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HIV and safe motherhood 8
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The majority of women in sub-Saharan Africa do not know their HIV status. But if they are to make appropriate choices about how to prevent their children from becoming infected, they need to have access to affordable confidential and voluntary counselling and testing. Counselling and testing should be offered to both the woman and her partner. Both parents are responsible for preventing HIV transmission to their children, not just the mother. Women, however, should never be pressured to include their partner in counselling and testing if they do not wish it.Counselling
HIV counselling is a confidential and supportive dialogue between a person and a trained counsellor. It should focus on both the-physical and emotional wellbeing of the person, and help them to make the decisions that are right for them. Counselling is not the same as giving advice or telling people what they should do. The counsellor's role is to listen to the individual concerns, raise issues that need to be considered, and provide information, emotional support and appropriate referral. Counsellors should avoid judging the person or their partner.
Counselling must be confidential - the person must be confident that the counsellor will not talk to anybody else about what they have discussed together. But this does not mean that counselling must only be between one individual and the counsellor. It may sometimes be better to counsel people together with their sexual partner. In societies where decisions about health and welfare are taken by the family, shared counselling with other family members can be helpful. Confidentiality is just as important in this situation.
The counsellor may be a health worker such as a midwife or a nurse, or may be a layperson. Peer counsellors - such as people who are themselves HIV positive - can be very valuable and health workers should welcome their help and involvement. Whoever takes on this role needs to be specially trained and to be a good listener. Counselling should be more about listening than about talking.
Pre-test counselling
Anyone thinking about having an HIV test should always have pre-test counselling. This is not only to ensure that the man or woman gives their informed consent to the test, but so that they have the chance to consider the impact that a positive result will have on their life and the life of their family. If, after counselling, the person decides not to have a test, the counsellor has no reason to pressurise them. The following guidelines may be helpful:
Be in a private area for counselling, where you will not be disturbed or overheard.
Assure the person that everything said is confidential and that you will not talk to anyone else about it. (You could have a poster on your wall making this clear and showing your commitment).
Talk through the reasons for HIV testing - theirs and yours. Look at both the benefits and the disadvantages.
Ask questions in a sensitive way to find out about current and previous risk behaviour. Remember that they may not know about their partner's risk behaviour.
Offer information about HIV and AIDS.
Offer information about the HIV antibody test, including information about the 'window period' of infection (this is the time between becoming infected and a blood test showing positive results).
Go through the implications of a positive test result for the person and their family.
Discuss the person's possible responses to a positive test result. They can think about who they would tell and where they might get support.
Be aware of what the person's concerns are and let these guide the discussion. For example, if a woman is being counselled and already has children, her major concern may be what will happen to them if she is HIV positive.
Go through the implications of a negative test result.
Provide information about how the test is done, how long before the results will be ready, and how they should find out the results.
Give enough time for them to think about whether or not they want to have the test.
If they decide to have the test, obtain informed consent
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HIV and safe motherhood
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Post-test counselling
Counselling after an HIV test is essential, whether or not the result is positive. Always meet with the person to give the result as soon as possible after the test.
If the result is negative
Deal with the feelings arising from a negative result and explain about the 'window period'.
Discuss ways to prevent HIV infection through safer sex and the importance of remaining negative for the rest of the pregnancy, during breastfeeding, and afterwards.
If the result is positive
Tell the person as clearly and gently as possible. Deal with their immediate feelings and explain the need for a supplementary test to confirm the result.
Give them time to understand and discuss the result.
Provide information in a way that they can understand, give emotional support and help them to discuss how they will cope.
Discuss how the person plans to spend the next few hours and days.
Identify what support they have.
Discuss who they want to tell about the result. Find out if they intend to tell their partner, help them to decide whether or not to tell them and, if appropriate, how to tell them.
Go through the ways they can take care of their own health and let them know about any available treatment.
For a pregnant woman, go through the ways to reduce the risk of transmitting HIV to her baby during pregnancy, labour and after the birth.
Discuss how she will feed the baby and the importance, if she breastfeeds, of exclusive breastfeeding.
Identify what difficulties or problems the person foresees and discuss how to deal with them.
Encourage them to ask questions.
Refer the person, where possible, to a community-support organisation and for follow-up care and counselling.
Encourage them to return for another session when they have had time to take in some of the information they have just heard. If appropriate, some information could be written down as the person is unlikely to be able to remember everything that was said.
Testing for HIV
What is an HIV test?
Testing for HIV is done on a blood sample. Most tests look for antibodies to the virus in the blood. Antibodies are produced by the body as it tries to fight the HIV virus. If no antibodies are found, the person is antibody negative (also called seronegative or HIV negative). If antibodies are found, the person is antibody positive (also called seropositive or HIV positive).
The test result may be negative if the person has been infected only recently. It can take up to three months from the time of infection for antibodies to be produced. This is known as the window period. Anyone who might have become infected in the last three months should take a second test three months after the first test.
Until recently, the most commonly used antibody test was the ELISA (enzyme-linked immunosorbent assay). ELISA testing needs skilled technical staff, equipment in good order, and a steady power supply. Now, simple or rapid assay tests are used more widely. These are quicker and easier to use than ELISA tests, and can be used for on-the-spot testing. They do not need highly trained staff or expensive laboratory equipment, although some do need refrigeration.
It is better to use a combination of tests to be sure of the results. The price of ELISA and other screening tests range from about US$0.45 to $2. Using a combination of rapid tests cost about US$5 per person.
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Deciding whether to be tested
Most women living in the developing world do not have a choice about whether to be tested for HIV, because the test is not available to them. It is thought that only one in twenty women in the developing world have been tested and know their status.
For those women who do have a choice, deciding whether to have a test should be done very carefully. The health worker should not try to persuade the woman to have the test - it should be a decision which she takes freely. Because of the fear and misunderstanding that surrounds HIV and AIDS, there is a lot of stigma towards HIV-positive people.
There are benefits and risks of testing, and these will vary for each woman. Some of the possible benefits of a pregnant woman knowing she is HIV positive are that she can:
take the measures available to her to keep herself healthy for as long as possible
decide, in countries where abortion is available, whether to continue the pregnancy
take appropriate steps to reduce the risk of transmitting HIV to her baby
tell her sexual partner(s) that she is HIV positive, so that they can be tested too
Some of the possible risks of knowing that she is HIV positive are:
her family may blame her for bringing HIV into the family and may react violently or make her leave her home
she may be stigmatised and looked down on by her neighbours and by health workers (if her HIV status is known about)
she may become anxious and depressed.
Even where HIV tests are available to all pregnant women, many choose not to have the test. And after having the test done, some women will not return to find out the result.
'My partner died six years ago. Before he died we talked, and he agreed, on my suggestion, to have an HIV test. We both took the test and were both diagnosed positive. Hell broke loose, but we got counselling and accepted the situation. I have since faced problems as a human being and as a health worker. Ill health may lead to me losing my job, which is a major worry. I see patients suffering and it is an indication of what I may face in the future. I always think about what people may say about me. However, knowing about HIV and AIDS does help me practise positive living.'
Health worker, Uganda
Being tested without consent
In some places, women find out they are HIV positive through routine testing during antenatal visits, without having been given adequate pre-test counselling and without their consent. This should be avoided if at all possible, but if a healthworker is meeting a woman for the first time after she has already been tested, she will need a particularly sensitive approach when being told her results.
'My first husband died of what I suspect was AIDS. I think I must have the virus too, especially when I know that we were having sex right throughout even in the month he died. I don't want to be told I've got it - even though I suspect it. It would break by heart to know for certain I would go through all that suffering like my husband.'
29 year old woman, Zambia
Testing babies
When babies are born they have their mother's antibodies in their blood. So if their mother is HIV positive, the baby's blood will often be positive too, until the baby is about 18 months old. If they do not have the virus, the mother's antibodies go away by this time. So antibody tests cannot tell if babies are themselves infected with HIV until the age of about 18 months. If an earlier test is negative, however, it does mean that the child is not infected.
There are tests which can give an accurate result earlier (such as PCR tests) but these are expensive and not usually available in developing countries.
Where to be tested?
Counselling and testing can be offered as part of an antenatal service or as a separate service. There are advantages in both types. Using the antenatal services may be more convenient for women and so increase the uptake of testing. But in a separate service there will often be links to ongoing support services for people living with HIV and AIDS. This will mean that continuing care for HIV-positive women may be available. If a woman is tested elsewhere and is found to be positive she should be encouraged to share the information with the antenatal services in order to ensure that she is given appropriate care and advice.
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