parent. Orphaned children are tion, and there’s also an article on made in advertisements. at a significantly higher risk of missing circumcision. R out on schooling, living in households All rights reserved. No part of this pub- that have less food security, taking on References available on request lication may be reproduced in any form significant caretaking responsibilities, without prior consent from the editor. suffering from anxiety and depression,

March 2013 / page 5 president Message from the president

Dr Francesca Conradie: President Southern African Clinicians Society

2013 is well upon us and exciting remember, like all medicine, it is not times coming up. “one size fits all.” Some patients will not be eligible, to mention some, those As of the 1st April 2013, fixed dose who have renal problems, those who combinations or FDC will be hitting work shifts and cannot take EFV and our clinics. And what does that mean those who are on second line already. to both to our patients and our prac- We will have to carefully counsel this tice? Firstly, it will make life easier group to make sure they do not inter- for the patients who are able to take rupt their medication. them- one tablet at night. The National Department of Health has designated So our next few months will be hectic Priority Groups in order to ensure we but filled with good change. R have sufficient stock. We do not ever want to have to change from FDC back to the split out medication. All new patients, pregnant and breastfeeding women who can take a tenofovir based regimen with EFV are in the first two groups. Then patients who are on a d4T- based regimen are in the next All new patients, priority group especially if they have pregnant and any toxicity. The next priority groups breastfeeding wom- are patients with TB who are stable en who can take on a TDF based regimen, then those a tenofovir based regimen with EFV with other comorbidities and finally are in the first two those who are on a stable TDF based groups. regimen. The introduction of FDC will make our lives easier but we have to

HIV Nursing Matters / page 6 page 42 March 2013 / page 7 August 2011 / page 43 news What are PMTCT Options A/B/B+? Author: Dr Nicola Wattrus, Programme Advisor, Woman and Child Health Technical Team, Wits Reproductive Health and HIV Research Institute (WRHI)

Co-Author: Dr Vivian Black, Director Clinical Programmes, Wits Reproductive Health and HIV Research Institute (WRHI) Member of Treatment Care and Support Technical Task Team South African National AIDS Council

ART for all pregnant women irrespective of CD4 cell count could achieve maximum coverage and could potentially lead to elimination of mother-to- child transmission of HIV, eliminating paediatric HIV.

South Africa’s current PMTCT guide- Truvada for women with CD4 counts pregnant women be initiated on to ART lines are in line with WHO’s 2010 >350 cells/mm³. All infants receive as soon as diagnosed HIV positive, and guidelines, offering a similar ‘Option NVP daily for the first 6 weeks of life, discontinued after cessation of breast- A’ (see table 1). The current PMTCT and this is discontinued if the baby is feeding if CD4>350cells/mm³, or re- programme offers life long antiretro- exclusively formula fed or mom is on main on lifelong ART if CD4<350cells/ viral therapy (ART) for women with ART, and continued until 1 week after mm³. All HIV exposed infants would CD4 counts <350cells/mm³, and AZT cessation of breastfeeding if the mom is receive AZT or NVP for 6 weeks only (Zidovudine) from 14 weeks gestation not on ART. irrespective of feeding method. followed by AZT 3hrly intrapartum with a single dose of Nevirapine (NVP) and WHO’s option B suggests that all Option B+ takes things one step further,

HIV Nursing Matters / page 8 news

Table 1: WHO Guidelines 2010: Three Options for PMTCT Programmes Woman receives: Treatment Prophylaxis (for CD4 count (for CD4 count < 350 cells/mm3) >350 cells/mm3) Infant receives: Option Aa Triple ARVs starting as Antepartum:AZT starting as Daily NVP from birth until soon as diagnosed, early as 14 weeks gestation 1 week after cessation of continued for life all breastfeeding; or, if not Intrapartum: at onset of breastfeeding or if mother From April 2013, labour, single-dose NVP is on treatment, through and first dose of AZT/3TC age 4-6 weeks we should have a fixed-dose-combi- Postpartum: daily AZT/3TC through 7 days postpartum nation (FDC) avail- Option Ba Same initial ARVs for bothb: Daily NVP or AZT from able where Emtric- birth through age 4-6 Triple ARVs starting as Triple ARVs starting as early weeks regardless of infant soon as diagnosed, as 14 weeks gestation itibine, Tenofovir feeding method continued for life and continued intrapartum and Efavirenz are and through childbirth if not breastfeeding or until offered as a single 1 week after cessation of all breastfeeding tablet to be taken Option B+ Same for treatment and prophylaxisb: Daily NVP or AZT from once a day. birth through age 4-6 Regardless of CD4 count, triple ARVs starting as soon weeks regardless of infant as diagnosedc, continued for life feeding method

Note: “Triple ARVs” refers to the use of one of the recommended 3-drug fully suppressive treatment options. For the drug abbrviations in the table: AZT (azidothymidine, zidovudine [ZDV]); NVP (nevirapine); 3TC (lamivudine). options.

a Recommended in WHO 2010 PMTCT guidelines b True only for EFV-based first-line ART; NVP-based ART not recommended for prophylaxis (CD4 > 350) c Formal recommendations for Option B+ have not been made, but presumably ART would start at diagnosis. and suggests that all pregnant women, child transmission to at least 2% at six women) may be easier to implement irrespective of CD4 cell count, should weeks and to less than 5% at 18 months and monitor. The same FDC for all be initiated on to lifelong ART, and by 2016”(3).ART for all pregnant adults and adolescents, including preg- again, all HIV exposed infants would women irrespective of CD4 cell count nant women,does away with multiple receive either AZT or NVP for 6 weeks could achieve maximum coverage and and often complicated guidelines.FDC’s only irrespective of feeding practice. could potentially lead to elimination could contribute to improved treatment of mother-to-child transmission of HIV, adherence(4). This paves the way for WHO published a programmatic eliminating paediatric HIV. The sooner a successful PMTCT regimen change to update in April 2012 to the PMTCT the ART regimen is started in pregnancy, a FDC for all South African pregnant guidelines, recommending that Option the sooner maximal reduction in trans- women irrespective of CD4 cell count. R B or B+ could be programmatically mission will occur. With the change to advantageous over option A(1). A using EFV in pregnancy and no longer References: single universal regimen would treat all using NVP, a universal regimen option 1. Programmatic Update: Use of Antiretrovi- HIV infected pregnant women prevent- has opened up to PMTCT programmes. ral Drugs For Treating Pregnant Women and ing maternal morbidity and mortality as ART to all pregnant women will help Preventing HIV infection in Infants. World Health well as prevent mother-to-child transmis- intensify South Africa’s PMTCT pro- Organisation, 2012. sion of HIV in-utero, intrapartum and gramme to attain virtual elimination 2. Goga AE, Dinh T-H, Jackson DJ, group ftSs. during breastfeeding. of mother-to-child transmission of HIV, Evaluation of the Effectiveness of the National and with the drive to promote exclusive Prevention of Mother-to-Child Transmission In 2010 the national infant HIV-expo- breastfeeding, triple ART for the mother (PMTCT) Programme Measured at Six Weeks sure prevalence in South Africa was could provide the greatest protection to Postpartum in South Africa. South African Medi- 32.0%, and the national mother-to-child HIV-exposed infants. cal Research Council, National Department of transmission (MTCT) rate measured at Health of south Africa and PEPFAR/US Centers 4-8 weeks of infant age was 3.5%(2). From April 2013, we should have a for Disease Control and Prevention. Although 3.5% transmission rate is fixed-dose-combination (FDC) avail- 3. SANAC. National Strategic Plan for HIV, STIs quite good, The National Strategic Plan able where Emtricitibine, Tenofovir and and TB 2012-2016. 2011. (NSP) on HIV, STI’s and TB 2012-2016 Efavirenz are offered as a single tablet 4. Connor J, Rafter N, Rodgers A. Do fixed- has a vision for South Africa: “ultimately to be taken once a day. This is the first dose combination pills or unit-of-use packag- zero new HIV infections due to vertical step in simplifying the current PMTCT ing improve adherence? A systematic review. transmission (MTCT), and preventing guidelines, as a common regimen for Bulletin of the World Health Organization. transmission of HIV to reduce mother-to- all (adolescents, adults and pregnant 2004;82:935-9.

March 2013 / page 9 New Year’s resolutions with FAD dieting Written by C Haupt RD(SA) owner of Family Kitchen

Choosing the correct diet for yourself can be very confusing because there is a lot of differing advice available and everybody from your mother to your hairdresser has an opinion on which is the best diet.

HIV Nursing Matters / page 10 dietician’s column

Now that the festive season is over, sustainable. The healthiest way to lose New Year’s resolutions have been weight is to maintain a steady weight Use your phone to made and life has returned to normal. loss over a longer period of time take photos of the Most often the resolutions are about (Mahnan L, 2004). Your aim should scale. Send your exercising more and losing weight. The be 220g-450g per week for people photo to a weight question is how do we lose the excess that are overweight or grade I obese. loss friend and weight gained over the festive period For people with a BMI of over 35 and keep it off in a healthy way. The they should aim to lose 450g – 900g help to monitor basic concept of weight is a delicate each other. balance between energy intake and energy expenditure(Saris W, 2006). hairdresser has an opinion on which is In order to achieve sustained and ef- To calculate BMI. BMI= the best diet. fective weight loss it is important that weight (kg)/height (m2) you have a scientific based nutritional BMI ranges(Mahnan L, 2004): There are a variety of different Fad education and counselling (Golay A, Underweight <18.5 diets that are recommended in the 2000). Firstly you need to be realistic, Normal 18.5- 24.9 popular media. Example of these are: work out how much weight you should Overweight 25- 29.9 the Atkins diet, Grapefruit diet, Low lose and how fast you should lose it Obesity grade i 30-34.9 carbohydrate diet, Beverley Hills diet, then you need to decide what diet you Obesity grade ii 35-39.9 Scarsdale Diet, Guilt-free diet, Choco- are going to follow and stick to. Extreme obesity ≥40 late lovers diet, F-Plan diet, Microdiet, The BBC diet, The Biogenic diet, The To calculate your ideal weight Calculate your ideal weight Rotation diet, Cambridge diet, The Hip Ideal weight = Desired BMI x and Thigh diet, HPLC diet and the Nib- To calculate your ideal weight, use the height (m2) blers diet (Bowyer C, 1991). All of the BMI. Your goal weight should give you diets have one aim; that is to reduce a BMI between of 18.5 -24.5. If your per week. This weight lose should be the energy intake of the dieter. There weight is in the obese range make a maintained for 6 months followed by are different ways in which to reduce more realistic goal of 10% weight loss. a maintenance diet before starting to energy intake to achieve weight loss, Even a small amount (3-5kg) of sus- diet for weight loss again (Mahnan L, some are “bad” and others are not. To tained weight loss has proven health 2004). Workout how long it would better understand the FAD diets they benefits in a person who is obese. This take you to get to your goal weight can be divided up into different cat- weight loss can help to prevent the and mark it out in your dairy. Moni- egories of diet: High fat, High protein, incidence of type 2 diabetes by 40 to toring your weight loss is also a very High carbohydrate and fibre, Very low 60%(Astrup A, 2006). Once you have important set to making sure that you energy diets and Dissociated diets. reached your first goal weight reassess maintain your weight loss(Astrup A, and start with a new goal. 2006). There are differ- Calculate how fast you should The biggest Question is which ent ways in which lose weight diet is the best diet to follow? to reduce energy intake to achieve Now that you know how much weight Choosing the correct diet for yourself weight loss, some you should lose, how fast should you can be very confusing because there is lose it? A common goal set is 10kg a lot of differing advice available and are “bad” and in one month but it is not healthy or everybody from your mother to your others are not.

Before you chose a diet you need to look at the science behind each diet. Below is a short list of some of the most popular diets:

Type of diet Name Reason for diet working What has been reported in scientific literature High fat, ;low carbo- Atkins (McAuley Reduction in amount of energy Initial weightloss is seen in the first 6 months. hydrate KA, 2006) intake. After 6 months there was an increase in the waist Produce high ketone production circumference, fat mass, triglycerides and 2 h (Mahnan L, 2004). glucose levels increased. There does not seem to be any benefit for cardiovascular or diabetic risk if the high fat diet is followed compared to the high carbohydrate diet (McAuley KA, 2006).

March 2013 / page 11 dietician’s column

Before you chose a diet you need to look at the science behind each diet. Below is a short list of some of the most popular diets: Type of diet Name Reason for diet working What has been reported in scientific literature High protein Zone The total energy intake is reduced, After 1 year there was maintenance in the weight HPLC diet by increasing the protein intake. loss, waist circumference, fasting triglycerides The energy reduction is the cause and insulin. The weight loss was of clinical of the weight loss. (Astrup A, importance. However there was a poor result for 2006). LDL due to the increased intake of saturated fatty Protein has a high satiating ef- acids (McAuley KA, 2006). fect compared to similar energy amounts of fat and carbohydrates hence the reduction in intake. High Carbohydrate, F-Plan diet This is closer to a balanced diet Over a 12 month period, there is weight main- high fibre Energy % from approach tenance and a reduction in fasting triglycerides, (McAuley KA, insulin and waist circumference. Has a role in 2006): improving variables found in insulin resistance Carbohydrate 55% (McAuley KA, 2006) Fat < 30% Protein 15% Fibre 25-30g/day Dissociated (low Beverley Hills diet The main principle of the diet is When compared to a low energy balanced diet; energy) (separating The Biogenic diet that the macronutrients should the resulting weight loss was similar. There did out of food macro- Energy % from the be separated out. For example fats not seem to be any benefit in separating out the nutrients) balanced diet (Golay and carbohydrates should not be macronutrients(Golay A, 2000). It did show A, 2000): eaten at the same time. The reason an improvement in plasma glucose, insulin and Carbohydrate 42% given is that the carbohydrate will HDL (Golay A, 2000). Fat < 31% cause insulin to spike and thus the Protein 27% resulting in fat storage. Balanced Decreased Energy % from the Supplies the body with reduced The balanced diet had a positive effect on systolic energy (4218 kJ) balanced diet (Golay energy but with adequate macro and diastolic blood pressure and an improve- A, 2000): and micronutrients ment in plasma glucose, insulin and HDL (Golay Carbohydrate 42% A, 2000). Fat < 31% Protein 27% Very Low energy Slimming supple- Severe energy deficiency. If more than 1 kg of weight is lost per week it is diets (1380 kJ) ments or liquid diets at the expense of lean body mass which can have Grapefruit diet effects on metabolic requirements. Often lack- Microdiet ing in nutrient adequacy. Not recommended in Cambridge diet people with a BMI<25(Bowyer C, 1991)

Recommended diet for healthy energy (fat stores). A reduction of hydrate should come from vegetables, and sustainable weight loss about 2100kJ to 4200kJ in energy fruits and whole grain products. If you want to lose weight in a sustain- may be required depending on your able and healthy way, a balanced age and physical activity. The energy Food should be a part of your life that diet with restricted energy is the most should come from the following split of is enjoyable and social. If you want to sustainable and healthy diet. This macronutrients. Energy should come be able to sustain your diet make sure means that the diet should be nutrition- from: carbohydrate 50-55%, protein that you are able to fit your diet into ally complete expect for energy which 15-25%, fat <30% and additional di- your lifestyle with a few minor chang- allows the body to use up excess etary fibre of 25-30g/ day. The carbo- es. Good luck and enjoy. R Reference Golay A, A. A. Y. J. B. P. S. S. m. N. G. R. d. T. on weight loss and features of insulin resist- Astrup A, 2006. Carbohydrates as macronu- N., 2000. Similiar weight loss with low energy ance. International Journal of Obesity, 30.pp. trients in relation to protein and fat for body food combining or balanced diets. Internal- 342-349. weight control. International Journal of Obesity, tional Journal of Obesity, pp. 492-496. Saris W, F. G., 2006. Simple carbohydrates pp. S4-S9. Mahnan L, E.-S. S., 2004. Food, Nutrition, & and obesity: Fact, Fiction and Future. Interna- Bowyer C, 1991. A diet for Slimming. Proceed- Diet Therapy. 11th ed. Philadelphia: Saunders. tional journal of obesity, Volume 30, pp. S1-S3. ings of the NUtrition Society, Volume 50, pp. McAuley KA, S. K. T. R. W. S. M. J., 2006. 433-440. Long-term effects of popular dietart approaches

HIV Nursing Matters / page 12 March 2013 / page 13 Behavioral, psychiatric, and cognitive problems in adolescents with Perinatal HIV Infection: Unrecognized consequences Brian C. Zanoni, MD, MPH Ragon Institute of Massachusetts General Hospital, Massachusetts Institute of Technology and Harvard Harvard Medical School

For perinatally HIV-infected adolescents, undetected cognitive impairments lead to poor academic or occupational performance. Also confounding the problem are frequent disruptions of social, occupational and academic activities because of clinic appointments or hospitalizations.

HIV Nursing Matters / page 14 current issue

Introduction: language skills, particularly in read- Many perinatally HIV-infected children ing and vocabulary. This contributes are surviving into adolescence and to lower full-scale IQ, higher rates of young adulthood due to increasing po- special education and school failure tency, durability and access to antiret- in HIV-infected adolescents compared roviral therapy (ART). Although these to HIV-exposed, HIV-negative adoles- tremendous advances have saved cents (Wood et al., 2009, Brackis-Cott many lives and transformed HIV from et al., 2009, Gadow et al., 2010). a fatal disease into a chronic disease, Those perinatally-infected adolescents there remain long-term consequences with high viral loads or advanced of HIV infection. Despite clinical disease at the time of diagnosis have improvement, high rates of cognitive, higher degrees of cognitive and learn- behavioral and mental health prob- ing problems. Unfortunately, the ad- lems persist in perinatally-infected dition of ART treatment only modestly adolescents (Wood et al., 2009). improves language scores in this population (Jeremy et al., 2005, Smith et Neurologic Effects of Perinatal al., 2012). Higher CD4 percent at ART HIV Infection initiation and longer duration of ART HIV inflicts damage on the central are associated with improved memory nervous system (CNS) by inducing and attention control (Koekkoek et al., inflammation that results in neuronal 2008). Increasing evidence strongly cell death. Exactly how this neuronal argues for earlier ART initiation in damage translates clinically depends HIV-infected children. Less time with ac- on numerous factors such as dura- tive viral replication could potentially tion of infection, immune control of mitigate some of the neurocognitive the virus, severity of disease, genetic effects of HIV-infection. However, even factors and mode of HIV transmission clinically and immunologically stable (Benton, 2011). One factor in particu- HIV-infected adolescents on long-term lar - severity of HIV disease - has been ART show more frequent behavioral significantly associated with lower and learning problems and lower de- full-scale intelligent quotient (IQ), learn- velopmental and cognitive scores than ing disorders, and psychiatric diagno- established childhood norms (Nozyce ses among HIV-infected adolescents et al., 2006, Souza et al., 2010). (Wood et al., 2009). Early initiation of ART in HIV-infected children as well as early detection and Learning Disabilities intervention in cognitive impairment For perinatally HIV-infected adoles- could potentially lead to better out- cents, undetected cognitive impair- comes for these adolescents. ments lead to poor academic or occupational performance. Also Mental Health confounding the problem are frequent The manifestation of emotional dis- disruptions of social, occupational tress among adolescents can present and academic activities because of in many different ways. Psychiatric clinic appointments or hospitalizations. symptoms, mental health issues, and Psychological stressors such as loss behavioral problems presenting in the of parents or family members, social context of HIV infection result from stigma, isolation, or fear related to dis- many complex, interacting biological closure might also contribute to poor and psychosocial factors. Healthcare performances. (Benton, 2011) workers should recognize that a combination of factors might affect an HIV-infected adolescents have poor adolescent’s mental health. Medical

March 2013 / page 15 factors such as the effect of the HIV poor adherence may impact physical negative adolescents with HIV-infected on the CNS, opportunistic infections, and mental health, it might also be a caregivers are less likely to be sexually substance abuse, access to medical sign of cognitive impairment that leads active than HIV-uninfected youth from care, and family history of mental to a downward spiral. Adolescents similar environments (Bauermeister et illness may affect the presentation of with cognitive impairment may find it al., 2009, Bauermeister et al., 2012, emotional stress (Benton, 2011). In difficult to regularly adhere to medical Elkington et al., 2012). Whether addition, environmental and social fac- therapy. This leads to suboptimal medi- developmental delays lead to delayed tors including family and peer relation- cation levels in the blood, triggering sexual activity in perinatally-infected ships, exposure to poverty, violence viral replication and drug resistance adolescents is unclear. Regardless of and abuse all play roles in shaping further increasing the risk for CNS HIV status, mental health, substance adolescents response to psychological disease (Benton, 2011). abuse, and economic factors are asso- distress (Benton, 2011). Several studies have shown a clear ciated with sexual risk behavior (Mel- association between cognitive, psycho- lins et al., 2009, Williams et al., 2010, Feelings of depression, social with- social and behavioral problems in HIV- Elkington et al., 2012). In addition, drawal, loneliness, and anger are com- infected adolescents with substance caregiver and peer behavior strongly mon among youths struggling to cope abuse, sexual risk activities and poor influence risky sexual behavior. with HIV. This often translates into high adherence to ART (Kapetanovic et al., rates of depression, substance abuse, 2011, Chandwani et al., 2012). In ad- Discussion conduct disorder, social phobia, oppo- dition, HIV-infected children with poor Perinatally HIV-infected children are sitional defiant disorder and attention adherence have been found to have living longer, healthier lives as a result deficit hyperactivity disorder among higher rates of behavioral impairment, of tremendous improvements in early HIV-infected adolescents (Kamau et al., including conduct problems, learning diagnosis and treatment. However, 2012, Pao et al., 2000, Mellins et al., problems, somatic complains, impul- they often suffer with undiagnosed be- 2006, Musisi and Kinyanda, 2009). sivity and hyperactivity (Malee et al., havioral, cognitive and mental health HIV disease severity also appears to 2011). problems. These issues can manifest as affect many psychological disorders. learning disabilities, substance abuse, A recent study found that adolescents Sexual Risk Taking or adherence problems. It is important with lower CD4 percent had more Perinatally-infected children often expe- for the healthcare team to identify severe conduct disorder symptoms rience developmental delay, stunting, and address these issues immediately. (Nachman et al., 2012). The same and delayed onset of puberty. Perina- Routine care should include screening study found that higher viral load was tally-infected adolescents and HIV- that evaluates psychosocial stressors, associated with more severe depres- school performance, and adherence. sion symptoms. Severity of disease and Currently, there is little data available delayed ART treatment impacts cogni- on effective interventions for these ado- tive, academic, and social functioning Feelings of de- lescents. Further research is necessary as well as the psychiatric symptoms. to assist with earlier detection, treat- Early diagnosis and ART initiation pressions, social ment, and monitoring of these issues to could help reduce some of this burden. withdrawal, lone- alleviate some of the burden accompa- For older children, adolescent-friendly nying illness. HIV medical and psychological sup- liness, and an- port, including mental health interven- The addition of youth-friendly services tions, should be integrated into routine ger are common in many clinical settings is designed medical care to optimize the health to support adolescents through this and well-being of HIV-infected adoles- among youths difficult period of their lives. By offering cents. more convenient hours, peer relation- struggling to ship building, adherence monitoring, Adherence cope with HIV. educational support, and psychosocial For HIV-infected adolescents on ART, support, these services are equipped adherence to their medical regimen is to address many of the behavioral critical to their physical, emotional and issues that develop during adoles- psychological well-being. Although cence. Diagnosing and addressing

HIV Nursing Matters / page 16 current issue these behavioral, cognitive and mental HODGE, J., DI POALO, V., DEYGOO, N. S. & MUSISI, S. & KINYANDA, E. 2009. Emotional issues early could result in improved NACHMAN, S. 2010. Co-occuring psychiatric and behavioural disorders in HIV seropositive longer-term outcomes for HIV-infected symptoms in children perinatally infected with adolescents in urban Uganda. East African HIV and peer comparison sample. Journal medical journal, 86, 16-24. adolescents. R of developmental and behavioral pediatrics : JDBP, 31, 116-28. NACHMAN, S., CHERNOFF, M., WILLIAMS, JEREMY, R. J., KIM, S., NOZYCE, M., NACH- P., HODGE, J., HESTON, J. & GADOW, K. D. References MAN, S., MCINTOSH, K., PELTON, S. I., 2012. Human immunodeficiency virus disease BAUERMEISTER, J. A., ELKINGTON, K., YOGEV, R., WIZNIA, A., JOHNSON, G. severity, psychiatric symptoms, and functional BRACKIS-COTT, E., DOLEZAL, C. & MELLINS, M., KROGSTAD, P. & STANLEY, K. 2005. outcomes in perinatally infected youth. Archives C. A. 2009. Sexual behavior and perceived Neuropsychological functioning and viral load of pediatrics & adolescent medicine, 166, peer norms: comparing perinatally HIV-infected in stable antiretroviral therapy-experienced HIV- 528-35. and HIV-affected youth. Journal of youth and infected children. Pediatrics, 115, 380-7. adolescence, 38, 1110-22. NOZYCE, M. L., LEE, S. S., WIZNIA, A., KAMAU, J. W., KURIA, W., MATHAI, M., NACHMAN, S., MOFENSON, L. M., SMITH, BAUERMEISTER, J. A., ELKINGTON, K. S., ATWOLI, L. & KANGETHE, R. 2012. Psychiatric M. E., YOGEV, R., MCINTOSH, K., STANLEY, ROBBINS, R. N., KANG, E. & MELLINS, C. morbidity among HIV-infected children and K. & PELTON, S. 2006. A behavioral and A. 2012. A prospective study of the onset of adolescents in a resource-poor Kenyan urban cognitive profile of clinically stable HIV-infected sexual behavior and sexual risk in youth perina- community. AIDS care, 24, 836-42. children. Pediatrics, 117, 763-70. tally infected with HIV. Journal of sex research, 49, 413-22. KAPETANOVIC, S., WIEGAND, R. E., PAO, M., LYON, M., D’ANGELO, L. J., SCHU- DOMINGUEZ, K., BLUMBERG, D., BOHAN- MAN, W. B., TIPNIS, T. & MRAZEK, D. A. BENTON, T. D. 2011. Psychiatric considera- NON, B., WHEELING, J. & RUTSTEIN, R. 2000. Psychiatric diagnoses in adolescents tions in children and adolescents with HIV/ 2011. Associations of medically documented seropositive for the human immunodeficiency AIDS. Pediatric clinics of North America, 58, psychiatric diagnoses and risky health behav- virus. Archives of pediatrics & adolescent medi- 989-1002, xii. iors in highly active antiretroviral therapy-expe- cine, 154, 240-4. rienced perinatally HIV-infected youth. AIDS BRACKIS-COTT, E., KANG, E., DOLEZAL, C., patient care and STDs, 25, 493-501. SMITH, R., CHERNOFF, M., WILLIAMS, P. L., ABRAMS, E. J. & MELLINS, C. A. 2009. The MALEE, K. M., SIROIS, P. A., KAMMERER, impact of perinatal HIV infection on older KOEKKOEK, S., DE SONNEVILLE, L. M., B., WILKINS, M., NICHOLS, S., MELLINS, school-aged children’s and adolescents’ recep- WOLFS, T. F., LICHT, R. & GEELEN, S. P. 2008. C., USITALO, A., GARVIE, P. & RUTSTEIN, R. tive language and word recognition skills. AIDS Neurocognitive function profile in HIV-infected 2012. Impact of HIV severity on cognitive and patient care and STDs, 23, 415-21. school-age children. European journal of adaptive functioning during childhood and paediatric neurology : EJPN : official journal of adolescence. The Pediatric infectious disease CHANDWANI, S., KOENIG, L. J., SILL, A. the European Paediatric Neurology Society, 12, journal, 31, 592-8. M., ABRAMOWITZ, S., CONNER, L. C. & 290-7. D’ANGELO, L. 2012. Predictors of antiretroviral SOUZA, E., SANTOS, N., VALENTINI, S., medication adherence among a diverse cohort MALEE, K., WILLIAMS, P., MONTEPIEDRA, SILVA, G. & FALBO, A. 2010. Long-term of adolescents with HIV. The Journal of adoles- G., MCCABE, M., NICHOLS, S., SIROIS, P. follow-up outcomes of perinatally HIV-infected cent health : official publication of the Society A., STORM, D., FARLEY, J. & KAMMERER, B. adolescents: infection control but school failure. for Adolescent Medicine, 51, 242-51. 2011. Medication adherence in children and Journal of tropical pediatrics, 56, 421-6. adolescents with HIV infection: associations ELKINGTON, K. S., BAUERMEISTER, J. A., with behavioral impairment. AIDS patient care WILLIAMS, P. L., LEISTER, E., CHERNOFF, M., BRACKIS-COTT, E., DOLEZAL, C. & MELLINS, and STDs, 25, 191-200. NACHMAN, S., MORSE, E., DI POALO, V. & C. A. 2009. Substance use and sexual risk be- GADOW, K. D. 2010. Substance use and its haviors in perinatally human immunodeficiency MELLINS, C. A., BRACKIS-COTT, E., DOLEZAL, association with psychiatric symptoms in perina- virus-exposed youth: roles of caregivers, peers C. & ABRAMS, E. J. 2006. Psychiatric disorders tally HIV-infected and HIV-affected adolescents. and HIV status. The Journal of adolescent health in youth with perinatally acquired human im- AIDS and behavior, 14, 1072-82. : official publication of the Society for Adoles- munodeficiency virus infection. The Pediatric cent Medicine, 45, 133-41. infectious disease journal, 25, 432-7. WOOD, S. M., SHAH, S. S., STEENHOFF, A. P. & RUTSTEIN, R. M. 2009. The impact of AIDS ELKINGTON, K. S., BAUERMEISTER, J. MELLINS, C. A., ELKINGTON, K. S., BAUER- diagnoses on long-term neurocognitive and psy- A., ROBBINS, R. N., GROMADZKA, O., MEISTER, J. A., BRACKIS-COTT, E., DOLEZAL, chiatric outcomes of surviving adolescents with ABRAMS, E. J., WIZNIA, A., BAMJI, M. & C., MCKAY, M., WIZNIA, A., BAMJI, M. & perinatally acquired HIV. AIDS, 23, 1859-65. MELLINS, C. A. 2012. Individual and contex- ABRAMS, E. J. 2009. Sexual and drug use tual factors of sexual risk behavior in youth behavior in perinatally HIV-infected youth: perinatally infected with HIV. AIDS patient care mental health and family influences. Journal of and STDs, 26, 411-22. the American Academy of Child and Adolescent GADOW, K. D., CHERNOFF, M., WILLIAMS, Psychiatry, 48, 810-9. P. L., BROUWERS, P., MORSE, E., HESTON, J.,

March 2013 / page 17 Dealing with stigma within Youth Friendly services(YFS) Monica Nkwanyana Nurse Manager, Youth Friendly Services (2010-2012) WRHI

Youth Friendly Services are important because they provide more age appropriate services for a vulnerable group who may otherwise find it difficult to access necessary health services.

HIV Nursing Matters / page 18 current issue

Introduction In a survey done by the Reproductive From the above statements it is clear Health Research Unit and LoveLife in that when a young person comes to According to WHO, adolescents are 2004 on HIV and Sexual Behavior the clinic they maybe experiencing one defined as 10-19-year-olds, youth as among young South Africans aged15 or more of the above-mentioned social 15-24 year olds, and young people as -24 years, stigmas. There is therefore a need for a 10-24 year old. This period can also service that is comfortable, accessible be defined within the cultural context • HIV prevalence was 10.2%. and non judgmental for the youth. of individual countries; i.e. the age • 67% of young people aged 15-24 established by a society for the transi- years reported having had sexual The Essential Service Package tion to adulthood could be perceived intercourse. for Youth Friendly Clinics, ac- as marking the end of adolescence. • 24% stated that they had sex cording to The National Adoles- An example is that in the South while under the influence of alcohol cent-Friendly Clinic Initiative in African National Youth Policy South Africa (NAFCI)document 2009-2014, youth is defined as These statistics indicate a need for any person between the ages more Youth Friendly Services. For such 1. Information, education and counsel- of 14 to 35. services to succeed, issues of stigma ling on sexual and reproductive health. need to be addressed. 2. Information, counselling and appro- Stigma according to Erving Goffman is priate referral for violence/abuse and a mark of disgrace associated with a mental health problems. particular circumstance, quality, or person.Goffman, Erving. (1963). Stigma: 3. Contraceptive information and coun- Notes on the Management of Spoiled selling, provision of methods including; Identity. Prentice-Hall.The three oral contraceptive pills, emergency forms of social stigma according contraception, injectable and con- to Goffman are: doms.

1. Overt or external deforma- 4. Pregnancy testing and counselling, tions, such as scars, physical manifes- antenatal and postnatal care. tations of anorexia nervosa, leprosy (leprosy stigma), or of a physical dis- 5. Pre and post Termination of ability or social disability, such as obe- Pregnancy(TOP) counselling and refer- sity. Because of loss of weight(wasting) ral. and skin problems which develop at the final stages of AIDS people can 6. Sexually transmitted Infections(STi’s) associate HIV with this. information, including information on 2. Deviations in personal traits, the effective prevention of STi’s and including mental illness, drug addic- HIV, diagnosis and syndromic manage- tion, alcoholism, and criminal back- ment of STi’s, including partner notifica- ground are stigmatized in this way- be- tion. cause of sex as one of the modes of transmission of HIV and most communities associate that with promiscuity. 3. Tribal stigmas are traits, imagined The environment or real, of ethnic group, nationality, for the youth should or of religion that is deemed to be a deviation from the prevailing normative be conducive, clean, ethnicity, nationality or religion–Some and bright with lots of the misconceptions about HIV\ AIDS is that the main route of infection of information, es- for males is via homosexual sex and pecially on health certain religious sectors do not tolerate issues of homosexuality, it therefore and career guid- makes it difficult for them to accept a person with HIV/AIDS. ance.

March 2013 / page 19 7. HIV information, pre and post-test or one on one basis. Files were given counselling, and appropriate referral out and they did not state why a per- for voluntary testing if services are not son was there. That ensured confidenti- available. ality and removed the stigma of being identified as HIV positive or having STI Experiences on how stigmatiza- etc. Each person that came in went to tion in the youth friendly service a private counselling room to say why provided by WRHI was pre- they wanted to be seen, this was done vented. by the community health worker.Stigma was addressed especially when work- I’ve been a nurse manager,employed shops were held or when peer educa- by Wits Reproductive Health and HIV tors were giving talks at schools and Institute (WRHI), in a Youth Friendly the clinic. Service for 2 years (2010-2012) at 17 Esselen Street. Youth from 12 to I tried to have an open attitude which 22 years old were consulted. Some of led to the youth confiding in me espe- them were still attending school, some cially with the issues of revealing their not attending school,some unemployed HIVstatus, sexuality and especially and some were from shelters and things like date rapes or sexual abuse. parks. Case Scenarios Staff Breakdown: Nurse Manager, • One of the cases was about a girl Community Health Care Worker, 10 that came wanting to be checked if she peer educators, Community Liaison had an STI or not. She was reassured Officer because there were no signs of infection. She kept coming until I had to re- The clinic had to be friendly with peer ally enquire if there was anything more educators that were between 18 to 28 that she wanted to talk to me about. years old and were out of school She revealed that she was raped a few months ago on her way home, Services provided: and she never spoke to anyone about • Sexual Reproductive Health Servic- it, and she expressed that she needed es such as FamilyPlanning, Treatment help. She was subsequently referred of Sexually Transmitted Infections, HIV for further counselling and pregnancy Management, Referral for Termination testing, HIV was excluded. of Pregnancy and other services like • Another case was about a 19 year psychologists, hospitals and social old boy who was staying with four girls worker. and having a sexual relationship with • HCT done at the clinic and at other all of them, apparently he was owning institutions such as the universities, es- a flat (Left to him by his late mom) and pecially during HIV/AIDS campaigns. the girls wanted a place to stay, so they For those found to be HIV positive, had to pay by having sex with him. The continuous counseling and support boy had an STI, which he got treatment was given. for, extensive health education was • Health education was given continu- given and he was encouraged to bring ously at the clinic,during workshops the girls for STi treatment. Condom us- and holiday programmes by the youth age and HCT was encouraged. friendly services team. School going youth at different schools around Hill- The abovementioned scenarios show brow were trained on peer education, how important it is to provide a comfort- so that they can support their peers at able and conducive environment for the school. youth because they are able to offload • The youth were first received into the some of their heavy burdens they are waiting room by the peer educators carrying and confide in someone who who gave them health talks as a group cares.

HIV Nursing Matters / page 20 current issue

Lessons learnt sudden change of mood. • Peer education programme is help- • Lack of communication between ful because peer educators are within youth and their parents, this makes the age group, so it becomes easy to them very scared to tell their parents if identify with them and seek advice and they are having difficulties. confide in them. • ARV drug stock outs are a major • The environment for the youth problem because it promotes lack of should be conducive, clean, and bright adherence. with lots of information, especially on health and career guidance Recommendations: • Introducing peer education pro- • Comprehensive services to be given grammes at schools is very important. as this will help minimize the issues of Because the peer educators are within the youth being stigmatized. reach,other students can consult them • Separate waiting area from the when they have problems and they will adults is very important. be referred to the clinic accordingly. • Training of the staff from the cleaner • Health care providers should have to the security guard is important so a non-judgmental attitude and be able that they can be able to understand to pick up key points during the consul- what issues the youth are dealing tation.The service provider should be with and avoid making comments that helpful. would stigmatize the youth. • The nurse should be competent • Extension of hours should be encour- enough to recognize some of the aged and the security made available. underlying issues. • Avoidance of drug shortages is • Liaising with other commu- important. This will promote adherence nity based organizations such as amongst the youth, especially with SANCA(SouthAfrican National Coun- regards to ARVs. cilonAlcoholism and Drug Depend- • Lots of parenting workshops to be ence), shelters, churches and universi- held, to minimize issues of communica- ties. Other NGO’s such as LoveLife tion between parents and the young provide a good source of referral people

Challenges Conclusion: • Problems with clinic security after Youth Friendly Services are important hours. The school going youth cannot because they provide more age appro- access the service after 16h00 and priate services for a vulnerable group that’s the time they come back after who may otherwise find it difficult to school. access necessary health services. R • Some of the health care provider’s negative attitudes from other pro- References: grammes might prevent youth from Melanie Pleaner (NAFCI/RHRU) coming to the clinic when they have through a collaborative process problems. Survey on: HIV AND SEXUAL BEHAV- • Some consultations are long, espe- IOUR AMONG YOUNG SOUTH cially if it is a difficult case, and that AFRICANS (2004) (RHRU and Love leads to long waiting times. Life). • Hillbrow community is known to be very mobile and that makes it very South African National Youth Policy difficult to do follow up because many 2009-2014 youth either give wrong or old ad- dresses. Goffman, Erving. (1963). Stigma: • Youth prefer to come to the clinic in Notes on the Management of Spoiled large groups which poses a challenge Identity. Prentice-Hall. when one of them is found to be HIV positive, it becomes obvious by their

March 2013 / page 21 The psychosocial challenges of HIV positive youth: the silent epidemic Nataly Woollett, M.A. Technical Head: Psychosocial; Wits Reproductive Health & HIV Institute (WRHI)

HIV positive patients have to endure the stigma and discrimination they feel from the community or service providers, but also, especially during adolescence, experience ‘self-stigma’(or ‘internalized stigma’) where an individual takes on the perceived stigma of others and stigmatizes themself.

HIV Nursing Matters / page 22 current issue

Today, 1.2 billion adolescents stand a higher rate of behavioural, social, have an enormous influence on inter- at the challenging crossroads be- and emotional problems, such as personal relationships, self-esteem and tween childhood and the adult world attention-deficit hyperactivity disorder, the practice of safe sex where honestly (UNICEF, 2011). Nine out of ten of depression, oppositional defiant disor- talking about sexual transmission and these young people live in the de- der, adjustment disorder, post-traumatic protection is crucial. veloping world and face especially stress disorder and anxiety, relative to profound challenges, from obtain- their uninfected peers. These problems To safeguard a child from experiencing an education to simply staying are also evident in adolescents but in ing stigma, caregivers often practice alive. Adolescents are vacillating in addition include suicidality and alco- ‘stigma management’ and delay a developmental stage that bridges hol abuse later in development. While disclosing the child’s diagnosis to the childhood and adulthood; a time of the virus itself or an opportunistic child as a result of shame and guilt, increased flux. At no other time except infection, such as one causing menin- fears of inadvertent disclosure to infancy do human beings undergo gitis or encephalitis, may lead to neuro community etc.As a result, between so much development in such a short developmental impairments that affect 25%-90% of school-aged HIV posi- period. During adolescence, children mental and psychomotor develop- tive children are unaware of their own gain 50% of their adult body weight, ment, it appears that the social context status (Close, 2003) regardless of become capable of reproducing, and of HIV (such as familial disruption, going to the clinic every 3 months to experience an astounding transforma- poverty, and stigmatization) may play pick up treatment.However, many chil- tion in their brains (UNICEF, 2011). All a greater role in the higher prevalence dren are being sensitized to HIV and these changes occur in the context of of mental health problems among this ART through life orientation classes rapidly expanding social spheres. Al- population(Domek, 2009). at school and through the media, so though most adolescents navigate this inadvertently they start to ‘figure it challenging developmental stage suc- A major distinction between HIV/AIDS out’ on their own. Unfortunately, as cessfully, it can be especially difficult if and other chronic or terminal illnesses the family system has not been hon- there are other stressors to overcome, is the stigma associated with the dis- est, stigma leads to an atmosphere of including HIV. HIV adds a significant ease. This stigma often stems from lack secrecy within the family that the child burden to adolescent development, in- of knowledge about HIV and how it is often senses. Children become acutely cluding issues of stigma, orphan hood transmitted. Stigma can adversely af- aware of their family’s feelings towards and bereavement, increased poverty fect adolescents and their caregivers in their diagnosis, through observing and food insecurity, high mobility and ways that have long-term negative psy- interactions with other adults and how inconsistent schooling, increased risk chological and social consequences they discuss or avoid the topic in their for teen pregnancy and exposure to (Close, 2003). HIV positive patients presence. Labelling the diagnosis violence, high sexual risk taking behav- have to endure the stigma and discrimi- as a secret that cannot be discussed iour, and especially, increased risk for nation they feel from the community or only serves to increase the stigma and poor mental health outcomes. service providers, but also, especially by adolescence, many of these HIV during adolescence, experience ‘self- positive children have internalized that Research with adults indicates that stigma’(or ‘internalized stigma’) where stigma to a degree that disastrously people living with HIV in both devel- an individual takes on the perceived impacts their self-esteem and identity oped and developing countries have stigma of others and stigmatizes formation. higher levels of mental disorder than themself. Internalized stigma has a non-HIV-infected populations (Freeman large effect on the paediatric popula- Healthcare providers play a significant et al., 2007). The reasons for this are tion through its influence on parents’ role in assisting families with the disclo- complex but include pre-morbid mental decisions to disclose. If parents or sure process. Many families choose conditions, the effects of the virus on caregivers have internalized the stigma to disclose in the clinic setting so they the central nervous system, the psy- and negative views of HIV/AIDS, their can receive the educational support of chological impacts of living with HIV/ likelihood of telling the child about the facility staff there. It is important to AIDS, side-effects of medication and his or her diagnosis decreases signifi- note that disclosure is a process rather results of social stigma and discrimina- cantly. If adolescents internalize the than a one-time event; caregivers need tion (Freeman et al, 2007). Mental stigma regarding their diagnosis, they to be aware of their responsibilities health disorders have been shown to are more likely to become depressed and create an atmosphere of asking occur with increased frequency among and engage in denial regarding their and answering questions about the HIV-positive children and adolescents. HIV status (Close, 2003). Adolescents virus and living with it with an attitude Studies conducted primarily in the may fear disclosing their status to oth- and pace of information giving that is United States have shown that HIV-pos- ers and feel shameful regarding their comfortable to the child/adolescent. itive children and adolescents display condition. Obviously, these factors Caregivers might also be asked to

March 2013 / page 23 disclose their own status, which they children and adolescents orphaned adolescents is expected to grow (Fer- should be prepared for. Through by AIDS were 117% more likely to be rand et al, 2009). While youth aged basic education about the virus, how suffering from post- traumatic stress dis- 10-19 accounted for 1% of the total it is transmitted, and treatment options, order than children/adolescents whose number of patients receiving HAART in much of the stigma surrounding HIV/ parents were alive, and also 67% South Africa in 2008, this proportion is AIDS can be dispelled. Through edu- more likely than children/adolescents expected to grow to approximately 5% cating communities at large, families orphaned by other causes, including by 2020, mainly as a result of verti- and children infected or affected by homicide, suicide and cancer (Cluver, cally infected children surviving into HIV/AIDS can receive much-needed 2011). Orphans and vulnerable chil- adolescence (Jaspan et el, 2009). Ad- support and will no longer feel alone dren are at increased risk for mental herence to HAART remains problem- in their struggle (Close, 2003). Obvi- health problems as a result of the typi- atic with this population as adolescents ously, if this is done satisfactorily, cal contexts of emotional deprivation are often challenged with maintaining adolescents can learn how to disclose and stigma of their upbringings; and strict routines and this is often linked to to their friends, and later their sexual lack of attention given to their mental mental health problems (Ferrand et al, partners in ways that do not disad- health outcomes. 2010; Mellins et al, 2004; Merzel et vantage them or their sexual partner. al, 2008). Furthermore, South Afri- HIV incidence remains highest among Unfortunately, youth friendly services cans between 13-19 years comprise 15-24yr olds, with approximately are not widely available in the public roughly 30% of the population (STATS 40% of horizontal transmission occur- health sector in South Africa (SANAC, SA, 2010), so treatment and care for ring within this age group (UNAIDS, 2011), and adolescents tend to get HIV-positive adolescents will become UNICEF, WHO, 2008). lost in adult systems of care or fall increasingly important over the next out of care as a result of their needs decade as more adolescents will Timing and mode of transmission not being met. Better information on require access to healthcare. Being may be important factors to con- adolescents is needed if health-care mindful of and addressing some of the sider as perinatally/vertically infected providers, community-level stakehold- psychosocial stressors of this popula- adolescents may experience different ers, caregivers, and policy-makers are tion would go a long way in improving psychological challenges given that to respond effectively to the specific the lives of adolescents and strengthen- they have lived with HIV for a signifi- needs of this group. For adolescents living the healthcare system response to cantly longer period, compared with ing with a chronic illness, transitioning an important population. R adolescents infected behaviourally/ into adulthood includes an important horizontally. Many adolescents who shift toward medical independence. contracted the virus from their mothers Youth need assistance from healthcare are orphaned by the time they reach professionals in taking charge of their Healthcare provid- adolescence. Resultantly, at a tender medical care and utilizing the health- age, they have had a fair dealing with care system to their advantage. Un- ers play a signifi- death and grief. Much of the grief fortunately, healthcare service involve- surrounding HIV/AIDS is quite normal- ment decreases in adolescence at the cant role in assist- ized in communities and these chil- same time that family involvement in dren/adolescents often do not receive youth’s health care also declines which ing families with much support with their losses (which has serious implications for future the disclosure pro- are enduring). Adolescents might miss health. As long as this population is their parent who died for the remain- overlooked and their clinical, psycho- cess, many fami- der of their lives and have complex logical and social needs remain poorly and unresolved feelings about the loss, understood, adolescents (including lies choose to dis- the family disruption, and their HIV those on ART) will remain one of the status that have never been adequately most vulnerable populations affected close in the clinic or compassionately managed by the by the HIV pandemic. Our failure to adults around them. Unresolved grief address this vulnerability threatens the setting so they can can lead to traumatic bereavement lives of these youth and jeopardizes receive the edu- symptoms (such as post-traumatic stress the successes of paediatric HIV treat- disorder (PTSD) – hypervigilence, ment efforts to date. cational support avoidance, dysregulation, re-experiencing, increased stress and hy- As access to highly active antiretroviral of the facility staff perarousal etc.) and depression if not therapy (HAART) improves globally, dealt with.A recent study reports that the population of vertically infected there.

HIV Nursing Matters / page 24 current issue

References: HIV: A qualitative study of psychosocial con- Ways to address the chal- texts. AIDS Patient Care and STDSs, 22(12), lenges of caring for the Close, K.L. (2003). Psychosocial aspects of pp977-987 HIV+ adolescents: HIV/AIDS: children and adolescents. In HIV • If you don’t like adolescents, it Curriculum for the Health Professional. Bay- Pettifor, A. E., Rees, H. V., Kleinschmidt, I., Stef- is probably best not to work with lor International Pediatric AIDS Initiative, Baylor fenson, A. E., MacPhail, C., Hlongwa-Madiki- them. College of Medicine. zela, L., Vermaak, K. & Padian, N. S. (2005). • Remember adolescents who Young people’s sexual health in South Africa: are having a particularly ‘hard Cluver, L., Orkin, M., Gardner, F. & Boyes, HIV prevalence an sexual behaviors from a na- time’ may present with increased M.E. (2011). Persisting mental health problems tionally representative household survey. AIDS, ‘attitude’. This is a good defence among AIDS orphaned children in South Africa. 19(14), 1525 1534 to getting others to ‘back off’… Journal of Child Psychology and Psychiatry, don’t be misled! Know that if 1-8. SANAC (2011). Getting to success: improving an adolescent presents this way, HIV prevention methods in South Africa. South they need an especially patient Domek, G.J. (2009). Facing adolescence and African National AIDS Council; HIV epidemic, and kind approach. adulthood: The importance of mental health response and policy synthesis. • Be open to engaging in con- care in the global pediatric AIDS epidemic. versations of disclosure and give Journal of Developmental and Behavioural Thurman, T.R., Brown, L., Richter, L., Maharaj, P. support on how to manage this Pediatrics, 30: 14,150 & Magnani, R. (2006). Sexual risk behaviour process. Ferrand, R.A., Lowe, S., Whande, B., Munaiwa, among South African adolescents: is orphan • Adolescents may say they L., Langhuang, L., Cowan, F., Mugurungi, O., status a factor? AIDS and Behaviour, 10 (6), know when they don’t (especially around sexual reproductive Gibb, D., Munyati, S., Williams, B.G. & Corbett, 627-635. health issues) – make sure you E.L. (2010). Survey of children accessing HIV explain every time. services in a high prevalence setting: time UNAIDS, UNICEF & WHO (2008). Children • Intergenerational sex (sugar for adolescents to count? WHO Bulletin, 88, and AIDS: Second Stocktaking Report. Geneva daddy) is abundant in our cul- pp428-434. UNICEF (2011). State of the World’s Children: ture…just because she appears Adolescence an Age of Opportunity. Geneva to be okay with it does not mean Ferrand, R.A., Corbett, E.L., Wood, R., Har- it is consensual (non-exploitative) grove, J., Ndhlovu, C.E., Cowan, F.M., Gouws, or that she has made informed E. &Williams, B.G (2009). AIDS among old- choices and can negotiate safe er children and adolescents in Southern Africa: sex. projecting the time course and magnitude of • Adolescents talk to other ado- the epidemic. AIDS, 23, pp2039-2046. lescents – if one adolescent has Freeman, M., Nkomo, N., Kafaar, Z. & Kelly, K. a bad experience with you, they (2007). Factors associated with prevalence of won’t come back and neither will mental disorder in people living with HIV/ their friends! AIDS in South Africa. AIDS Care, 19(10), • Adolescence is a time of pp1201-1209 experimentation…just because they do it now doesn’t mean they Jaspan, H.B., Li, R., Johnson, L., & Bekker, L.G. will do it always…opportunities to (2009). The emerging need for adolescent- educate are important. focused HIV care in South Africa. The • To be of most benefit to the Southern African Journal of HIV Medicine, Dec growing adolescent, an adult Opinion Piece, pp9-11. needs to be a constant and consistent Mellins, C. A., Brackis-Cott, E., Dolezal, C., & • figure, available as a sound- ing board for the youth’s ideas Abrams, E. J. (2004). The role of psychosocial without dominating or overtaking and family factors in adherence to antiretroviral the emerging, independent iden- treatment in Human Immunodeficiency Virus- tity of the young person – don’t infected children. The Pediatric Infectious get caught up in power struggles Disease Journal, 23, 1035-1041. with youth, you will lose! • Adolescents have RIGHTS and Merzel, C., vanDeventer, N. & Irvine, M. we need to uphold them. (2008). Adherence to antiretroviral therapy among older children and adolescents with

March 2013 / page 25 ‘Vaku vaku’. ‘Iturr nash’. ‘Spaka paka’. The Sexual and Reproductive Health Needs of Adolescents living with HIV

By: A Armstrong1, B Pungula2, Z Sobantu1, E Cheserem3, K Moshal1,4 1CHIVA SA, KwaZulu Natal, South Africa; 2YAFS Clinic, Nseleni Community Health Centre, KwaZulu Natal, South Africa; 3Caldecot Centre, Department of Sexual Health and HIV, King’s College Hospital, London, United Kingdom; 4Department of Infectious Diseases, Great Ormond Street Hospital for Children, London, United Kingdom.

A Armstrong – BNS, RGN, NMP, DipTN, DTM+H, MSc Int. Health B Pungula – DipN, RGN, RGM, CHN, DipPHC, DipHIV, Z Sobantu – BCUR (Hons), RGN, RGM, CHN, Occ.HN E Cheserem - MBChB, MRCP, DipHIV K Moshal - MBChB, MRCP(UK), MRCPCH, DTM+H

Adolescents living with HIV have the same sexual and reproductive needs as other adolescents. They do not lose their desire for sex or to have families.

HIV Nursing Matters / page 26 clinical update

Adolescents, defined as those aged this is a highly stigmatised transmissible with HIV, participants voiced their 10 – 19, contribute significantly to infection.12 This often has an enormous concerns and called for healthcare shaping the future course of the HIV impact on their sexual health, relation- workers to ‘Stop being mothers and epidemic. An estimated 2 million ado- ships and emotional wellbeing. 12 fathers, be health providers’.23 Health- lescents are living with HIV globally.1 care workers’ personal views about In South Africa, data from 2009 esti- Adolescents living with HIV have the adolescent sex are shaped by soci- mates that between 264 000 – 322 same sexual and reproductive needs etal and cultural norms and taboos. 000 10 – 19 year olds and between as other adolescents.13 They do not Unfortunately these views often create 840 000 – 1 030 000 young people lose their desire for sex or to have a barrier to discussions around sex, re- (15 -24 year old) are living with HIV.1 families.13 Many have had sex, or lationships and other issues important Evidence shows that risk of sexu- intend to in the future, and have numer- to adolescents. This results in missed ally transmitted infections (STIs) and ous unanswered questions relating opportunities for thorough sexual and pregnancy clusters at adolescence and to sex.13,14 They have concerns about reproductive health (SRH) assessments young adulthood.2,3 The average age infecting others, having children safely, and the effective provision of pertinent of sexual debut for a South African and disclosing to partners.12,13,14 In information to promote healthy and adolescent is 15.4 Only 13% of those a Ugandan study of young people safe sexual practices.24 who have had multiple partners report living with HIV, only one-third of the condom use during their last sexual respondents had never had sex, and There are a growing number of stud- contact, and 31% of males between of these, 86% intended to have sex in ies that have documented the sexual 15 - 24 years report more than one the future.14 The desire to have children and reproductive health needs of partner in the last 12 months.4 and a family has also been extensively adolescents living with HIV, with many documented.12,13,14 In a Kenyan study, emphasising the gaps that exist within The increase in access to antiretroviral three quarters of participants wanted health services to address them.13-15,25- therapy (ART), means more children to have children in the future, although 27 The individual and public health who were infected through mother to most aimed to delay this to later in consequences of not addressing these child transmission are surviving into ad- life.13 Despite this, low rates of contra- needs, namely new HIV infections, olescence and adulthood.5,6,7 Likewise, ceptive use (66%) were reported, 68% unwanted pregnancies and sexually the increased availability and uptake of sexually active female respondents of HIV testing and counselling (HTC) had already been pregnant and three has allowed more adolescents with quarters of those were unintended vertically transmitted infection to know pregnancies.13 Similarly, in a study Consultation of their status.8 Additionally, concerted from the United Kingdom of young efforts in HTC have also assisted in the women born with HIV, one-fifth had young people identification of ‘slow progressors’ – been pregnant and 75% of these were vertically infected HIV positive patients unplanned pregnancies.15 living with HIV, who are diagnosed in adolescence, as, due to the slow decline of their This population brings unique chal- participants immune systems, they do not present lenges.11,12,16 Health professionals unwell, or earlier in life.9,10 working in pediatric and adult services voiced their con- have limited experience with, and feel Adolescence is a period of transition under-equipped to address them.16,17 cerns and called between childhood and adulthood.11 Healthcare workers often feel con- It is a developmental stage character- strained by lack of human resources, for healthcare ized by physical, psychological, social time or space to provide care.18 workers to “Stop and emotional growth and change.11 However the greatest challenge they It is also a time of sexual exploration, face is communicating effectively with being mothers taking sexual risks, the forming of adolescents, particularly when discuss- sexual identity and development of ing sex.19,20,21 Qualitative studies involv- and fathers, and relationships. Adolescents living with ing adolescent living with HIV have HIV must learn, not only to live with a documented their concerns regarding be health pro- chronic illness, but also to deal with the judgmental attitudes of healthcare the emotional and psychological issues workers.12,21,22,23 At the 2006 Global viders” associated with the knowledge that Consultation of young people living

March 2013 / page 27 transmitted infections and their impact ing disclosure at work, school and in on mortality and morbidity, further sexual relationships. highlights the importance of strengthening health services.24,28 In a study They need health services that are of barriers to sexual and reproductive accessible at appropriate times – for health programming for young people example, after school and weekends. living with HIV in Uganda, Obare These services should be safe, confi- and colleagues suggest that program- dential, and provide access to con- ming gaps are due to the lack of clear doms, lubricants and a choice of family guidelines and policy, as well as a planning methods. Adolescents living limited capacity to offer the services re- with HIV also need services which quired. 20 As South Africa moves from provide easy access to support groups treatment initiation to long-term treat- and peer support workers at commu- ment and care, health services need nity and clinic level: having peers they to adapt to provide the long-term care can relate to is an important source of and support her population needs: this support. includes SRH for adolescents. Adolescents are more likely to reduce For health services to be able to prop- their risk behavior when the relevant erly address the SRH needs of adoles- information, skills and services are cents and support the implementation provided in an enabling and protec- of the strategies outlined above, an tive environment.29 Young people integrated model of service delivery, living with HIV attending the Global which includes the long-term manage- Consultation also expressed frustration ment of HIV, and SRH, needs to be de- with the inadequate and inaccessible veloped. Integral to the success of this information specific to the needs of is the development of the clinical and young people with HIV, especially communication skills and knowledge with regards to SRH.23 Similarly, the of the healthcare workers, through Ugandan study showed a disconnect training and mentorship. Ongoing between the information provided by operational research, which involves services and the actual needs and the adolescent population it is being desires of the young people.13 designed to serve, is vital to build clear evidence based care. Actively engag- Adolescents living with HIV need re- ing adolescents living with HIV and spectful, non-judgmental, caring health civil society is imperative for ensuring care workers who create a platform that services are responsive to their for them to discuss issues around needs as well as building meaningful SRH. Such healthcare workers would partnership. Ultimately, clear and com- provide them with health promotion prehensive national guidelines, policies information, guide them in developing and leadership are essential to sustain harm-reduction skills and assist them in and support this process. making informed decisions. They need the ongoing provision of accurate For more information about information before their sexual debut. CHIVA South Africa’s Adoles- This includes information on: puberty; cent Programme visit: http:// understanding their bodies; condom www.chiva-africa.org/ use; condom negotiation; STI signs and symptoms; types of sex and HIV/ Or contact the Adolescent Pro- STI transmission risk; available fam- gramme Coordinator at: alice. ily planning methods; pre-conception [email protected] advice; how to, when to and whom to disclose their status to; as well as their Adolescent Resources available rights and responsibilities concern- at: http://www.chiva-africa.org/

HIV Nursing Matters / page 28 clinical update adolescent-programme.html 44: 874 - 878. 20. Obare F, Birungi H, Kavuma L. Barriers to Sexual and Reproduction Health Programming Acknowledgement – Special 10. Ferrand R, Corbett E, Wood R, Hargrove J, for Adolescents living with HIV in Uganda. Ndhlovu E, Low S, Whande B, Cowan F, Gou- Population Research Policy Review 2011, 30: thanks to the peer support work- ws E, Williams B. AIDS among older children 151-163. ers from the YAFS Clinic at Nseleni and adolescents in Southern Africa: projection Community Health Centre in KwaZulu the time course and magnitude of the epidemic. 21. Hodgson I, Ross J, Haamujompa C, et Natal for taking the time to share their AIDS 2009, 23(15): 2039-2046. al. Livingas an adolescent with HIV in Zam- views regarding important aspects of bia – lived experiences, sexual health and SRH care for adolescents living with 11. Campbell T, Beer H, Wilkins R, Sherlock reproductive needs. AIDS Care 2012, 24(10): E, Merrrett A, Griffiths J. “I look forward. I feel 1204-1210. HIV. R insecure but I am ok with it”. The experience of young HIV+ people attending transition prepa- 22. Pediatric AIDS Treatment for Africa. Plan- Reference: ration events: a qualitative investigation. AIDS ning HIV/AIDS Care for Adolescents in the 1. United Nations Children’s Fund. Opportunity Care 2010, 22(2): 263-269. Western Cape Province. Cape Town: Pediatric in Crisis: Preventing HIV from early adolescence AIDS Treatment for Africa, 2010. to young adulthood. New York: United Nations 12. Li R, Jaspen H, O’Brien V, Rabie H, Cotton Children’s Fund, 2011. M, Nattrass N. Positive futures?: a qualitative 23. World Health Organization, United Na- study on needs of adolescents on antiretroviral tions Children’s Fund. Global Consultation on 2. Santos R. Young People, sexual and repro- therapy in South Africa. AIDS Care 2010, Strengthening the Health Sector Response to ductive health and HIV. Bulletin of the World 22(6): 751-758. Care, Support, Treatment and Prevention for Health Organization 2009, 87: 877-879. Young People Living with HIV. Geneva: World 13. Obare F, van der Kwaak A, Adieri B, Health Organization, 2008. 3. Gore F, Bloem P, Patton G, Ferguson J, Owuor D et al. HIV-positive adolescents in Joseph V et al. Global burden of disease in Kenya: Access to sexual and reproductive 24. World Health Organization/United Na- young people aged 10-24 years: a systematic health services. KIT Development Policy & tions Children’s Fund. Strengthening the Health analysis. Lancet 2011, 377(9783): 2093-2102. Practice 2010, 33. Sector Response to Care, Support, Treatment and Prevention for Young People Living with 4. Shisana O, Rehle T, Simbayi LC, et al. South 14. Birungi H, Obare F, Mugisha J, Hum- HIV. Geneva: World Health Organization, African national HIV prevalence, incidence, phres E, et al. Preventative service needs of 2008. behaviour and communication survey 2008: young people perinatally infected with HIV in A turning tide among teenagers? Cape Town: Uganda. AIDS Care 2009, 21(6): 725-731. 25. Koeing L, Pals S, Chandwani S, Hodge K, HSRC Press, 2009. Abramowitz S et al. Sexual Transmission Risk 15. Williams B. Pregnancy outcomes in women Behaviours of Adolescents with HIV Acquired 5. Joint United Nations Programme on HIV/ growing up with HIV acquired perinatally or in Perinatally or Through Risky Behaviour. Journal AIDS. Report on the Global AIDS Epidemic. early childhood. HIV Medicine 2010, 11(1): Acquired immune Deficiency Syndrome 2010, Geneva: Joint United Nations Programme on 144. 55(3): 380-390. HIV/AIDS, 2008. 16. Miles K, Edwards S, Clapson M. Transition 26. Fernet M, Wong K, Richard M, Otis J et 6. Coovadia H, Mantell J. Adolescents and from paediatric to adult services: experiencesof al. Romantic relationships and sexual activities HIV in Sub-Saharan Africa: A timely Issue HIV-positive adolescents. AIDS Care 2004, of the first generation of youth living with HIV and Missed Opportunity. Clinical Infectious 16(3): 305-314. since birth. AIDS Care 2011, 23(4): 393-400. Diseases 2010, 51(7): 852-854. 17. Maturo D, Powell A, Major-Wilson H, 27. Marhefka S, Valentin C, Pinto R, Demetriou 7. Gray G. Adolescents HIV - Cause for Con- Sanchez K, et al. Development of a protocol N et al. “I feel like I’m carrying a weapon.” cern in Southern Africa. PLOS Medicine 2009, for transitioning adolescents with HIV infection Information and motivations related to sexual 7(2). to adult care. Journal of Pediatric Health Care risk among girls with perinatally acquired HIV. 2011, 25(1): 16-23. AIDS Care 2011, 3: 1-8. 8. World Health Organization, Joint United Nations Programme on HIV/AIDS and United 18. Coovadia H, Jewkes R, Barron P. Health in 28. World AIDS Campaign. Briefing Paper, Nations Children’s Fund. Towards universal ac- South Africa 1, The health and health system of Youth Positives: Living their Rights. Cape Town: cess: scaling up priority HIV/AIDS interventions South Africa: historical roots of current public World AIDS Campaign, 2010. in the health sector. Geneva: World Health health challenges. Lancet 2009, 374: 817-834. Organization, 2009. 29. Dick B, Ferguson J, Chandra V, Brabin L, 19. Global Network of people living with HIV. Chatterjee S, Ross D. Review of the evidence 9. Ferrand R, Leuthy R, Miller R, Corbett E. Priorities and Recommendations coming from to increase young people’s use of health HIV Infection Presenting in Older Children the Young People Living with HIV Consultation. services in developing countries. World Health and Adolescents: A Case Series from Harare, Amsterdam: Global Network of people living Organization Technical Health Series 2006, Zimbabwe. Clinical Infectious Disease 2007, with HIV, 2010. 938: 151-204.

March 2013 / page 29 Voluntary Medical Male Circumcision and Adolescents: An opportunity for nurses to contribute to an HIV free generation

A Christensen, MS, CNS, T Adamu Ashengo, MD, MPH, D Bossemeyer, BSN, A Hellar, MD, MMed, MBA, H R Mahler, MHS, E Necochea, MD, MPH, K A Curran, MHS.

1 Jhpiego, USA 2. International Health Department, Johns Hopkins Bloomberg School of Public Health. 3. Jhpiego, Mozambique 4. Jhpiego Tanzania

VMMC reduces men’s risk of acquiring HIV through heterosexual intercourse by approximately 60% .4-12 Because uncircumcised men exposed to HIV are more likely to become infected due to characteristics of the foreskin tissue, removing the foreskin through VMMC provides partial, lifelong protection against HIV infection. However, VMMC does not provide complete protection from HIV; therefore, it is important to educate circumcised men to continue to use other risk reduction strategies such as limiting the number of sexual partners and using condoms consistently and correctly.4,5,6

HIV Nursing Matters / page 30 clinical update

Introduction infection (STI) screening and treatment, for clients who test positive; screening Preventative health care is depend- and to present positive sexual norms and treatment for STIs; provision of ent on engaging healthy individuals and behaviors before they enter into male and female condoms (including to take charge of their health care the prime of their sexual lives. promotion of their correct and consist- decisions and make informed choices ent use); and provision of risk reduction to prevent disease. All too often, we VMMC Overview counseling. perform under crisis management VMMC reduces men’s risk of acquiring conditions—diagnosing, educating HIV through heterosexual intercourse Adolescents and VMMC and treating patients once disease has by approximately 60% .4-12 Because In many countries, the majority of already taken hold. Voluntary Medical uncircumcised men exposed to HIV are demand for VMMC services is coming Male Circumcision (VMMC) provides more likely to become infected due to from adolescents (see Figure 1) pos- an ideal platform for nurses and other characteristics of the foreskin tissue, sibly due to its association with the rite health workers to educate and counsel removing the foreskin through VMMC of passage to adulthood.13,14 In Tanza- healthy individuals and counteract this provides partial, lifelong protec- nia and Mozambique, for example, trend. tion against HIV infection. However, 82% and 75% of males respectively, VMMC does not provide complete who sought VMMC were aged 10- Women are generally easier to en- protection from HIV; therefore, it is 19.14,15 To ensure age appropriate, ethi- gage in health care, as they are seen important to educate circumcised men cal and high-quality care, adolescents in family planning, antenatal and post- to continue to use other risk reduction seeking these services require special natal care, and in preventative care strategies such as limiting the number considerations. for their children such as vaccination of sexual partners and using condoms clinics. Voluntary HIV counseling and consistently and correctly.4,5,6 Adoles- Demand for VMMC services is created testing is another platform where there cents and men who undergo VMMC through a variety of avenues. First must is the potential to reach healthy indi- are educated and counseled regard- be the provision of high-quality care, viduals, but a recent UNICEF report ing the partially protective effect of as adolescents that are satisfied with indicates most youth in sub-Saharan Af- VMMC the day of the procedure, with their service will be more likely to rec- rica are not taking advantage of these ongoing reinforcement at all follow up ommend VMMC to their peers. Coun- VCT services.1 Adolescents, particu- visits. tries are also increasing the demand larly male adolescents—a notably hard for VMMC services through traditional to reach population—have little reason The World Health Organization media sources such as radio, print ads or desire to engage in the health (WHO) recommends a minimum (billboards) and branding (such as sector.2 Occasions that bring male package of services to be offered in t-shirts). The use of community mobiliza- adolescents and health care workers combination with the VMMC proce- tion and active referral programs—re- (HCWs) together must therefore be dure. These services include: provider ferring males to VMMC from HCT sites maximized to allow for discussion of initiated counseling and testing with and other health services—also aids preventive health practices, education linkages to HIV care and treatment in creating demand. In Tanzania, a and counseling. Figure 1: Age Distribution Data of VMMC Clients in Iringa and Njombe Voluntary Medical Male Circumcision Regions in Tanzania (as of December 2012, Jhpiego). (VMMC) services, which are targeted to healthy, HIV negative males, provide one such opportunity. Adolescents make up 23% of the total population in sub-Saharan Africa, and are an extremely vulnerable group for HIV infection due to age, biology and legal status.1 While HIV prevalence rates have been on the decline in the younger population,3 a recent UNICEF report suggests that only 33% of adolescent males in sub-Saharan Africa have a comprehensive knowledge of HIV.1 VMMC is a chance to offer these young men HIV education, testing and counseling, and sexually transmitted

March 2013 / page 31 research study found that adolescent broader HIV and other STI prevention cent understands what he is about males seem to be attracted by a “cam- concepts—including delaying sexual to undergo. Ensuring that patients paign” mode of service delivery.17 The debut—and should be educated on cor- have a clear understanding of campaign approach provides VMMC rect and consistent condom use. Older, what to expect during and after the services in high volume at specific sexually experienced adolescents procedure—including pain expecta- periods in time. Campaigns are often need more in-depth information about tions and management—helps to designed to target certain populations HIV and other STIs, and counseling on appease fear. (e.g., during school holidays to provide risk reduction strategies. At all ages, VMMC to adolescents). Strategies positive gender and age appropriate Referral for VMMC – Adolescents adopted by the campaign to generate norms should be addressed. who are HIV negative and enter the demand included the widespread dis- health care system through other semination of messages focused on the Table 1 displays adolescent norms entry points (such as voluntary provision of free VMMC and mobili- along with recommendations about counseling and testing, or outpa- zation of the community by specially age-specific care and the implications tient services) also need to be edu- trained community mobilizers. for VMMC. cated and referred to VMMC services. Communities play a vital role Age appropriate care - VMMC High-quality Care - Nurses and in referring young men for VMMC is currently provided in a variety of other HCWs offering VMMC have as well, through schools, churches, setting, including hospitals, clinics and a fantastic forum to provide health home health and other community mobile sites. And while it is offered services to adolescents seeking organizations. It is also essential to men of all ages, adolescents must VMMC; however, they need to to educate parents and guardians receive counseling and messaging ap- ensure that they employ high-quality on the benefits of VMMC, so they propriate for their age. Some facilities care practices tailored to these can encourage their sons or wards offer “youth days” for VMMC, while adolescent clients. This age group, to seek the services. Ultimately, others triage patients by age, and offer especially those on the younger adolescents of both sexes should specific group education and indi- end of the spectrum, may need be educated on the health benefits vidual counseling tailored to different reassurance, as they can be fearful of VMMC, as older adolescent girls age categories. While preteens may of providers and the impending pro- can be encouraged to promote only need basic information about cedure. Individual counseling for VMMC and choose circumcised how to care for their sexual organs, younger adolescents must involve partners. Mother, grandmothers young teens should be introduced to the provider assessing if the adoles- and caregivers are also essential to

Table 1: Adolescents and VMMC - Norms and Recommended Care.17

Adolescent Norms Age-Specific Care VMMC Implications Fears separation from peer Encourage social Provide age-specific VMMC group counseling to keep adolescents group interaction with within their peer group peers Provide VMMC services or days that are youth specific Use terms such as “many young people” to indicate attendees are not alone or different Fears loss of control Collaborate with Explain VMMC and follow up procedures carefully and ensure the adolescent understanding Encourage partici- Engage the adolescent with the necessary follow up procedures to pation in self-care have them take charge of their own care activities Allow choices whenever possible Desires independence Treat more as an Educate and counsel the adolescent regarding VMMC (not just the adult than a child parent/guardian) Avoid authoritarian Ensure the provision of the adolescent’s assent (not just parent/ controls guardian consent) Be honest and Provide empathetic care and counseling prior to the VMMC pro- encourage open cedure communication Show respect

HIV Nursing Matters / page 32 clinical update educate, as they play a vital role in health professionals working with adolescents. informing their sons, grandsons and males in their community about the Table 2. VMMC Fast Facts for Nurses and Providers Working with benefits of VMMC. Adolescents. VMMC reduces the risk of female-to-male sexual transmission of HIV Consent and Assent - VMMC is a surgical procedure that requires by approximately 60%. Adolescent males and females should be informed the appropriate consent procedure that VMMC is only partially protective against HIV and, therefore, pa- as defined by law. Although ado- tients need to continue to use risk reductions strategies (such as reducing the number of sexual partners and using condoms correctly and consist- lescents under age 18 generally 4, 5, 6 do not have the legal right to give ently). informed consent, they have the VMMC should be offered as a package of sexual health services, including: right to participate in decisions HIV testing and counseling and linkages to care and treatment; provision affecting their health, and therefore and promotion of correct and consistent use of male and female condoms; should provide assent for the surgi- screening and treatment for STIs; and risk reduction counseling. cal procedure. If an assent is given, A one-time health intervention, VMMC provides life-long partial protec- parents or guardians are respon- 7, 8, 9 sible for providing consent, and tion against HIV as well as some other STIs. should be informed of the risks and Evidence shows that VMMC reduces some STIs, particularly ulcerative benefits of the procedure. Providers STIs, including chancroid, herpes and syphilis, as well as balanitis, phimo- should defer circumcision in ado- sis, and penile cancer. 18, 19 lescent clients who do not provide assent for the procedure, even if the VMMC also benefits women. Circumcision has an association with a re- parent or guardian has provided duction in penile human papilloma virus, which is associated with cervical consent. cancer in female partners. Female partners of circumcised men also have lower rates of bacterial vaginosis. 20, 21 The Role of Nurses in VMMC Help Seeking Behavior. 2007. WHO Discus- in sub-Saharan Africa Conclusion The demand for VMMC from ado- sion Papers on Adolescents. WHO Depart- ment of Child and Adolescent Health and Nurses play a vital role in VMMC lescents in many countries is high, Development. http: http://whqlibdoc.who.int/ implementation and scale up in the bringing this hard to reach popu- publications/2007/9789241595711_eng.pdf WHO identified 14 VMMC priority lation in contact with the health (accessed 11 February 2013) countries.* In addition to working system. Adolescence is a forma- WHO UNAIDS. Young people are lead- as VMMC educators, HIV counse- tive time for young males; they are ing the HIV prevention revolution. 2010. lors, triage nurses, surgical assis- broaching adulthood and the sexu- http: http://data.unaids.org/pub/out- tants, and post-op caregivers, in al and reproductive responsibilities look/2010/20100713_outlook_youngpeo- countries such as Tanzania, South that come with transition. Nurses ple_en.pdf (accessed 11 February 2013) Africa (Eastern Cape), Zambia, can play a vital role in VMMC ser- Bailey RC et al.. Male circumcision for HIV Kenya, and Mozambique, nurses vices by creating demand for and prevention in young men in Kisumu, Kenya: are also performing the VMMC providing high-quality, age appro- A randomized controlled trial. Lancet 2007, procedure. Data show that there is priate VMMC services to this next 369(9562): 643–656. little difference in VMMC adverse generation. VMMC is a proven Gray RH et al. Male circumcision for HIV event rates of nurses compared to biomedical intervention that has the prevention in men in Rakai, Uganda: A other VMMC providers.15 As nurses potential to avert millions of HIV randomized trial. Lancet 2007, 369(9562): continue to provide these services infections and directly contribute to 657–666. to men, particularly adolescents, the world goal of creating a HIV Auvert B et al.. Randomized, controlled inter- they need to take advantage of this free generation. R vention trial of male circumcision for reduction unique opportunity to engage with of HIV infection risk: The ANRS 1265 Trial. this younger generation. Nurses Reference List PLoS Medicine 2005, 2(11): e298. can play a pivotal role in ensuring UNICEF. Progress for Children: A report card Auvert B et al. 2011. “Effect of the Orange that adolescents have a positive for adolescents. 2012. http: http://www.unicef. Farm (South Africa) Male Circumcision Roll-out experience with VMMC and the org/publications/files/Progress_for_Chil- (ANRS-12126) on the Spread of HIV.” IAS health sector as a whole. dren_-_No._10_EN_04272012.pdf (accessed 11 February 2013) Conference, Rome, 17–20 July. Barker G. Adolescents, Social Support and Kong X et al. 2011. “Longer-Term Effects of Table 2 presents VMMC facts for Male Circumcision on HIV Incidence and Ris

March 2013 / page 33 Tool to aid disclosure for HIV-positive adolescents to their romantic partners

By: Shanaaz Kapery Randeria Psychosocial Case Manager -Adolescent ProjectWRHI

Adolescents in the working group who had disclosed their status to their partners mentioned feeling relieved, ‘like a burden had been lifted off their shoulders’ and that their partners were supportive and their relationship stronger than before the disclosure.

“HIV is not just a virus. It is also a disease of society and human relationships …” Mark Heywood (2009)

HIV Nursing Matters / page 34 clinical update

Introduction: from the ‘Disclosure Tool’ working Step 3: Assessing partner readiness group include a feeling of relief, Step 4: Disclosing HIV status Disclosure of HIV status is a voluntary increase in self-esteem, less anxiety, Step 5: Post-disclosure support process as indicated in the South obtaining support from family and African Constitution as well as the romantic partners, a deeper romantic Step 1: Accepting one’s HIV- Children’s Act 38 of 2005. This means relationship (which does not neces- positive status that no person should be coerced sarily imply a sexual relationship) The most important step in the disclo- into disclosing HIV status; special encouraging partners to get tested and sure process was accepting one’s HIV- circumstances however may require feelings of accomplishment and pride. positive status. Acceptance was not just disclosure without consent. The time about telling a trusted person that one at which disclosing one’s HIV-positive Disadvantages of disclosure include was HIV-positive; it was the feeling of status occurred as well as to whom the fear of abandonment (friends, fam- truly believing in oneself, acknowledg- was therefore at the discretion of the ily and community) and consequent ing and being confident that ‘I have HIV-positive individual. isolation (self-imposed or external), a future that I can work towards’ and violence, stigma and discrimination (ex- as one adolescent said ‘a person has Adolescents are particularly vulner- perienced, vicariously or perceived), to be happy inside to appreciate what able both for infecting and being being accused of promiscuity and loss you have around you-a sense of value.’ infected with HIV as a result of drug of social and economic support. The future gaze of believing that ‘I will and alcohol abuse and sexual debut at not die soon…’ and ‘that I can have a this stage of development (Augustine, Health professionals should always career, a family and material things …’ 2008). encourage disclosure, bearing in mind was important in accepting one’s HIV- that each individual’s circumstances positive status. Disclosure of HIV status: are unique and being mindful of the disadvantages of disclosure. Step 2: Gaining correct HIV/ A facility in Soweto runs psychosocial AIDS information programs, which are youth-friendly, Steps in the disclosure process: Steps 2 and 3, were interchangeable rights-based and developmentally and did not necessarily follow on from informed in an attempt to normalize A group of HIV-positive adolescents living with HIV by regarding it as a from the facility in Soweto mentioned long-term condition and not an ill- above have embarked on a ground- ness. When discussing HIV, words breaking task to identify the steps in the Adolescents like ‘secret’ and being ‘sick because I process of disclosing their HIV status to am HIV-positive’ which have negative their romantic partners. are particu- connotations, are replaced with words such as ‘confidentiality’ in which the Disclosure was defined as a ‘process larly vulnerable individual has a sense of control over of telling someone of choice, some- both for infect- who learns about my status’ and ‘l thing very personal’. HIV disclosure am an adolescent who knows my HIV specifically was the process of telling ing and being status’-so that the adolescent is not someone about one’s HIV-positive sta- defined by the virus but instead has a tus. The need to prepare one’s partner infected with sense of accomplishment and control. to be informed about one’s HIV status HIV as a result was found to be a process involving Disclosure can contribute to the reduc- many steps before the person could be of drug and tion of HIV-transmission through ne- trusted with the information. gotiating safer sex practices, increase alcohol abuse in adherence to ARV’s and accessing The ‘Disclosure Tool’ working and sexual de- important services and treatments, such group identified 5 steps to be as treatment for sexually transmitted followed for disclosure of one’s but at this stage infections, termination of pregnancy, HIV status to romantic partners. psychosocial support, counselling and Step 1: Accepting one’s HIV-positive of development youth groups for example (Serovich, status 2001). Step 2: Gaining as much informa- (Augustine, tion and knowledge about HIV/AIDS 2008) The advantages of disclosing one’s (including rectifying mis-information HIV status, as noted by adolescents and myths)

March 2013 / page 35 each other. Step 2 included obtaining ward off the damaging and debilitat- reaction, if it was negative, or where sexual reproductive health informa- ing effects of stigma and discrimination they could hear your conversation was tion, where to access services and a post- disclosure in adolescents. The important. Ensuring your safety was comprehensive knowledge and under- working group adolescents mention essential, preferably where one could standing about HIV. Support groups, that youth –groups, regular support call on someone for help if the situation the internet, peer groups, counselling, groups in health-care facilities and turned violent. A room in one’s house school, trusted adults like teachers and strong condemnation,( from the top where the door could be shut for caregivers or older siblings, and health down), of stigma and discrimination privacy but with other people at home facilities were the main source of in- are ways to address the challenge. was a suggestion. formation. The adolescents mentioned The fear of stigma and discrimination that it was important to find someone in adolescence is markedly amplified The disclosure should preferably be whom they could trust and confide in as compared to that experienced by done when both you and your partner in order to feel comfortable with them. adults. This is particularly difficult for are relaxed, over a weekend as an the adolescent because of the need example. Times which were not suit- Step 3: Assessing partner readi- to ‘fit-in’ and the desire for a sense of able for disclosure included exam time, ness: belonging while disconnecting from after work or when you know your Adolescents in the working group felt significant adults. partner is experiencing a stressful time the need to ‘test’ whether they could or experience. trust their partners with the knowledge Step 4: Disclosing of their HIV-positive status first before Disclosure is an anxiety-provoking Role-playing the disclosure as well as disclosing their status. This finding is experience (Kardas-Nelson, 2010). positive and negative outcomes of the different to the findings from a group in Adolescents mentioned that they would process is a good way to be prepared the Unites States which states that after only disclose their status to long-term for possible outcomes. In this way both disclosure the partner can be educated partners when a commitment to shar- expected and the unexpected aspects about HIV (Velasquez, 2012). ing a future, getting married, was es- that can occur during the process can tablished. Long term relationships were be explored. The romantic partners, not necessar- those that lasted 2 years or longer. ily sexually active, were asked on Step 5: Post-disclosure support more than one occasion how they felt Lack of communication skills and about Post-disclosure support is important about HIV; how they felt about HIV- how to broach the topic were two regardless of whether the outcome of positive people; how they felt about additional obstacles identified that pre- the disclosure is positive or negative. having an HIV-positive partner as vented the actual disclosure of one’s well as observed for their behaviour HIV status to partners. If the outcome is positive, then the need and reactions when HIV discussions to support the partner is important. The occurred. The decision to disclose was Learning to convey the intended mes- partner may want detailed HIV/AIDS heavily dependent on the responses of sage as well as being able to with- information from a ‘professional’ rather partners. stand negative responses was essential than hearing it from his/her HIV posi- in attempting to disclose one’s status. tive partner. The need to be tested, if The extent of the anxiety accompany- The benefits of accepting one’s status he/she has not already done so, fear ing disclosure was evidenced even was crucial during this stage of the of being HIV-infected or how to stay when it was found that the partner process, especially if the partner’s re- negative (if he/she is not HIV-positive), accepted HIV-positive people and sponse to the disclosure was negative. sexual reproductive health while living would continue dating an HIV-positive with HIV, finding ways of supporting partner. The fear of rejection and Adolescents in the working group the HIV positive partner are some of subsequent stigma and discrimination who had disclosed their status to their the possible concerns and factors that from the partner because of HIV was partners mentioned feeling relieved, will require support after disclosure. implicated in the reluctance to disclose. ‘like a burden had been lifted off their shoulders’ and that their partners If the outcome of disclosure is nega- Stigma: were supportive and their relationship tive, the partner will need support to stronger than before the disclosure. deal with it. There might be a need for Literature (Erku, 2012) and the ‘Disclo- a safe place to go to or to live in for a sure Tool’ working group indicate that The timing and place of disclosing while if violence or the threat occurs. stigma and discrimination are impor- was important. Choosing a quiet, safe Emotional and psychological counsel- tant deterrents to disclosure. Many and place rather than a public one where ling and support may be necessary to varied interventions are required to others could witness the partner’s deal with the rejection and possible

HIV Nursing Matters / page 36 clinical update stigma and discrimination that follow young people (15-24 years). The USA or even joining a support group for in comparison had an adult HIV preva- HIV-positive adolescents to share simi- lence rate of 0.6% of which 0.2% was lar experiences. young people (UNICEF, n.d.)

The experience of joining a support In order for adolescents to disclose group, at the above-mentioned facil- their HIV status to their partners, they ity, has been cited as a useful tool have to perceive that doing so would in dealing with living with HIV as an reap positive benefits that outweigh adolescent as well as how to buffer the perceived negative outcomes oneself against negative experiences (Serovich, 2001). This translates into like stigma and discrimination. Ado- being accepted and valued as a part- lescents from the group say that they ner and creates sense of belonging, learnt from the group that ‘If you are despite being HIV-positive. HIV-positive it is not the end of the A positive effect of disclosing one’s world, it is just the beginning’ and ‘… HIV status to partners is the possibil- it helps me to feel good about myself ity of negotiating safer sex practices. and they don’t judge… the main rea- In the presence of greater access to son is to get support’. ARV’s and a change in behaviour the high HIV prevalence rate in the 15-24 Discussion: year old age group can potentially be decreased. Research indicates that AIDS orphans are more at risk for mental health chal- Conclusion: lenges than non-orphaned children (Cluver et al, 2008). Anger, guilt, The South African Constitution and depression and anxiety are feelings the Children’s Act 38 of 2005 give commonly experienced by adoles- children and adolescents the right cents, regardless of HIV status. to confidentiality and privacy. This applies to their HIV status as well. The need for good mental health An adolescent cannot be forced to amongst adolescents is vitally impor- disclose his/her HIV status, and should tant at this developmental stage since disclose only after being prepared to it impacts on the formation of a healthy do so. However, given the high HIV personal and sexual identity, and prevalence amongst adolescents and creates a buffer against negative peer the advantages of disclosure to their pressure. well-being, mental health, support and treatment, disclosure should be encour- Disclosure can therefore be seen to aged. The steps identified above to contribute to positive mental health out- prepare adolescents for disclosure to comes by reducing stress and anxiety their romantic partners is a guideline in HIV-positive individuals (Serovich, developed by HIV-positive adolescents 2001). to assist with the daunting task. Health workers occupy an important While statistics indicate reductions in place in the HIV arena, as a point of HIV transmission, globally we are still contact for adolescents; their role in faced with the challenge of high HIV the reduction of HIV infection cannot transmission rates in the 15-24 year be emphasized enough. The process old population (Nicholson, 2012). HIV of disclosure is not easy-not for the infections amongst adolescents 15-24 adolescent or for the health worker years old account for 40% of new equipping the adolescent for the dis- infections in adults (UNAIDS 2012). closure process! R In South Africa in 2009 had an HIV prevalence of 17.8% amongst adults References are available on (15-49 years old) of which 9% was request

March 2013 / page 37 The struggle addressing HIV in adolescents will continue for quite some time. However, there are many people and organizations attempting to battle the major issues that prevent us from eliminating HIV.

Improving engagement, retention of care and ARV treatment adherence amongst adolescents through the WhizzKids United programme introduced by The Africaid Trust in Edendale, Umgungund- lovu District, KwaZulu Natal By Marcus McGilvray, RN (Greenwich University), BA (HONs) in Health Management (Brighton Universi- ty), CEO & Founder The Africaid Trust,Dr N Madlala, MBCHB (Limpopo University), BSc (Limpopo Uni- versity), & Michael Brown Woliver MIPH (University of Sydney), BA (East Carolina University)

HIV Nursing Matters / page 38 clinical update

The South African Government ‘roll outcomes are particularly devastating and, as a result, an individual’s level out’ of Highly Active Antiretrovial in resource-limited settings and devel- of adherence can change over time Therapyies (HAART) in 2004 success- oping countries where treatment op- (Ammassari et al., 2002; Ickovics & fully transformed HIV infection into a tions are severely limited and second Meade, 2002; Kagee, 2008). Ac- chronic disease managed in primary line ARV regimens are extremely costly cording to Skhosana, Struthers, Gray, care. In well-resourced countries, (Nam, Fielding, Avalos, Dickinson, and McIntyre (2006), adherence is a antiretroviral therapy (ART) has made Gaolathe, Geissler, 2008). process that requires adjustment over survival of HIV-infected children into time and across different aspects of an adolescence and adulthood the norm Cohorts studies in sub-Saharan Africa individual’s lifestyle. (Gortmaker SL, Hughes M, Cervia J, et have shown that adolescents are less al, 2001). This can now be expected likely to adhere to ARV’s than adults South Africa is currently home to the in low and middle-income countries (Nachega JB, Hislop M, Nguyen H, highest number of HIV-infected people with functioning HIV treatment pro- Dowdy DW, Chaisson RE, Regensberg (5.7 million) in the world (UNAIDS, grammes. Adolescent HIV patients L, Cotton M, Maartens G., 2009), 2009). According to antenatal clinic include surviving perinatal infected and have lower survival compared to data, KwaZulu-Natal (KZN) has the children, those who are ‘behaviourally younger children (Bakanda C, Birungi highest HIV prevalence of any prov- infected’, usually through consensual J, Mwesigwa R, Nachega JB, Chan ince in South Africa (National DoH, sex or drug use (CDC, 2011), and K, Palmer A, Ford N, Mills EJ., 2012). 2008). Most of these individuals those who are victims of sexual assault Despite increasing research in devel- acquire HIV in the second or third (Meel BL, 2005). oped countries, studies on the special decades of life, with young females needs of HIV-infected adolescents in at highest risk; approximately 10% of Successful management of HIV and sub-Saharan Africa are scant. adolescent girls aged 15-19 years are AIDS through the use of ARV’s re- infected, rising to 50% in the 25-29 quires an adherence rate of not less Two key predictors of well- year age range (Welz T, Hosegood V, than 70 - 95%, which will prevent the being, viral suppression and Jaffar S, Batzing-Feigenbaum J, Herbst emergence of resistant strains of HIV survival have been identified K, Newell ML., 2007). and reduce viral load to undetectable among HIV-infected patients levels (Chesney, 2004; WHO, 2006). since the advent of ARV’s: The Greater Edendale Area (GEA) on ARV’s must be taken in the right dos- 1) Engagement and retention in care the outskirts of Pietermaritzburg sits in age, at the right time, everyday for a (Mugavero MJ, Lin HY, Willig JH, the heart of this epidemic, home to ap- lifetime. Essentially, this can equate Westfall AO, Ulett KB, Routman JS, proximately 300,000 people and high to an adolescent having to take up to Abroms S, Raper JL, Saag MS, levels of poverty, unemployment and 240 tablets per month, typically twice Allison JJ, 2009) violence. Edendale hospital (EDH) is per day. 2) Adherence to ARV’s (Kahana SY, an 860-bed district and regional facil- Rohan J, Allison S, Frazier TW, ity located within the GEA. Although Effective adherence support among Drotar D, 2012). HIV counselling and testing (HCT) is of- adolescents may be regarded as fered through this facility, resources to being decisive in primary care if the With regard to point one, in South meet the specific needs of adolescents young person is to enjoy a healthy Africa patients aged 13 years or more living with HIV are sparse. In response life and longevity. One must also note are typically seen by generalist or to meeting the sexual and reproductive that non-adherence has devastat- adult medicine providers, in an environ- health needs of adolescence in the ing implications that go well beyond ment where multi-disciplinary care GEA, The Africaid Trust launched the that of the individual alone. Not only is currently unavailable for the vast WhizzKids United (WKU) programme can sub-optimal adherence result in majority of patients. With regard to the in 2006 and launched its WKU Health virologic failure and the development second point, adherence is a com- Academy within the grounds of EDH in of drug-resistant forms of HIV that can plex dynamic behaviour influenced 2010. undermine the effectiveness of HAART by characteristics of the individual, and limit future treatment options for the clinical setting, the relationship The WhizzKids United programme is individuals, but on a societal level this between the clinical provider and designed to engage youth in HIV & can lead to an increased prevalence individual, the treatment regime, the AIDS prevention, care, treatment and of HIV resistant strains in communities, disease, and the surrounding context support through the universal language which can severely compromise South in which the individual lives, and the of football. Engagement of youth in Africa’s fight against HIV and AIDS health care system. These relationships GEA begins in school life orientation (Laurence, 2004; WHO, 2006). These can be reciprocal and reinforcing lessons with WKU’s ‘On the Ball’ life

March 2013 / page 39 skills curriculum which uses each facet the grounds of EDH. The word ‘acad- ence support group using football and of ‘the beautiful game’ to interpret emy’ resonates far more positively with individual counselling, family planning, and illustrate valuable life skills. The youth than the word ‘clinic’. treatment and management of sexually programme strives to overcome the transmitted diseases, ARV treatment, motivational problems of ‘conventional The WKU Health Academy has a staff management and support. HIV prevention programmes’ by har- compliment of 1 part-time Doctor, 4 nessing the youth’s passion for football Nurses, 4 Lay Counsellors, 4 Com- On entering the Health Academy to establish essential skills in their daily munity Life Skills Trainers/Counsellors, youth are put at ease by the welcom- life behaviour. Understanding a goal 1 orphan and vulnerable (OVC) cook ing and warm staff coupled with bright in football is easy but what about a and 3 Admin Clerks. The Professional coloured surrounds. Age and interest- goal in life? To score a goal in football staff contingent is salaried by EDH appropriate magazines, pop corn and you have to beat the defenders and whilst managed by The Africaid Trust. TV occupy the short waiting times. the goalkeeper but what obstacles do In promoting a ‘youth friendly’ culture, you have to overcome in life to achieve staff not only meet and converse with Recreational and educational activities your goals? How do you prevent HIV adolescents and their families on their help to draw youth into the Academy. infection becoming your biggest obsta- own level, but also dress in Liverpool Such activities including homework cle in life? Without rules in football the FC or Nike shirts, both partners of the clubs, internet centre, drama, arts and game isn’t fun but does the same apply programme, creating a more informal crafts, dance, choir, sports and mixed to life? These are some of the ques- atmosphere. Uniforms are regarded gender football league not only help tions that are explored by boys and as to formal and “off putting” by the retain youth, but they also allow staff girls. On completion of the 16 session youth. to develop a more complete under- curriculum youth are encouraged to standing of patients. Regular rapport attend the WKU Health Academy for Youth attending sexual health risk helps build up trust allowing staff to one-on-one three monthly sexual health assessment are at the same time optimise the bio-psychosocial aspects risk assessment and HIV counselling evaluated for OVC status according to of the youth’s lives which helps improve and testing, HCT. First however, they UN guidelines on OVC determinants. adherence in HIV positive youth. take part in a graduation ceremony - a Through these regular assessments World Cup football tournament with and counselling sessions the required On-going weekly internal training each team of six (three boys and three health services are then identified for staff including adolescents , their girls) representing one of the thirty two and provided to the young person behaviour, biological, physiological, teams which played in the FIFA 2010 within the Health Academy. These social and psychological changes and World Cup™! comprehensive services offered under adolescence adherence counselling one roof include amongst many oth- encourages the unique needs of youth WKU Health Academy is a stand- ers, one-on-one counselling, couple to be central in all services offered. alone ‘youth friendly’ clinic built within counselling, rape counselling, adher-

HIV Nursing Matters / page 40 clinical update

Sipho (name changed) is typical of so Sipho faced. The counsellor had to HIV patients in urban Botswana. Social Science many youth receiving ARV treatment. support Sipho during a time when he & Medicine 67, 301–310. Sipho, 15 years of age was referred was tired of the responsibility of caring to the Health Academy from a local for himself when his peers appeared to 7) Nachega JB, Hislop M, Nguyen H, Dowdy DW, Chaisson RE, Regensberg L, Cotton M, hospital as he relocated to live with be leading carefree lives. Maartens G. Antiretroviral therapy adherence, his Grandmother due to the loss of his virologic and immunologic outcomes in adoles- Mother to HIV. He has been on ARV’s Since the beginning of ARV treatment cents compared with adults in southern Africa. J for 7 years and for the first 4 years in October 2011, of the approximately Acquir Immune Defic Syndr 2009;51:65–71. responded well to treatment, notably 300 regular defaulters to treatment due to his caregiver giving him his that have been transferred for treat- 8) Bakanda C, Birungi J, Mwesigwa R, medication. Last year his viral load ment at the Health Academy, there has Nachega JB, Chan K, Palmer A, Ford N, Mills fluctuated due to challenges with ad- been a marked improvement in adher- EJ. Survival of HIV-infected adolescents on herence as an adolescent responsible ence in 87% of cases. antiretroviral therapy in Uganda: findings from for taking his own medication. He was a nationally representative cohort study in Uganda. PLoS ONE 2011;6:e19261. still not informed of his status and was As the Health Academy develops with experiencing treatment fatigue. During its very limited funding supply the hope 9) Mugavero MJ, Lin HY, Willig JH, Westfall home visits to assess need for support, is that this model will be replicated in AO, Ulett KB, Routman JS, Abroms S, Raper JL, a WKU lay ccounsellor would meet partnership with the Department of Saag MS, Allison JJ. Missed visits and mortality with the Grandmother to discuss the Health. R among patients establishing initial outpatient need for full disclosure to Sipho. After HIV treatment. Clin Infect Dis 2009;48:248-56. much counseling with the grandmother, the counsellor disclosed Sipho’s status References 10) Kahana SY, Rohan J, Allison S, Frazier TW, to him. Like so many adolescents faced 1) Gortmaker SL, Hughes M, Cervia J, et al. Ef- Drotar D. A meta-analysis of adherence to with the same news, he defaulted on fect of combination therapy including protease antiretroviral therapy and virologic responses in HIV-infected children, adolescents, and young his treatment. Coming to terms with the inhibitors on mortality among children and adults. AIDS Behav 2012. DOI 10.1007/ resentment of not being told his status adolescents infected with HIV-1. New Engl J Med 2001;345:1522-8. s10461-012-0159-4. by his mother, coupled with anger, guilt, stigma, the permanency of HIV 2) Centers for Disease Control and Prevention. 11) Ammassari, A. et al., (2002). Correlates and embarrassment were challenges HIV among Youth. Atlanta: US Department of and predictors of adherence to highly active Health and Human Services; 2011. Available at antiretroviral therapy: Overview of published lit- www.cdc.gov/hiv/youth/pdf/youth.pdf. erature. Journal of Acquired Immune Deficiency Syndrome, 31, S123-S127. Successful man- 3) Meel BL. Incidence of HIV infection at the time of incident reporting, in victims of sexual 12) Skhosana, N. L., Struthers, H., Gray, G. agement of HIV assault, between 2000 and 2004, in Transkei, E., & McIntyre, J. A. (2006). HIV disclosure Eastern Cape, South Africa. Afr Health Sci and other factors that impact on adherence and AIDS through 2005;5:207-12. to antiretroviral therapy: The case of Soweto, South Africa. African Journal of AIDS Research, the use of ARV’s 4) Chesney, M. (2004). Review – adherence 5, 17-26. requires an adher- to HAART regimes. In J. Laurence, Medica- tion adherence (pp. 17-26). New York: Mary 13) UNAIDS. AIDS epidemic update. Geneva: ence rate of 70- Liebert, Inc. Joint United Nations Programme on HIV/AIDS Bangsberg DR. Less than 95% adherence to (UNAIDS) and World Health Organization 95%, which will nonnucleoside reverse-transcriptase inhibitor (WHO); 2009. therapy can lead to viral suppression. Clin prevent the emer- Infect Dis. 2006;43:939-941 14) National Department of Health. The National HIV and Syphilis Prevalence Survey, gence of resistant 5) Laurence, J. (2004). Introduction: The chal- South Africa, 2007. Pretoria: National Depart- lenge of medication adherence in HIV/AIDS ment of Health; 2008 strains of HIV and and the consequences of adherence failure. In reduce viral load J. Laurence, Medication adherence (pp. 1-10). 15) Welz T, Hosegood V, Jaffar S, Batzing- New York: Mary Liebert, Inc. Feigenbaum J, Herbst K, Newell ML. Continued to undetectable very high prevalence of HIV infection in rural 6) Nam, S. L., Fielding, K., Avalos, A., Dickin- KwaZulu-Natal, South Africa: a population- levels. son, D., Gaolathe, T., Geissler, P. W. (2008): based longitudinal study. AIDS 2007;21:1467- The relationship of acceptance or denial of HIV- 72. status to antiretroviral adherence among adult

March 2013 / page 41 Youth Friendly Clinics In partnership with the Department of Health, loveLife is running its Adolescent and Youth Friendly Services Programme in some public clinics in South Africa. Through the programme, a variety of health services are made more easily accessible to young people, writes Thandiwe McCloy

HIV Nursing Matters / page 42 loveLife report

Young people have also loveLife implemented its AYFS initiative confidential. in 2000 to ensure that health services are acceptable, accessible, afford- “In this way, a welcoming and support- been too afraid to access able, available and effective for youth ive environment is created for youth, through on-going mentoring and sup- increasing their chances of coming to sexual and reproductive port. clinics for information and services, returning when they need to and rec- health (SRH) services at Dr Memory Muturiki, the Executive ommending these services to friends,” Manager of AYFS, explains that the says Dr Muturiki. programme endeavours to optimise the clinics, fearing judgmen- use of available community resources The AYFS Programme at clinics offers in providing a comprehensive health a range of SRH services, including tal attitudes from staff. services package to young people. condoms, contraceptive education and “Other objectives of the programme provision, various contraceptive meth- Included in the train- are integrating health promotion ods, with an emphasis on dual method information, including HIV prevention protection as well as male and female ing provided by loveLife messaging in all settings where young condom demonstrations. people live, work and engage in sports and other recreational activities,” adds Through AYFS, young people can also is the importance of all Dr Muturiki. access HIV Counselling and Testing (HCT), pregnancy testing and coun- clinic employees treat- In striving to encourage youth to selling, and antenatal and post natal access clinic services, AYFS includes care. In some clinics, antiretrovirals ing young people with loveLife Senior Technical Advisors are dispensed. Available services also training Master Trainers at clinics at the include treatment and education on the utmost respect, non- Provincial and District level. As part of sexually transmitted infections (STIs), the training is how to develop attitudes, pre and post counselling for Termina- values and perceptions that are more tion of Pregnancy (TOP) and referrals judgmental attitudes and friendly and supportive to young peo- for TOP. Referrals to organisations of- ple accessing health services. These fering support for drug and substance professionalism as well as Master Trainers then go on to impart abuse as well as advice on oral health this information to all clinic employ- are also part of the package. By using keeping sensitive issues ees – including health care workers, these amenities, young people reduce grounds men, clerks and cleaners, and their risk of unplanned pregnancy, all those who come into contact with contracting HIV and other STIs. They they discuss confidential. young people at clinical projects. The are also able to benefit from loveLife’s reason for this training is that there brochures and publications supply- have been cases of clinic staff not ing a wealth of positive lifestyle and In line with its efforts to encourage giving young people the services they healthy sexuality information. young people to take a holistic ap- need because they believe it’s more proach to caring for their health, love- important to turn their time and atten- Aside from offering SRH services and Life is running its Adolescent and Youth tion to older patients who tend to suffer information, AYFS provides treatment Friendly Services (AYFS) programme more ailments. for tuberculosis, chronic diseases, in 479 primary health care clinics disability and injuries. As part of AYFS throughout South Africa. Young people have also been too are also general health tests, such as afraid to access sexual and reproduc- glucose and anaemia tests. Education, The overall objective of AYFS is to tive health (SRH) services at clinics, counselling and appropriate referral provide a package of services that is fearing judgmental attitudes from staff. for sexual exploitation, violence and primarily moulded to maintain optimum Included in the training provided by abuse as well as various other mental health and good lifestyle practices loveLife is the importance of all clinic health issues are also available. among youth and adolescents. employees treating young people with the utmost respect, non-judgmental Dr Muturiki adds that through AYFS, As South Africa’s largest HIV preven- attitudes and professionalism as well young people are able to access ser- tion programme for young people, as keeping sensitive issues they discuss vices in separate rooms from adults, so

March 2013 / page 43 contributing to greater confidentiality tial service package and ensure that for them. proper referral systems are in place Due to the suc- at different settings and at all levels of In promoting a holistic approach to cess of AYFS, health care. health, AYFS staff also provide youth with information on the importance of mechanisms are Clinics achieving these minimum a balanced diet and regular exercise. standards will be recognised as currently being implementing AYFS. However, they are To give young people the information put in place to still expected to commit to eventually and motivation they need to make achieving all 10 norms and standards healthy lifestyle choices, loveLife ensure that the of AYFS, which include healthcare groundBREAKERS (gBs) and Mpint- workers providing relevant health and shis - peer motivators and commu- programme is im- wellness information to young people nity mobilisers - implement loveLife’s plemented across in various settings, such as schools, healthy sexuality and positive lifestyle youth centres, places of safety and programmes at clinics running the South Africa with workplaces. AYFS initiative. These programmes are also available in schools, community- quality, consist- “Many young people tend to only based organisations and loveLife ency and sustain- come to the clinic when they are ill,” Y-Centres (youth centres) throughout explains Dr Muturiki. “By healthcare South Africa. ability. workers providing health education to

Young people can also benefit from valuable information in health talks delivered by gBs and Mpintshis through the AYFS initiative.

This comprehensive package of AYFS services focus on priority areas of adolescent and youth health decided on through consultations between the Department of Health, loveLife, the World Health Organisation and other key stakeholders.

To be registered as an AYFS, clinics need to provide health services in these priority areas. They have to meet five minimum standards which include Management System Support for effective provision of adolescent and youth programmes through capacity development of the manager and service providers. They have to be appropriate to the needs of adolescents and youth, accessible and available to them at times that are convenient. Staff also needs to have been trained on the importance of embodying attitudes, values and perceptions that are friendly towards young people accessing SRH services. Clinics need to have the drugs, medical supplies and equipment to provide the essen-

HIV Nursing Matters / page 44 loveLife report

can’t use condoms with their baby’s father as they’ve been together for a long time. I tell them that HIV and STIs don’t discriminate between long and short term relationships and there is no measuring stick to check if your partner is cheating on you.”

But Botlhale gets a great sense of satis- faction when young people comply to contraceptives, adding that she always reminds them to use dual method contraception.

“I also really enjoy informing young people about healthy lifestyle living, such as the dangers of drinking and smoking and the importance of good nutrition and regular exercise,” she says. “In this way, youth are taught about the huge value of leading positive lifestyles from a young age and will hopefully put their knowledge into practice throughout their lives. This way, we help to prevent high levels of morbidity and chronic disease in our youth in the broader community, they Y-Centre clinics are called Vitality country.” can play a powerful role in promoting Rooms and offer services similar to preventative care. They also decrease those at AYFS in public health clinics. Mpho Mokuoa (24) is just one of the the number of youth coming to clinics, Botlhale Mokwape is a nurse and line young people who benefits from the so reducing the burden on our health manager at the Vitality Room in the Vitality Room at the Bafokeng Y-Centre. systems.” Royal Bafokeng Y-Centre, situated in “I mostly go for HCT, while some of my Luka in the North West Province. She friends go there for contraceptives,” As part of AYFS, loveLife trains explains that young people mostly visit she says. “Whenever something isn’t healthcare workers in primary health the Vitality Room for HCT, contracep- right with my body, like when I some- care clinics to carry out periodic re- tives and treatment of STIs. In future, times get pimples during my period, I assessments that determine the extent she would like to do more school visits come to the room for treatment. to which their facility has improved its and door-to-door campaigns to make youth friendliness. young people more aware of Vitality “The nurse there is friendly, easily Room services and encourage them to approachable and answers any ques- Due to the success of AYFS, mecha- use the facility. “There are still perceptions I have. The service is good and nisms are currently being put in place tions among youth that if you go to a it’s great that it’s free. At the Vitality to ensure that the programme is clinic for SRH services, the nurse will Centre, the service is quicker than at implemented across South Africa with judge you,” says Botlhale. “Some be- clinics, where you often have to wait in quality, consistency and sustainability. lieve myths about contraceptives mak- long queues.” ing you infertile. I want more young R Aside from being available in public people to come to the Vitality Room so health clinics, AYFS is also implement- they can receive correct health infor- ed at clinics in seven loveLife Y-Centres mation. I want them to know that they (youth centres). ln total, loveLife has 20 will be treated with respect and receive Y-Centres across South Africa which the help they need.” offers young people healthy sexuality and positive lifestyle information, While she enjoys her work, she says sports activities and skills development it can be difficult to get older youth to opportunities. use condoms. “Some of them say they

March 2013 / page 45 CHIVA South Africa By: A Armstrong1, Z Sobantu1, J Houghton1, K Naidoo1,2, K Moshal1,3

1CHIVA SA, KwaZulu Natal, South Africa; 2Department of Paediatrics, University Of KwaZulu Natal, South Africa; 3Department of Infectious Diseases, Great Ormond Street Hospital for Children, London, United Kingdom; CHIVA Africa, United Kingdom.

A Armstrong – BNS, RGN, NMP, Dip TN, DTM+H, MSc Int. Health Z Sobantu – BCUR (Hons), RGN, RGM, CHN, Occ.HN J Houghton – RGN, RSCN, Dip TN, MsC Soc Anth K Naidoo – MBcHB, DCH, FC (Paeds) K Moshal - MBChB, MRCP (UK), MRCPCH, DTM+H

Our mission is to improve the skills and confidence of healthcare professionals caring for and treating children and adolescents with HIV and their families, allowing them to scale up their services and provide long-term quality care to their patients.

HIV Nursing Matters / page 46 profile

CHIVA South Africa is a non-gov- they teach and mentor, and to (aged 10 -19 years old) living with ernment organisation that facilitates ensure the quality and sustainability HIV, whether based in adult, pediatric the sharing of knowledge, skills and of our programmes. or primary health care settings are experience in the treatment of HIV- 3) Replicating invited to attend. District HIV, AIDS, infected children and adolescents with • To expand to other provinces of STI’s and TB (HAST) coordinators government healthcare professionals. South Africa and elsewhere in and operational managers, assist in In providing practical support, mentor- Africa. identifying the multidisciplinary team ship and teaching we work with all • To promote continued learning members who would most benefit from disciplines of healthcare staff to assist through provision of free teaching these workshops. Already in 2012, with task shifting and role develop- resources. our current workshop series has been ment. CHIVA South Africa started in delivered in 6 districts of KZN with September 2004, as a collaborative Adolescent Programme over 900 participants attending from project between CHIVA (Children’s In 2008, in response to the observed all healthcare disciplines. HIV Association of the UK and Ire- growing needs and on the request land), the University of KwaZulu-Natal of health care professionals involved Our current workshop series is based and the Department of Health (DoH) with the pediatric programme, CHIVA on participatory learning and action of KwaZulu-Natal (KZN). Since then South Africa launched their dedicated approaches to engage the experience the programme has expanded to the Adolescent Programme. Adolescents of health care professionals that are Eastern Cape Province (2008) and the living with HIV need to be able to attending. It includes four workshops North West Province (2010). access, and be retained in, services. covering adherence, disclosure, This impacts their quality of life and sexual and reproductive health and Our mission is to improve the skills and life expectancy, as well as aiding the adolescent friendly services, which confidence of healthcare professionals prevention of new HIV infections. The incorporate themes of multidisciplinary caring for and treating children and requirement for health services to working, collaboration and counsel- adolescents with HIV and their families, address adolescents’ needs creates ling. Each workshop gives participants allowing them to scale up their services unique challenges for health profes- the opportunity to explore challenges, and provide long-term quality care to sionals who are committed to provid- identify key guiding principles and put their patients. ing adolescents living with HIV the into practice the skills they have learnt. highest quality support and the most Our main objectives are: effective health services. Health ser- Each year the programme is modi- 1) Teaching vices need to make a concerted effort fied following analysis of participant • To provide practical and technical to reduce barriers to, and challenges feedback and identification of prior- support for all members of the multi within, services to ensure delivery of ity areas for future support. This has disciplinary team. quality HIV care. To address the needs allowed for each series of teaching to • To produce relevant, comprehensive, of this growing cohort and the health build upon the previous, ensuring con- practical teaching resources based professionals who look after them, tinuous learning and ensuring that we on local guidelines. further teaching, mentorship and health are responsive to the learning needs 2) Partnering system strengthening is required. of healthcare professionals and the • To work closely with the provincial adolescents they serve. Departments of Health to assist them The CHIVA SA adolescent programme in the implementation of local and develops and delivers workshops, Although adolescent HIV care is a national policies for paediatric and seminars and master classes aimed growing healthcare focus in South adolescent health care delivery. at healthcare professionals treating Africa, other countries that have had • To support key staff at provincial adolescents in KwaZulu Natal, as well access to ART for longer periods have hospitals and associated health as supporting potential strategies to been managing the care of adoles- facilities on a regular basis. address the health system challenges cents living with HIV for over a dec- • To increase our in-country volunteer in providing services to adolescents ade. To draw upon their experiences base from within South Africa’s living with HIV. The 2012/2013 work- and to learn from their challenges, health and NGO sectors, for the shop series is being held in all districts CHIVA South Africa invites both local benefit of both the volunteers of KwaZulu Natal. All healthcare and international multidisciplinary ex- themselves, the health professionals professionals working with adolescents perts in the field to volunteer their time

March 2013 / page 47 profile to facilitate teaching and mentoring. o CHIVA South Africa resources, as Additionally, in partnership with love well as links to other helpful resourc- Life we have the privilege of having the Adolescents living es, are available through our web expertise and insight of local young with HIV need to site – www.chiva-africa.org South African ground BREAKERS to o Visit our Facebook page which facilitate our youth friendly services be able to access, is updated regularly with resources, workshops. and be retained in, workshops and recent research on paediatric and adolescent HIV In addition to our current workshop services. This im- – www.facebook.com/ series, in 2013 we will be: pacts their quality CHIVAAfricaPage • Hosting a master class on the Clini- o From more information regarding cal Management of Adolescent HIV of life and life ex- adolescent HIV and provision of • Working with key stakeholders services contact alice.armstrong@ to develop provincial strategies for pectancy, as well as chiva-africa.org service provision to adolescents aiding the preven- o For the paediatric programme con- living with HIV tion of new HIV tact [email protected] • Providing support to clinics in their or [email protected] R development of adolescent HIV infections. services and support services. other volunteers from around the Below, in their own words, participants world. Also as a young person it in 2012, share their experience of was a great opportunity to advocate the CHIVA South Africa adolescent for other young peoples service programme: delivery needs’ • ‘With youth friendly service I learnt • ‘Being part of this experience made that simple changes with no money me realised how much I love my job make dramatic effect. My attitude and reinforce the reason why I’m being the first thing to change’ doing it’ • ‘This workshop empowers people in • ‘The workshop was more of facilita- area that needs more attention!’ tion than it being a lecture, that gave • ‘As a school nurse I will be more people a chance to give their aware of adolescents living with HIV participation and it served also as issues. This workshop will help me to a platform for facilitators to learn assist them especially with adher- from participants’ ence’ • ‘I have not thought about how to empower an adolescent to adhere to treatment rather than just tell them what to do! This will now change’ • ‘I will be more respectful to my patients and listen more plus understand adolescents more’

Quotes from facilitators in 2012: • ‘It has been a super week! It has really improved my facilitations skills. It was nice to have healthcare workers value our views as young people despite their age or profession’ • ‘The workshops were very informa- tive. It was great to interact with

HIV Nursing Matters / page 48 what to do

Test your knowledge Quiz 1. By what percentage does VMMC reduce a man’s risk of acquiring HIV infection?

2. VMMC can only be performed in a hospital set up. True or False

3. Successful management of HIV and AIDS through the use of ARV’s requires an adherence rate of 70%-95%, to prevent the emergence of resistant strains of HIV. True or False

4. The increase in access to antiretroviral therapy (ART) means more children who were infected through mother to child transmission are surviving into adolescence and adulthood.True or False.

5. According to the National DoH, 2012, which province in South Africa has the highest HIV prevalence?

6. Between 25%-90% of school-aged HIV positive children are unaware of their own status, regardless of going to the clinic every 3months to pick up treatment. True or False.

7. In children, severity of HIV disease and delayed ART treatment impact cognitive, academic, and social functioning as well as psychiatric symptoms. True or False.

8. According to the Children’s Act (Act 38, 2005), at what age can a child consent for an HIV test?

9. According to current PMTCT guidelines, HIV positive pregnant women in South Africa are being given Option B+. True or False.

10. Which patients are prioritised to be the first group to receive fixed dose combination(FDC)?

Get all the answers on the next page (Page 50) March 2013 / page 49 what to do FIDSSA 5 Answers to the Quiz questions Changing Attitudes

1. VMMC reduces men’s risk of acquiring HIV through heterosexual intercourse by approximately 60%. From this Article “Voluntary Medical Male Circumcision and Adolescents: An opportunity for nurses to contribute to an HIV free generation” 2. False: Age appropriate care - VMMC is currently provided in a variety of setting, including hospitals, clinics and mobile sites. From this article “Voluntary Medical Male Circumcision and Adolescents: An opportunity for nurses to contribute to an HIV free generation” 3. True: Successful management of HIV and AIDS through the use of ARV’s requires an adherence rate of 70 - 95%, which will prevent the emergence of resistant strains of HIV and reduce viral load to undetectable levels (Chesney, 2004; WHO, 2006; Bangsberg, 2006). From this article “Improving engagement, retention of care and ARV treatment adherence amongst adolescents through the WhizzKids United programme introduced by The Africaid Trust in Edendale, Umgungund- lovu District, KwaZulu Natal” 4. True: The increase in access to antiretroviral therapy (ART), means more children who were infected through mother to child transmission are surviving into adolescence and adulthood. From this article “ ‘Vaku vaku’. ‘Iturr nash’. ‘Spaka paka’. The Sexual and Reproductive Health Needs of Adolescentsliving with HIV” 5. According to antenatal clinic data, KwaZulu-Natal (KZN) has the highest HIV prevalence of any province in South Africa 10-12 October 2013 (National DoH, 2012). From this article “Improving engagement, retention of care and ARV treatment adherence amongst adolescents through the WhizzKids United programme introduced by The Africaid Trust in Edendale, Umgungundlovu Dis- 5th FIDSSA CONFERENCE trict, KwaZulu Natal” 6. True: As a result, between 25%-90% of school-aged HIV positive children are unaware of their own status (Close, Champagne Sports Resort Drakensberg 2003) regardless of going to the clinic every 3 months to pick up treatment. From this article “The psychosocial challenges KwaZulu Natal, South Africa of HIV positive youth: the silent epidemic” 7. True:Severity of disease and delayed ART treatment impacts cognitive, academic, and social functioning as well as the ◗ Antibiotic stewardship ◗ Current vaccination challenges psychiatric symptoms. From this article “BEHAVIORAL, PSYCHIATRIC, AND COGNITIVE PROBLEMS IN ADOLESCENTS ◗ HIV and TB and controversies WITH PERINATAL HIV INFECTION: UNRECOGNIZED CONSEQUENCES” ◗ Multi-resistant Gram negatives ◗ New therapeutics 8. Anecdotal reports suggest that access to HIV Counselling and testing for adolescents remains challenging despite clear ◗ Insights from the microbiome ◗ Frontiers in diagnostics guidance from the Children’s Act (Act 38, 2005) that children 12 years and older with sufficient maturity can independent- ◗ Infectious Diseases in ◗ Workshops and training ly consent for an HIV test. From the “Guest Editorial comments.” marginalised populations and 9. South Africa’s current PMTCT guidelines are in line with WHO’s 2010 guidelines, offering a similar ‘Option A’ From the mass gatherings

“NEWS articleWhat are PMTCT Options A/B/B+?” For further information contact the FIDSSA Conference Office 10. All new patients and pregnant and breastfeeding women who can take a tenofovir based regimen with EFV are in the Tel: +27 (0)11 463 5085 Fax: +27 (0)11 463 3265 first two groups. From “The President’s comments” email: [email protected], [email protected] www.fidssa.co.za

A4 - FIDSSA Advert.indd 1 2013/01/16 9:05 PM FIDSSA 5 Changing Attitudes

10-12 October 2013

5th FIDSSA CONFERENCE Champagne Sports Resort Drakensberg KwaZulu Natal, South Africa

◗ Antibiotic stewardship ◗ Current vaccination challenges ◗ HIV and TB and controversies ◗ Multi-resistant Gram negatives ◗ New therapeutics ◗ Insights from the microbiome ◗ Frontiers in diagnostics ◗ Infectious Diseases in ◗ Workshops and training marginalised populations and mass gatherings

For further information contact the FIDSSA Conference Office Tel: +27 (0)11 463 5085 Fax: +27 (0)11 463 3265 email: [email protected], [email protected] www.fidssa.co.za

A4 - FIDSSA Advert.indd 1 2013/01/16 9:05 PM where to go

NDOH/SANAC The AIDS Helpline a national toll- free, operates on a 24/7 basis and is Nerve Centre Hotlines utilized by people from all walks of life in urban and rural areas, in all eleven • Any HCT concerns from facility languages at no cost from a landline and district managers should be telephone. reported to the NDOH/SANAC Annually, the Line provides anonymous, confidential and accessible tel- Nerve Centre Hotline and, spe- AIDS Helpline ephonic information, counselling and cific emails for each province: referrals to over 300 000 callers. 0800 012 322 The AIDS Helpline plays a central role • Western Cape: 012-395 9081 The National Toll free AIDS Helpline in providing a deeper preventative and [email protected] was initiated in 1991 by the then Na- more supportive service to those in- • Northern Cape: 012-395 9090 tional Department of Health’s (NDoH) fected and affected by the disease, but [email protected] “HIV/AIDS, STD’s and TB Directorate”. also serving as an entry point in terms of accessing services from government, • Eastern Cape: 012-395 9079 The objective of the Line is to provide a national, anonymous, confidential private sector and other NGOs/ CBOs [email protected] and accessible information, counsel- • KZN: 012-395 9089 ling and referral telephone service for Cases presented to the range from [email protected] those infected and affected by HIV testing, treatment, transmission, TB, • Free State: 012-395 9079 and AIDS, in South Africa. Medical Male circumcision, etc. [email protected] In 1992, LifeLine was requested by The AIDS Helpline incorporates the • 012-395 9087 Mpumalanga: NDOH, to take over the management Treatment line. The treatment support [email protected] of the Line by rotating it between the services were included to complement • Gauteng: 012-395 9078 thirty-two existing community-based the services provided by lay counsel- [email protected] LifeLine Centres, and manning it with lors on the line. The Treatment Line is volunteer counsellors. In 2000, in manned by nurses who provide quality, • Limpopo: 012-395 9090 response to an increasing call rate, a accurate, and anonymous telephone [email protected] centralised Counselling Centre was information and/or education on • North West: 012-395 9088 established in Braamfontein, Johannes- antiretroviral, TB and STI treatment [email protected] burg, to house the AIDS Helpline

HIV Nursing Matters / page 52 where to go

NDOH/SANAC Nerve and easy access point for information on HIV and AIDS to Centre Hotlines any member of the public, in all of • Any HCT concerns from facility the 11 official languages, at any and district managers should be time of the day or night. • Telephone Counselling: Trained reported to the NDOH/SANAC lay-counsellors offer more than mere facts to the caller. They are Nerve Centre Hotline and, able to provide counselling to specific emails for each those battling to cope with all the province: emotional consequences of the pandemic. • Referral Services: Both the South • Western Cape: 012-395 9081 African Government and its NGO [email protected] sector have created a large AIDS Helpline network of service points to • Northern Cape: 012-395 9090 0800 012 322 provide a large range of services [email protected] (including Voluntary Counselling and Testing, medical and social • Eastern Cape: 012-395 9079 services) to the public. The AIDS The National AIDS Helpline Helpline will assist the caller to [email protected] (0800-012-322) provides a contact and use these facilities.The • KZN: 012-395 9089 confidential, anonymous 24-hour toll- National AIDS Helpline works free telephone counselling, closely with the Southern African [email protected] information and referral service for HIV Clinician’s Society to update • Free State: 012-395 9079 those infected and affected by HIV and maintain the Karabo Referral and AIDS. Database. www.sahivsoc.org [email protected] • Treatment Line: A specialised • Mpumalanga: 012-395 9087 The helpline was initiated in 1991 and service of the AIDS Helpline, the is a partnership of the Department of Treatment Line, is manned by [email protected] Health and LifeLine Southern Africa. Professional Nurses. They provide • Gauteng: 012-395 9078 The Helpline, manned by trained lay- quality, accurate and anonymous counsellors, receives an average of telephone information and/or [email protected] 3,000 calls per day, and is seen as a education on antiretroviral, TB and leading telephone counselling service • Limpopo: 012-395 9090 STI treatment. They also provide within the SADC region. relevant specialised medical [email protected] referrals to individuals affected Services Offered by the AIDS • North West: 012-395 9088 and infected by HIV and AIDS in Helpline: South Africa. [email protected] • Information: The Line creates a free

March 2013 / page 53 where to go

HIV Nursing Matters / page 54 where to go

March 2013 / page 55 UNITING NURSES IN HIV CLINICAL EXCELLENCE, BECOME A MEMBER.

Who are we? Member Benefits We are a member-based Society that promotes quality, Join today and gain instant support from a credible comprehensive, evidence-based HIV health care, by: organisation. The Society helps connect you with the best minds in HIV health care. Build your knowledge, advance your 1 LEADING • PIONEERING profession and make a difference by getting involved now! We are a powerful, independent voice within Southern Africa with key representation from the most • Free quarterly subscriptions to the Southern African experienced and respected professionals working in the Journal of HIV Medicine fight against HIV. • Free monthly subscription to the Society’s e-newsletter, Transcript 2 CONNECTING • CONVENING • ENGAGING • E-learning through CPD-accredited clinical case studies Through our network of HIV practitioners, we provide and on-line discussion group forums a platform for engagement and facilitate learning, • Free quarterly subscriptions to HIV Nursing Matters camaraderie and clinical consensus. • Weekly SMS clinical tips for nurse members • Free CPD-accredited continuing education sessions 3 ADVOCATING • INFLUENCING • SHAPING • Listing in the Society’s online HIV provider referral With our wealth and depth of clinical expertise, we can network help health care workers take their practice to a new level. We are constantly improving and expanding our knowledge, and advocating for clinical and scientific best SOCIETY CONTACT DETAILS: practice. Tel: +27 11 341 0162 • Fax: +27 11 341 0161 Email: [email protected]

Post: Suite 233, Private Bag X2600, PostNet, Killarney, Houghton, 2041 www.sahivsoc.org